Cardiac rehabilitation is a multi-disciplinary treatment and secondary prevention program for patients with various cardiac disorders, including recovery from heart attack and bypass surgery, which includes exercise, education, counseling, and lifestyle changes to help the patient return to previous levels of health and functioning and prevent recurrence of cardiac problems.
The purpose of cardiac rehabilitation is to provide comprehensive, multifaceted treatment, education, and secondary prevention for cardiac patients and individuals with heart disease risk factors, in order to aid recovery and prevent recurrence of heart problems. Cardiac rehabilitation programs can improve quality of life, help patients return to their previous level of functioning in work and daily life, increase fitness, facilitate heart-healthy behavior changes and management of risk factors, and reduce costs by decreasing frequency and expense of hospital stays.
Exercise, or certain kinds of exercise, may be contraindicated in the presence of some medical conditions. Conditions included are acute heart failure, angina at rest, second or third degree heart block, excessively low or high blood pressure, orthopedic problems, continued ischemia, aortic stenosis or mitral valve disease, or other health conditions in addition to the cardiac disorder. Exercise might also need to be discontinued if certain problems or symptoms such as the following occur: failure of monitoring equipment, lightheadedness, confusion, nausea, angina that occurs while exercising, excessive rise in blood pressure, or unusual heart rate. In addition, certain precautions may be taken before any cardiac patient begins an exercise program or session. Some of these include recording heart rate, blood pressure, and cardiac rhythm at each supervised session, and educating the patient in how to prepare for the exercises (proper breathing, dressing appropriately, avoiding smoking, etc.). Any preexisting medical conditions should also be taken into consideration when planning exercise treatments.
Cardiac rehabilitation is a comprehensive, multidisciplinary approach to treatment and secondary prevention for patients with various forms of cardiac disorders, such as post myocardial infarction (heart attack), bypass surgery, chronic stable angina pectoris, and heart transplant. It involves a cardiac rehabilitation team, which can be comprised of primary care and specialty physicians, nurses, physical therapists, exercise physiologists, occupational therapists, mental health professionals and dieticians. The physician may choose to participate in various roles, or refer patients to physical therapists and other practitioners or hospital departments.
A specially qualified physical therapist or RN may provide or direct cardiac rehabilitation services. At least one member of the physical therapy department or other team of practitioners in charge should be ACLS (Advanced Cardiac Life Support) certified, and a cardiopulmonary specialist should be included. The ACLS certification, which can be obtained during a one-day training course provided by the American Heart Association, is a level higher than CPR, and allows the practitioner to perform intubation and use a defibrillator.
Cardiac rehabilitation can be broken into three phases. Phase I, inpatient treatment in a hospital, can begin as early as 24 hours after a cardiovascular event. Phase II, outpatient treatment, can take place at the hospital, in a community center, in a medical center, or at the patient's home or place of employment. Phase III, referred to as the secondary prevention or maintenance phase, is performed more independently by the patient, with the goal of maintaining benefits and preventing further cardiac problems. An individual patient may participate in cardiac rehabilitation for a few weeks, six months, or longer. Many programs are conducted in groups, but the exercise prescription and other facets of treatment are individually designed to meet the specific medical needs and preferences of each patient.
The main components of a cardiac rehabilitation program are exercise, education, counseling, and behavior modification. Physical therapists may play a large part in the exercise component, as well as some aspects of patient education. Some of the goals of exercise are to restore or improve fitness, increase exercise tolerance and functional capacity, regain levels of functioning equivalent to those prior to the disease or surgery, and improve confidence and mood. Exercise and education by a physical therapist or other qualified practitioner can also help the patient manage and improve other risk factors and associated conditions such as diabetes, obesity, high blood lipids (fats), and stress. Inactivity itself is now recognized as a coronary risk factor, and thus exercise is an essential part of treatment for many reasons. A physical therapist may also be especially appropriate for work with cardiac patients who also have musculoskeletal problems. For example, bypass recipients may have problems with mobility of the shoulder or other joints.
The other components of the rehabilitation program may include education about the heart condition and its risk factors, counseling for psychological aspects of heart disease, stress management, vocational or occupational counseling, and guidance in adopting healthier behaviors. Some of the lifestyle or behavioral changes encouraged include smoking cessation and a lower fat diet, and management of other controllable coronary disease risk factors such as smoking, high blood pressure, high cholesterol, obesity, stress, and a sedentary lifestyle.
