Cardiac rehabilitation (CR) is a cost-effective, life-enhancing and life-saving treatment for patients recovering from cardiac illness—from myocardial infarction, revascularisation, angina, heart failure, etc. Its main aims are to help the patient to recover as quickly and completely as possible and then to reduce to a minimum the chance of recurrence of the cardiac illness—it should be an integral step in the management of the patient’s condition. Despite the inclusion of CR in the National Service Framework for coronary heart disease only a minority of cardiac patients join CR programmes. Suggestions are made for increasing the uptake.
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WHAT IS CARDIAC REHABILITATION?
Cardiac rehabilitation (CR) is a multidisciplinary intervention for people with heart disease. Its main aims are to help the patient to recover as quickly and completely as possible and then to reduce to a minimum the chance of recurrence of the cardiac illness. It has a 50-year history and an extensive evidence base that shows it to be one of the most beneficial and cost-effective treatments available to patients with coronary disease.
HOW IS CR PROVIDED?
Rehabilitation is appropriate after hospital admission for a cardiac diagnosis (myocardial infarction, acute coronary syndrome, cardiac surgery or angioplasty, defibrillator implant, cardiac transplantation) or after any step change in a cardiac condition (new-onset angina, diagnosis of heart failure). CR should be an integral step in the management of the patient’s condition. In the UK and most European countries, CR is divided into four phases. In the United States and some other countries CR is divided into three phases—phases II and III being combined. This leads to some confusion in the literature. The stages and pattern of CR are covered in a number of guidelines1–5 and are summarised here:
When the medical condition is stable and before hospital discharge, clinical staff provide education about the event and its causes, give advice on lifestyle changes, including activity, smoking cessation and diet, and ensure that secondary prevention drugs have been prescribed. Ideally, this is provided by a member of the CR team who can ensure that the patient is then enrolled into the CR programme.
This is the period of convalescence at home before phase III begins. It includes continued education with reinforcement of healthy living advice and encouragement to increase physical activities—provided by telephone or by visits from a member of the CR or primary care team.
There are two main models of phase III CR in the UK. The most commonly used is a period of supervised, group, outpatient rehabilitation which usually starts about 2 weeks after angioplasty, 4 weeks after myocardial infarction or 6 weeks after heart surgery. Before joining the programme the patient is assessed, including the clinical history, the results of any investigations (electrocardiogram, echocardiogram, blood lipids, fasting blood sugar), a physical examination (weight, blood pressure, etc) and physical and psychological function tests. A course of graduated exercise training is the centrepiece and is supplemented by education (topics include the cause of heart attacks and the risk factors and how to remedy them, diet, common cardiac misconceptions, the role of drug treatment, the place of exercise in heart disease), risk factor monitoring and correction, stress management and relaxation training.
These programmes were once almost exclusively hospital-based but are now increasingly provided in community settings. National and international clinical guidelines emphasise the need to move away from a one-size-fits-all pre-ordained programme to “individualised” or “menu-based” programmes based on an assessment of each patient’s rehabilitation needs, followed by a process of negotiation about changes to lifestyle: for example, patients who do not wish to take part in group exercise programmes might be helped to initiate activities such as, walking, swimming, cycling or gardening. Cognitive behavioural methods of behaviour change such as motivational interviewing and goal setting should augment didactic health education as the method for producing behaviour change. The key is the active support and interest of the healthcare worker who works with the patient and relevant others in a problem-solving capacity. Although there is a general willingness amongst clinicians to adopt these suggestions, limits on resources and training have meant that the more traditional programme still predominates.
The duration of phase III should depend upon the level of risk and the responses of the patient and may vary from 4 weeks in the young fit patient and (ideally) to 6 months or more in older, less fit and higher-risk patients. At the end of the programme, risk factors and medication should be checked and lifestyle and exercise goals and strategies for long-term compliance should be discussed with the patients.
