Cardiac rehabilitation

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Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life". [1] CR is a comprehensive model of care delivering a wide range of established health interventions, including structured exercise, patient education, psychosocial counselling, risk factor reduction, and behavior modification, with a goal of improving patient's quality of life and reducing the risk of future heart problems. [2] [3]

Contents

CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. [4] Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.

Medical illustration of a human heart that is being assisted by a pacemaker. Cardiovascular system - Pacemaker -- Smart-Servier.png
Medical illustration of a human heart that is being assisted by a pacemaker.

Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology [5] and the European Society of Cardiology, [6] among other associations. [7] [8] Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator). [9] However, some populations, including women [10] [11] and older patients [12] , are less likely than others to seek out and complete these types of programs.

Settings

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. [3] Hybrid programs are also increasingly being offered. [13] [14] There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same. [15] Home-based cardiac rehabilitation is generally considered to be a safe alternative to traditional CR. [16] Home-based programs with technology are similarly shown to be effective. [17] [18] [19] In a typical cardiac rehabilitation setting, the patient is cared for by a team of professionals that is typically led by a cardiologist. [4] In home-based cardiac rehabilitation programs, patients are supported by a similar team of professionals, but the patient is responsible for completing the program without direct supervision. [20] While CR is generally considered to be cost effective [21] , it is worth noting that many insurances, including Medicare, do not cover home-based cardiac rehabilitation programs [22]

Uses and requirements

CR is useful for those who are recovering from a recent cardiac emergency, those who need assistance managing their chronic stable angina symptoms, those who have recently undergone cardiac surgeries, and in many other cases. [23] However, traditional CR is not an option for some individuals. Some patients are discouraged from participating in the typical exercise component of CR, including those with unstable angina, intracavitary thrombus, and more. [23]

Cardiac rehabilitation phases

Inpatient program (phase I)

Engaging in CR before leaving the hospital can hasten patient's recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient's current status, and gradually progresses their therapeutic exercises. [24]

Phase I is also an ideal time for the patient and their family to receive information regarding what is to be expected after their release. This includes information regarding their ADLs (activities of daily life) and the importance of stress management. During this time, patients are also assessed to determine if they will need assistive devices following their release from the inpatient program. [23]

Outpatient program (phase II)

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. [25] It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery. [26] [27] [28] This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues. [29] [27] Shorter time to start is associated with better outcomes. [30]

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. [3] A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program. [25]

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity. [25]

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered, [31] and it is well-established that the more the better. [32]

Post-Cardiac Rehabilitation (phase III)

Immediately following phase II, patients are encouraged to continue their recovery from home. While it is recommended that patients continue to attend follow-up visits with their physicians, phase III is predominantly carried out by the patients themselves. During this phase, the patient is expected to continue taking their medications as prescribed, to continue the exercises that they have been taught, and to ensure that they make the appropriate lifestyle changes to avoid another cardiac event. [33] Challenges persist for optimizing and maintaining cardiovascular health among people with CVD and this includes a need for longer term support and care rather than a time-limited traditional rehabilitation program [34] [35] .

Benefits

Participation in CR may be associated with many benefits. [36] Cardiac rehabilitation decreases the risk that patients will have further complications due to heart disease, with studies showing that CR decreases the chance of dying from heart complications in the next five years by about 35%. [37] . The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence. [38]

CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity, [39] and is cost-effective. [40] In addition, cardiac rehabilitation has been shown to reduce negative symptoms, help foster positive lifestyle changes, and encourage patients to continue taking their medications on a daily basis. [37] There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues, [41] atrial fibrillation, [42] heart transplant recipients, [43] and heart failure. [44]

While CR is generally considered safe and effective, there are rare cases in which patients undergoing cardiac rehabilitation experience physical complications as they complete the exercise aspect of these programs. [45]

Psychological health and cardiac rehabilitation

Poor psychological health has been shown to have a negative impact on patients' recovery process as well as their willingness and ability to complete rehabilitation. [46] Unresolved depression and anxiety have also been shown to increase the risk of mortality following the completion of rehabilitation programs. [47] Because of this, psychological intervention is a common practice in CR. [46]

Additionally, research suggests that screening for psychological distress is a helpful way to assess a patient's risk of further cardiovascular complications due to the negative effects of psychological distress on CVD outcomes. [48] However, this type of psychological health screening is still underutilized in modern cardiac rehabilitation programs. [48]

Under-use of cardiac rehabilitation

CR is significantly under-used globally. [49] Rates vary widely. [50]

Under-use is caused by multi-level factors. [51] [52] At the health system level, this includes lack of available programs. [53] At the provider level, low referral rates are a major barrier. [54] [55] At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible, [56] but most can be mitigated. [57] Women, [10] [11] ethnocultural minorities, [58] [59] older patients, [12] those of lower socio-economic status, with comorbidities, and living in rural areas [60] are less likely to access CR, despite the fact that these patients often need it most. [61]

Strategies are now established on how we can mitigate these barriers to CR use. [62] [63] It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html). [64] It is also key for healthcare providers to promote CR to patients at the bedside. [65] The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.