Many economic and medical benefits have been associated with cardiac rehabilitation, including decreased disability and improved functional capacity, less likelihood of mortality and recurrent morbidity, and decreased medical costs. Another benefit is that the use of electrocardiograph and other forms of objective and subjective assessment in ongoing supervised rehabilitation can lead to detection of problems and adjustments in the patient's treatment. Reasons for cost effectiveness of this form of treatment include reduction in disability and health care costs, fewer re-hospitalizations, and improved productivity. Despite these benefits, only about 11-38% of qualified candidates generally participate. Although many insurance companies cover all or part of a cardiac rehabilitation program, coverage is not available to all patients, and may be limited in terms of length of treatment or conditions covered.
A cardiac rehabilitation program is usually prescribed and overseen by a physician, and generally begins in the hospital, under the direction of appropriate hospital departments, and after exercise testing and other preparatory procedures have been administered. An EKG will likely be given before the rehabilitation program begins, and then be used as an ongoing monitoring method by the physical therapist or other rehabilitation team members.
The patient may continue with a maintenance or secondary prevention program, and should maintain the healthy habits they have gained, including regular exercise to maintain improved fitness and associated physical and psychological benefits.
Patients are closely monitored for any exercise-related health complications, and the rehabilitation team is equipped to detect and manage possible emergencies. Cardiac rehabilitation is a safe treatment option, and serious problems are rare.
Participation in a cardiac rehabilitation program can help the heart patient return to physical and emotional/social well-being and be able to function in their lives and work as near as possible to their pre-illness level of functioning. In fact, their overall quality of life and health may be improved. Patients also learn new ways of taking care of their health so that recurrence of illness or symptoms and re-hospitalization are minimized, and deterioration of existing conditions is less likely.
Electrocardiogram (EKG/ECG)— A test that records electrical activity of the heart. It may be used to detect a heart attack, because injured cardiac muscle causes abnormal conduction of electrical impulses.
Ischemia— Shortage of blood supply to a body tissue or organ (to the heart in the case of cardiac ischemia), which can cause tissue death. Cardiac ischemia can lead to heart attack or abnormal cardiac rhythms.
Myocardial infarction (MI)— The medical term for a heart attack. When cardiac ischemia, narrowing of a coronary artery or arteries, decreases blood supply to the heart muscle (myocardium), it can cause muscle tissue death (infarction).
Secondary prevention— The prevention of a recurrence of illness, such as another heart attack.
Health care team roles
After a prescription is made by the primary care physician or cardiac specialist, various health care professionals are involved in the program, including a physical therapist or exercise physiologist, nurses, an occupational therapist, dietician, and mental health professional. A nurse specializing in cardiac rehabilitation, an exercise physiologist or physical therapist, or the physical therapy department may manage the patient's rehabilitation program, in consultation with a physician.
Agency for Health Care Policy and Research (AHCPR). "Cardiac Rehabilitation: Exercise Training and Education, Counseling, and Behavioral Interventions" and "Recovering from Heart Problems Through Cardiac Rehabilitation" (patient guide). These can be obtained by writing or calling: Cardiac Rehabilitation. AHCPR Publications Clearinghouse. P.O. Box 8547. Silver Spring, MD 20907. (800) 358-9295.
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). 7600 Terrace Avenue, Suite 203. Middleton, WI 53562. (608) 831-6989. 〈http://www.aacvpr.org/〉.
American College of Sports Medicine (ACSM). 401 W. Michigan St. Indianapolis, IN 46202-3233. (317) 637-9200.
American Physical Therapy Association (APTA). 1111 North Fairfax Street. Alexandria, VA 22314. (703) 684-2782. 〈http://www.apta.org〉.
Johns Hopkins Bayview Medical Center. 〈http://www.jhbmc.jhu.edu/〉.
Mayo Clinic. 〈http://www.mayoclinic.com〉.
Cardiac rehabilitation is an individualized, medically supervised program of exercise and education for people with heart disorders including those recovering from cardiac surgery .
Cardiac rehabilitation is designed to improve the quality of life and extend the life of individuals with heart disease . It provides a comprehensive program of treatment, exercise, nutritional and lifestyle education, vocational counseling, psychological counseling, and caregiver education for people with congenital heart abnormalities, individuals who are recovering from heart attack and all types of cardiac surgery, and those with chronic conditions such as congestive heart failure .