The other widely used model is a 6-week, home-based programme using written and audio-taped materials and supervised by phone, or through home visits, by a specially trained “facilitator”, usually a nurse or physiotherapist. This method, The Heart Manual, has been shown in numerous randomised trials to be better than “usual care”6 and to produce comparable gains to those of hospital-based CR.7–10
To aid the assessment of a patient’s needs and progress and to provide audit measures of performance, a national minimum dataset and an online database have been developed and endorsed by the British Heart Foundation and the British Association for Cardiac Rehabilitation.11 Taking part in the annual audit is one of the minimum standards for CR.
This phase is the lifelong continuation of the new lifestyle habits. The British Association for Cardiac Rehabilitation has an established scheme for training instructors working in fitness centres to provide continued exercise for cardiac patients. Medical follow-up is in primary care with annual (or more frequent if indicated) checks for symptoms, exercise habit, smoking habit, weight, blood pressure, blood lipids and medication. In the UK, general practitioners are rewarded for providing several aspects of continued secondary prevention (aspirin, β blocker and statin prescription as well as some outcomes, including adequate control of blood pressure and cholesterol levels).
WHAT ARE THE BENEFITS OF CR?
Increased physical fitness: The general level of fitness in the community is undesirably low12 and in patients with coronary heart disease it is lower still.13 This level is further reduced by the enforced reduction in activities which follows acute myocardial infarction or coronary artery bypass grafting. The physical training aspect of CR improves physical fitness by between 25 and 30%14—or even more for very vigorous programmes.15 The initial improvement is mediated by peripheral effects but, after a year or more of exercise training, increases in cardiac performance can be expected.15 16
Reduced angina: For those with residual reversible ischaemia, improved fitness lessens cardiac workload at any level of exercise, thus increasing the threshold for angina—with reduction of the total ischaemic burden. The effect of exercise training in this respect is as great as that of β blockade.17
Enhanced coronary blood flow: Since coronary angiography is performed with the patient at rest it is not possible to show an anatomical increase in coronary collateral circulation with physical training. However, patients with angina have been shown by thallium scanning to have better myocardial perfusion during exercise after physical training.18
Reduced arrhythmias: Exercise training increases the threshold for ventricular ectopic activity and controlled trials have shown that ectopic beats are less prevalent in trained than untrained postinfarct patients.19
Improved lipid profiles: Controlled trials have shown that coronary patients taking part in vigorous training programmes show a rise in high-density lipoprotein cholesterol and a fall in total cholesterol. This benefit is lost if the patient gains weight. A combination of diet and exercise can result in regression of atheroma.18
Lowered blood pressure: Exercise training reduces blood pressure during exercise and at rest.19
Psychological benefit: CR can improve quality of life with increase in confidence, wellbeing and happiness and with decreases in anxiety and depression.22 These benefits are small and relatively short lived if exercise alone is used. The addition of stress management and relaxation training as part of the programme significantly enhances this effect.23
Return to work: Most people in employment before a heart attack will return to work after 3–6 months. Some controlled trials of CR have shown an earlier return to work for the intervention group but others have not. For a minority of patients disabled either physically or psychologically by their coronary disease formal rehabilitation has been shown to result in renewed employment.24 Some occupations such as large goods vehicle drivers or public service vehicle drivers need to attain a high level of fitness if they are to pass the necessary treadmill test to regain their licences and this is often only possible with exercise training.
Improved survival: Meta-analyses of randomised controlled trials of CR, including 8940 patients from 48 randomised controlled trials, have shown a reduction in total mortality of 20% and of cardiac mortality of 26% over 3 years.25 The reduction in mortality is small in the first year but increases with time. In a meta-analysis of 63 randomised trials of secondary prevention programmes, including 21 295 patients, Clark et al found the mortality reduction after 1 year to be 0.97 (95% CI 0.82 to 1.14) and after 2 years to be 0.53 (95% CI 0.35 to 0.81).26 They also found that non-fatal infarction was reduced, though this has not been shown in previous smaller meta-analyses. The mortality benefit has also been shown in a meta-analysis of rehabilitation for patients with heart failure.27
WHAT ARE THE DANGERS OF EXERCISE-BASED CR?