Training more healthcare professionals to deliver CR can also help. [66] CR programs can also join a registry to assess and improve their utilization—among other quality indicators. [67] [68] [69] Offering programs tailored to under-served groups such as women may also facilitate program participation. [70] [71] [72] [73] Global experts have proposed the 5 P's for umproving quality and uptake of cardiac rehabilitation programs as follows (1) personalization, (2) processes and systems, (3) patient-centered care, (4) parlance, and (5) partnership and unity [74] . United groups are driving new approaches and data driven-approaches to care such as SOLVE-CHD.

Cardiac rehabilitation societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR. [75] The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, [76] ICCPR seeks to promote CR in low-resource settings, [77] among other aims outlined in their Charter. [78] CR societies offer registries, clinician certification, [79] and program certification, [80] among other resources.

References

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  4. 1 2 Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. (August 2019). "Nature of Cardiac Rehabilitation Around the Globe". eClinicalMedicine. 13: 46–56. doi:10.1016/j.eclinm.2019.06.006. PMC   6733999 . PMID   31517262.
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  55. ↑ Ghanbari-Firoozabadi M, Mirzaei M, Nasiriani K, Hemati M, Entezari J, Vafaeinasab M, et al. (2020-01-01). "Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting". Rehabilitation Process and Outcome. 9: 1179572720936648. doi: 10.1177/1179572720936648 . PMC   8282146 . PMID   34497466.
  56. ↑ Shanmugasegaram S, Gagliese L, Oh P, Stewart DE, Brister SJ, Chan V, Grace SL (February 2012). "Psychometric validation of the cardiac rehabilitation barriers scale". Clinical Rehabilitation. 26 (2): 152–164. doi:10.1177/0269215511410579. PMC   3351783 . PMID   21937522.
  57. ↑ Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL (February 2019). "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 2019 (2): CD007131. doi:10.1002/14651858.CD007131.pub4. PMC   6360920 . PMID   30706942.
  58. ↑ Midence L, Mola A, Terzic CM, Thomas RJ, Grace SL (November–December 2014). "Ethnocultural diversity in cardiac rehabilitation". Journal of Cardiopulmonary Rehabilitation and Prevention. 34 (6): 437–444. doi: 10.1097/HCR.0000000000000089 . PMID   25357126.
  59. ↑ Koehler Hildebrandt AN, Hodgson JL, Dodor BA, Knight SM, Rappleyea DL (September 2016). "Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A Systematic Review". Journal of Cardiopulmonary Rehabilitation and Prevention. 36 (5): 320–330. doi: 10.1097/HCR.0000000000000183 . PMID   27496250. S2CID   10829735.
  60. ↑ Leung YW, Brual J, Macpherson A, Grace SL (November 2010). "Geographic issues in cardiac rehabilitation utilization: a narrative review". Health & Place. 16 (6): 1196–1205. doi:10.1016/j.healthplace.2010.08.004. PMC   4474644 . PMID   20724208.
  61. ↑ Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, et al. (November 2016). "Participation and adherence to cardiac rehabilitation programs. A systematic review". International Journal of Cardiology. 223: 436–443. doi:10.1016/j.ijcard.2016.08.120. PMID   27557484. S2CID   205234011.
  62. ↑ Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL (February 2019). "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 2019 (2): CD007131. doi:10.1002/14651858.cd007131.pub4. PMC   6360920 . PMID   30706942.
  63. ↑ Aljehani R, Grace SL, Aburub A, Turk-Adawi K, Ghisi GL (April 2023). "Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers". Healthcare. 11 (8): 1196. doi: 10.3390/healthcare11081196 . PMC   10138187 . PMID   37108029.
  64. ↑ Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, et al. (February 2011). "Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study". Archives of Internal Medicine. 171 (3): 235–241. doi:10.1001/archinternmed.2010.501. PMID   21325114.
  65. ↑ Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL (August 2020). "Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course". BMC Health Services Research. 20 (1): 768. doi: 10.1186/s12913-020-05619-2 . PMC   7439558 . PMID   32819388.
  66. ↑ Babu AS, Heald FA, Contractor A, Ghisi GL, Buckley J, Mola A, et al. (May 2022). "Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers, and Impact". Journal of Cardiopulmonary Rehabilitation and Prevention. 42 (3): 178–182. doi:10.1097/hcr.0000000000000655. hdl: 10315/40874 . PMID   34840246. S2CID   244714261.