The short-term goals of cardiac rehabilitation are to control, and ideally to improve, symptoms of heart disease and address the psychological effects of heart surgery or heart disease. The long-term goals are to effect lifestyle changes that retard the progression of atherosclerosis and reduce the risk of sudden cardiac death by educating the patient in ways to increase fitness, improve diet , maintain a healthy weight, and to reintegrate into work, family, and social environments. Care team members needed to meet these goal include a supervising cardiologist, cardiac nurse, physical therapist , exercise physiologist, respiratory therapist, nutritionist or dietitian, occupational therapist, psychologist or psychiatrist, vocational counselor, social worker, and rehabilitation case manager.
Cardiac rehabilitation is a medically supervised therapy. The appropriate level of activity is tailored to each individual. Cardiac tests such as an electrocardiogram (EKG) and stress test are done at regular intervals to maintain a program that is appropriate for the patient. Pulse rate and blood pressure at rest and following exercise often are monitored at each session.
Cardiac rehabilitation programs are offered in many settings: inpatient and outpatient rehabilitation centers, long-term care facilities (e.g., assisted living communities and nursing homes ), hospitals, community health facilities, and at home through home health providers. Individuals should look for a program that is accredited by the Commission of Accreditation of Rehabilitation facilities (CARF). The facility should have at least one member of the staff present at all times that is certified in advanced cardiac life support (ACLS). This is emergency cardiac first aid certification one step beyond cardiopulmonary resuscitation (CPR) .
Steps of recovery
Phase 1 begins in the hospital as early as 24–48 hours after leaving the intensive care unit (ICU) but while still in a coronary care unit. The patient will likely be seen by a cardiac nurse, physical therapist, exercise specialist, dietitian, and social worker. Educational materials are provided for the patient and education classes may be offered to family member and caregivers. The patient begins passive assisted range of motion exercises, and after a few days will be encouraged to sit on the edge of the bed or in a chair and perform simple self-care activities.
While still in the hospital, but usually after leaving the coronary care unit, the patient will begin walking with assistance in their room and up and down the hall at least twice a day. Heart rate and blood pressure will be monitored before and after exercise. A discharge rehabilitation plan will be developed with the assistance of the cardiologist, rehabilitation team, family/caregivers and patient.
Phase 1 continues for 2–6 weeks after the patient is discharged from the hospital to home or a rehabilitation hospital. The patient may receive home visits two or three times a week from a physical therapist and occupational therapist. A social worker or case manager continues to assist the patient and family in coordinating the rehabilitation program.
Phase 2 generally takes place at a rehabilitation facility that provides constant medical supervision. A physician determines the appropriate level of exercise. Pulse and blood pressure are monitored and an EKG is often done before and after exercise. The goal of this phase is to extend exercise tolerance and improve patients' daily lives by increasing the activities they can safely do without becoming fatigued. Sessions usually occur three times a week. Dietary counseling continues, as do psychological and vocational counseling as needed. The goal of dietary counseling is to get the patient to consistently follow a heart-healthy diet that will retard or reverse atherosclerosis and to have the patient reach and maintain a healthy weight. Patients who smoke should also implement a plan to permanently stop smoking . This phase may last from 3–6 months.
Phase three is a lifetime maintenance program of exercise and diet. The patient participates in activities he or she enjoys such as walking, bicycling, or attending moderate exercise classes at places such as gym or senior center. This phase does not require medical supervision. The goal of phase three is to establish lifetime habits that promote heart health.
Less than one-third of eligible cardiac patients in the United States and Canada participate in a cardiac rehabilitation program after surgery or heart attack. Many insurance programs pay for some or all of a rehabilitation program, but for people with inadequate or no insurance, the financial cost of the program is a significant barrier. Other challenges involve organizing family assistance to get the patient to and from the program in phase 2. The greatest barrier to completing this program, however, is resistance to the lifestyle changes necessary to promote heart health, such as eating a low-fat, reduced calorie diet and quitting smoking.
Electrocardiogram (EKG) —A noninvasive test records the electrical activity of the heart and is useful is assessing general heart health.
Stress test —A test that involves an electrocardiogram during rest and exercise to determine how the heart responds to stress.
Cardiac rehabilitation is a very safe program. Compared to those who do not enter a cardiac rehabilitation program, individuals who complete the program have a better quality of life and a substantially reduced risk of sudden cardiac death. Because phases 1 and 2 of this program are medically supervised, few emergencies are likely to occur, and the staff on hand will have been trained to handle them.