A fear that physical training may not be safe, other than for patients at low risk, has led to many patients being excluded from rehabilitation programmes. This is a mistake—physical training for cardiac patients is remarkably safe and serious complications are very rare. They include:
Ventricular fibrillation. In a US multicentre study the rate of ventricular fibrillation was calculated as one per 111 996 patient-hours of exercise.28 Immediate defibrillation is usually effective, reducing the actual mortality to one per 783 972 patient-hours.
Acute myocardial infarction. In the same study the rate of acute myocardial infarction was one infarct per 294 118 patient-hours of exercise.
Ventricular and atrial arrhythmias. These are common during CR exercise but seldom produce problems.29
Angina and silent ischaemia. These are also common during exercise sessions, the frequency depending on the clinical mix of patients treated.
Postural hypotension. This is most often seen in patients with angina receiving β blockers, particularly after prophylactic use of glyceryl trinitrate.29 It may take up to 30 min to resolve.
WHO CAN BENEFIT FROM CR?
CR should benefit nearly all patients recovering from an acute cardiac event or after development of a new stage in their illness. In England, the National Service Framework for coronary heart disease recommended in 2000 that patients after acute myocardial infarction, coronary artery bypass grafting and percutaneous coronary intervention should be offered CR, with a target of 85% of these groups being offered CR by 2002.30 This target seems high but has been shown to be attainable.31 The National Service Framework recommended that once these patients were catered for, CR should be offered to other groups, such as those with angina, heart failure and patients with implanted defibrillators. In practice, the great majority of rehabilitation programmes are limited, by funding or by unnecessarily conservative local protocols, to taking only postinfarct and revascularisation patients. This is despite the evidence that patients with heart failure, angina and arrhythmic conditions may experience the same or even greater benefits. For example, patients with heart failure not only have an improved prognosis but also can achieve an improvement of one grade in their New York Heart Association score, a very real quality of life gain.27
HOW ARE THE BENEFITS OF CR PRODUCED?
It is not clear which aspect of the rehabilitation confers the improvement in survival. There is no difference in the mortality benefits of exercise-only programmes compared with exercise combined with comprehensive rehabilitation,25 26 or compared with programmes which provide risk factor education and counselling without an exercise component.26
WHO PROVIDES CR?
CR is a multidisciplinary activity. The British Association for Cardiac Rehabilitation Minimum Clinical Standards32 and the Scottish Intercollegiate Guidelines Network3 for CR recommend that the team should include at least a nurse, physiotherapist, dietician, pharmacist and clinical psychologist as well as having administrative support. Data from the National Audit of Cardiac Rehabilitation33 show that few programmes in the UK reach these levels of staffing. For example, only 60% had a physiotherapist, 20% a dietician and 10% a psychologist. In general, CR services have developed haphazardly, championed by local enthusiasts, usually nurses or physiotherapists, who have seen a therapeutic gap for their patients and filled it as best they could. Often this was by “borrowing” time from the other professions required for this multidisciplinary activity. These are professions that have little power in the committees rooms where spending is decided. The National Audit of Cardiac Rehabilitation survey showed that only 32% of CR coordinators held a budget.33
HOW MUCH DOES CR COST AND IS IT COST EFFECTIVE?
The cost for each patient rehabilitated depends upon the model used and the number of staff employed. For the Heart Manual programme it is in the region of £200/patient.8 For hospital-based programmes the approximate costs vary from £185 to £550/patient.34
Research carried out by the University of Bristol in 2001 indicated a cost per patient, including National Health Service overheads (capital, equipment, etc) of around £486.35 The National Audit of Cardiac Rehabilitation survey in 2005–6 found a similar average cost (after allowing for inflation) of £550.