  67. ↑ Grace SL, Elashie S, Sadeghi M, Papasavvas T, Hashmi F, de Melo Ghisi G, et al. (July 2023). "Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry". International Journal for Quality in Health Care. 35 (3). doi:10.1093/intqhc/mzad050. PMC   10329404 . PMID   37421311.
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  69. ↑ Grace, Sherry L; Hagström, Emil; Harrison, Alexander S; Phillips, Samara; Bovin, Ann; Yokoyama, Miho N; Niebauer, Josef; Makita, Shigeru; Raidah, Fabbiha; Back, Maria; on behalf of the ICRR Investigators (2024-11-01). "Cardiac rehabilitation registries around the globe: current status and future needs". European Journal of Preventive Cardiology. 31 (16): e117 –e121. doi:10.1093/eurjpc/zwae182. ISSN   2047-4873. PMC   11571179 . PMID   38775788.
  70. ↑ Mamataz T, Ghisi GL, Pakosh M, Grace SL (June 2022). "Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis". Maturitas. 160: 32–60. doi:10.1016/j.maturitas.2022.01.008. hdl: 10315/40875 . PMID   35550706. S2CID   246424701.
  71. ↑ Mamataz T, Ghisi GL, Pakosh M, Grace SL (September 2021). "Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review". BMC Cardiovascular Disorders. 21 (1): 459. doi: 10.1186/s12872-021-02267-0 . PMC   8458788 . PMID   34556036.
  72. ↑ Ghisi GL, Kin SM, Price J, Beckie TM, Mamataz T, Naheed A, Grace SL (December 2022). "Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline". The Canadian Journal of Cardiology. 38 (12): 1786–1798. doi: 10.1016/j.cjca.2022.06.021 . hdl: 10315/40876 . PMID   36085185. S2CID   251967685.
  73. ↑ Ghisi, Gabriela Lima de Melo; Supervia, Marta; Turk-Adawi, Karam; Beleigoli, Alline; Contractor, Aashish; Mampuya, Warner M.; Grace, Sherry L. (2024-02-01). "Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation". CJC Open. Why Her Heart Matters: Evidence-Based Practice and Practice-Based Evidence. 6 (2, Part B): 425–435. doi:10.1016/j.cjco.2023.10.008. hdl: 10576/53081 . ISSN   2589-790X. PMC   10935990 . PMID   38487061.
  74. ↑ Redfern, Julie; Gallagher, Robyn; Maiorana, Andrew; Candelaria, Dion; Hollings, Matthew; Gauci, Sarah; O’Neil, Adrienne; Chaseling, Georgia K.; Zhang, Ling; Thomas, Emma E.; Ghisi, Gabriela L. M.; Gibson, Irene; Hyun, Karice; Beatty, Alexis; Briffa, Tom (2024-09-30). "Cardiac rehabilitation and secondary prevention of CVD: time to think about cardiovascular health rather than rehabilitation". npj Cardiovascular Health. 1 (1): 22. doi:10.1038/s44325-024-00017-7. ISSN   2948-2836. PMC   11442299 . PMID   39359645.
  75. ↑ Grace, Sherry L (2023-01-02). "Evidence is indisputable that cardiac rehabilitation provides health benefits and event reduction: time for policy action" . European Heart Journal. 44 (6): 470–472. doi:10.1093/eurheartj/ehac690. ISSN   0195-668X. PMID   36746185.
  76. ↑ Turk-Adawi K, Supervia M, Ghisi G, Cuenza L, Yeo TJ, Chen SY, et al. (July 2023). "The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go?". eClinicalMedicine. 61: 102092. doi: 10.1016/j.eclinm.2023.102092 . PMC   10388569 . PMID   37528847.
  77. ↑ Grace, Sherry L.; Taylor, Rod S.; Gaalema, Diann E.; Redfern, Julie; Kotseva, Kornelia; Ghisi, Gabriela (July 2023). "Cardiac Rehabilitation" (PDF). JACC: Advances. 2 (5): 100412. doi: 10.1016/j.jacadv.2023.100412 . ISSN   2772-963X. PMC   11198422 . PMID   38938991.
  78. ↑ Grace SL, Warburton DR, Stone JA, Sanderson BK, Oldridge N, Jones J, et al. (March–April 2013). "International Charter on Cardiovascular Prevention and Rehabilitation: a call for action". Journal of Cardiopulmonary Rehabilitation and Prevention. 33 (2): 128–131. doi:10.1097/HCR.0b013e318284ec82. PMC   4559455 . PMID   23399847.
  79. ↑ Babu, Abraham Samuel; Heald, Fiorella A.; Contractor, Aashish; Ghisi, Gabriela L. M.; Buckley, John; Mola, Ana; Atrey, Alison; Lopez-Jimenez, Francisco; Grace, Sherry L. (May 2022). "Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): EVALUATION OF REACH, BARRIERS, AND IMPACT". Journal of Cardiopulmonary Rehabilitation and Prevention. 42 (3): 178–182. doi:10.1097/HCR.0000000000000655. hdl: 10315/40874 . ISSN   1932-7501. PMID   34840246.
  80. ↑ Turk-Adawi, Karam I.; Elshaikh, Usra; Contractor, Aashish; Hashmi, Farzana Amir; Thomas, Emma; Raidah, Fabbiha; Grace, Sherry L. (2023-11-09). "Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings". International Journal of General Medicine. 16: 5199–5214. doi: 10.2147/IJGM.S423209 . hdl: 10576/52666 . PMC   10643168 . PMID   38021048.
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