Multiple studies show the benefit of participating in cardiac rehabilitation. People completing the program have greater independence in their daily lives and less premature disability than those who do not. Cardiac rehabilitation is a safe and effective therapy for those who stick with the program.
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American Association of Cardiovascular and Pulmonary Rehabilitation, 401 North Michigan Avenue, Suite 2200, Chicago, IL, 60611, (312) 321-5146, (312) 673-6924, [email protected], http://www.aacvpr.org.
American Heart Association, 7272 Greenville Avenue, Dallas, TX, 75231, (800) 242-8721, http://www.americanheart.org.
National Heart Lung and Blood Institute Health Information Center, P.O. Box 30105, Bethesda, MD, 20824-0105, (301) 592-8573; TTY: (240) 629-3255, (240) 629-3246, http://www.nhlbi.nih.gov.
Tish Davidson AM
Cardiac rehabilitation is a comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional condition of patients with heart disease.
Heart attack survivors, bypass and angioplasty patients, and individuals with angina, congestive heart failure, and heart transplants are all candidates for a cardiac rehabilitation program. Cardiac rehabilitation is prescribed to control symptoms, improve exercise tolerance, and improve the overall quality of life in these patients.
A cardiac rehabilitation program should be implemented and closely monitored by a trained team of healthcare professionals.
Cardiac rehabilitation is overseen by a specialized team of doctors, nurses, and other healthcare professionals. Members of the cardiac rehabilitation team may include a dietician or nutritionist, physical therapist, exercise physiologist, psychologist, vocational counselor, occupational therapist, and social worker. The program frequently begins in a hospital setting and continues on an outpatient basis after the patient is discharged over a period of six to 12 months.
Components of a cardiac rehabilitation program vary by individual clinical need, and each program will be carefully constructed for the patient by his or her rehabilitation team.
- Exercise. Exercise programs typically start out slowly, with simple range-of-motion arm and leg exercises. Walking and stair climbing soon follow. Blood pressure is carefully monitored before and after exercise sessions, and patients are taught how to measure their heart rate and evaluate any possible cardiac symptoms during each session. Patients with advanced coronary disease may require continuous ECG monitoring throughout their exercise sessions. Once discharged from the hospital, the patient works with his cardiac team to create an individual exercise plan.
- Diet. Cardiac patients will work with a nutritionist or dietician to develop a low-fat, low-cholesterol diet plan. Patients with high blood pressure may be put on a salt-restricted diet and instructed to limit alcohol intake. Weight loss may also be a goal with obese cardiac patients.
- Counseling. A psychologist or social worker can help cardiac patients with issues that may be contributing to their heart condition, such as stress and anxiety. Relaxation techniques may be taught to patients to help them deal with these feelings. Cardiac patients frequently experience a period of depression, and group or individual counseling can be beneficial in overcoming these feelings. Vocational counselors can assist cardiac patients in returning to the workforce.
- Education. The patient and family should be fully educated on the physical limitations of the patient, his recommended diet and exercise plan, his emotional status, and the lifestyle changes required to improve the patient's overall health.
- Smoking cessation. Cardiac patients who smoke are twice as likely to have a heart attack in the following five years than non-smoking patients. These patients are strongly encouraged to enroll in a smoking cessation program, which typically includes patient education and behavioral counseling. Nicotine replacement therapy, which uses nicotine patches, nose spray, or gum to wean patients off of cigarettes, may also be part of the program. Antidepressants and anti-anxiety medication may be helpful in some cases.
Long-term maintenance is a critical feature of cardiac rehabilitation. Patients require support from their healthcare team, family, and friends to continue the lifestyle changes they implemented during the rehabilitation period.
The risks of another heart attack during cardiac rehabilitation are slight, and greatly reduced by careful, continuous monitoring of the physical status of the patient.
The outcome of the cardiac rehabilitation program depends on a number of variables, including patient follow-through, type and degree of heart disease, and the availability of an adequate support network for the patient. Patients who successfully complete the program will ideally reach an age-appropriate level of physical activity and be able to return to the workforce and/or other daily activities.
American Heart Association. 7320 Greenville Ave. Dallas, TX 75231. (214) 373-6300. 〈http://www.americanheart.org〉.
Angina— Chest pain.
Bypass surgery— A surgical procedure that grafts blood vessels onto arteries to reroute the blood flow around blockages in the arteries (arteriosclerosis).