In the UK, the National Institute for Health and Clinical Excellence estimated the incremental cost-effectiveness ratio for CR after acute myocardial infarction “is about £7860 and £8360 per quality-adjusted life year gained for men and women, respectively”.34 36 The cost effectiveness of CR is supported by evidence from 15 health economic evaluations conducted in North America and Europe. Papadakis et al estimated that the cost per life year gained ranged from US$2193 (£1218) to US$28 193 (£15 663).37 Fidan et al have compared the cost effectiveness of a number of cardiovascular interventions from 2000 to 2010. Aspirin and β blockers for secondary prevention, angina or heart failure at <£1000 per life year gained were the only interventions which were found to be more cost effective than CR which came in at £1957 per life year gained. Less cost-effective secondary prevention interventions include angiotensin-converting enzyme inhibitors (£3398), statins (£4601), coronary artery bypass grafting (£3239) and angioplasty (£3845–£5889). Even less cost-effective interventions include primary angioplasty for myocardial infarction (£6054–£12 057, according to age) and statins for primary prevention (£27 828–£69 373 per life year gained).38
WHO, IN THE UK, IS GETTING CR?
There has been a steady increase in the number of centres providing CR in the UK over the past 35 years and now every hospital in the UK which treats acute cardiac problems has access to one. However, <30% of “eligible” patients join CR programmes. Inclusion varies by diagnosis (from 18% of angioplasty patients, through 26% of patients with myocardial infarct to 72% of patients with a coronary artery bypass graft) and by geographical region.39 The National Service Framework target for 85% of eligible patients to be invited to join is a very long way from being met and the intention to include other groups such as patients with angina, heart failure and an implanted defibrillator is unlikely to happen in the foreseeable future. All of these groups, particularly patients with heart failure,27 have been shown to benefit from attendance at rehabilitation programmes.
Some groups, including women,40 the elderly,41 the deprived42 and ethnic minorities43 are less likely to be invited to attend or to enrol in CR programmes. Other barriers include significant comorbidity and living far from the rehabilitation centre.44
Adherence to the rehabilitation programme varies widely but is generally reported as being between 65 and 85%. Those least likely to complete the programme include all those in the groups least likely to be invited and also persistent smokers, depressed patients and those who lack family support.45
WHY IS UPTAKE OF CR SO LOW?
There are a number of explanations for the poor uptake of CR. First, many patients are not invited to take part; a survey by the Healthcare Commission in 2004 showed that 60% of patients who had had an acute event claimed not to have been invited to take part in CR despite it being available in the hospital they had attended.46 This may reflect poor funding or poor organisation on the part of those providing CR but it also reflects a lack of support from doctors and cardiologists. Unlike other European countries,47 very few CR programmes in the UK enjoy the active involvement of a cardiologist or doctor.48 Endorsement of the importance of CR by the patient’s doctor is known to be one of the most effective ways of promoting attendance at CR40 and at the very least it should be made a routine part of the patient pathway.
Not all patients want to or can attend a group programme. Offering infarct patients the choice of using the Heart Manual or attending a group resulted in the majority (60%) of those suitable for rehabilitation choosing the former. Combining both methods and organising CR across the primary/secondary boundaries, resulted in an area of Cornwall meeting the National Service Framework 85% target, one of the few parts of the country to do so.31
CR is an essential part of the care of cardiac patients but is poorly supported by clinicians and those planning and funding health services and as a result is often poorly organised, staffed and attended. The achievement of optimal attendance may be helped by attention to the following:
Funding every CR programme to at least the level specified in the Minimum Clinical Standards set out by the British Association for Cardiac Rehabilitation32;
Inclusion of CR in tariffs for the management of coronary heart disease;
Inclusion of CR in the Quality and Outcomes Framework of the new GP contract;
Use of the National Audit for CR to reveal inadequate provision and the practices associated with better uptake and patient outcomes;
Practical support from the local cardiologist(s), doctors, cardiac network and general practitioners;
Inclusion of rehabilitation in the patient pathway, with automatic referral after a cardiac event or new diagnosis;
Encouragement to attend and endorsement of the benefits to patients by all healthcare staff having contact with cardiac patients
Individualised menu-based rehabilitation tailored to the patient’s own needs and aims;
A choice of group or home-based CR;
The provision of group sessions at a time and place convenient to patients.
Until good quality CR is available to the majority of patients with heart disease they will continue to die prematurely and many others will live unnecessarily symptomatic and disabled lives.
Competing interests: None.
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