Cardiac Rehabilitation

Cardiac rehabilitation is the process by which a person who is suffering from ischaemic heart disease, or who has had a myocardial infarction is encouraged to achieve their full potential in terms of physical and psychological health. In order to be successful, cardiac rehabilitation must draw on the skills of many members of the health care team and involve a combination of education, psychological support, exercise training and behavioural change.^1,2 Although the mechanism by which it occurs is not yet fully understood, cardiac rehabilitation which includes a programme of structured exercise is now generally believed not only to improve morbidity but also reduces mortality in patients who have suffered a myocardial infarction (MI).^3,4 It has been thought for many years that all patients, regardless of gender or age, who have ischaemic heart disease and/or cardiac failure might benefit from cardiac rehabilitation⁵ but for optimal effect cardiac rehabilitation programmes should be structured and tailored to the individual patient following an initial assessment.

This approach has recently been endorsed by the National Institute for Health and Clinical Excellence (NICE).⁶ The main thrust of the latest guidance is that cardiac rehabilitation should be made more accessible. The salient points are as follows:

• All patients who have had a MI should be offered a cardiac rehabilitation programme which includes an exercise component.
• A range of options should be offered. Patients should be encouraged to attend the options appropriate to their needs, but should not be excluded from the entire programme if they do not want to take up one or more particular component.
• If the patient has a cardiac or other condition which limits physical exercise this should be treated before this component is offered. A suitably qualified healthcare professional may be able to adapt the physical component to make it more suitable for the patient.
• Patients with stable left ventricular dysfunction can be offered the physical component.

• When cardiac rehabilitation services are planned, the needs of the particular local community should be taken into account, including health and social factors and deprivation.This will ensure that there is maximum engagement with those who have the greatest need, thereby ensuring that services are accessible and relevant to all MI patients.
• Services should be culturally sensitive. This may mean employing bilingual peer educators or cardiac rehabilitation assistants reflect the diversity of the local population.
• The physical component should be adapted to meet the needs of older patients and those with signficant comorbidities. The provision of transport to the service may need to be considered.
• Patients should be offered mixed sex or single sex classes.
• It is important for patients health beliefs and basic level of health literacy to be established before lifestyle advice is offered.
• All healthcare professionals who come into contact with post-MI patients, including senior medical staff, should promote cardiac rehabilitation services. Various methods of contact should be considered, including verbal, postal and telephone communication.

• Programmes should include general health education and information on how to deal with stress.
• An integrated and co-ordinated approach from primary and secondary care teams at this stage e.g using a validated structured plan such as "The Heart Manual" can improve psychological well being and overall outcome. This may be particularly appropriate for patients unwilling or unable to access secondary care-based services, since much can be achieved using a home-based approach. ⁷
• Most patients who have sustained a MI can return to work. Account should be taken of the type of work, the work environment, and the physical and psychological state of the patient.
• Due regard should be given to the latest guidance from the Driver and Vehicle Licensing Agency (DVLA).⁸
• Patients can usually fly within 2-3 weeks. If there have been complications, expert advice should be sought.
• Patients with a pilot's licence will need to seek the advice of the Civil Aviation Authority before they can pilot a plane.
• Depending on psychological and physical status, most patients can resume normal daily activities.
• Patients should be taught how to use the Metabolic Equivalent Level system (METS ).⁹ This is a useful method of calculating the intensity of a particular activity so that physiological demand can be monitored. Patients who have had a complicated MI may need expert advice.
• Patients involved in competitive sports may need expert advice to assess the level of risk.

• Patients should be offered basic stress management advice but will not usually need more complex treatment such as cognitive behavioural therapy.
• Partners and carers should be involved if this is in accordance with the patient's wishes.
• Patients with anxiety or depression should be managed according to the appropriate NICE guidance.^10,11

Whilst NICE gives an overall view and sets some gold standards for the provision of services, it may also be useful to view the cardiac rehabilitation journey as a number of stages appropriate to various levels of recovery, as follows:

Stage 1 - The initial stage following MI or cardiac event

• Assessment of patient's physical/psychological condition
• Assessment of risk factors e.g. diet, smoking, exercise, lipid profile
• Reassurance and correction of any misconceptions
• Education
• Initial mobilisation
• Plan for discharge

Stage 2 -The post-discharge stage

The early discharge period is the time at which the patient is the most vulnerable, and psychological distress at this stage is a predictor of poor outcome and increased use of hospital services independent of the physical damage to the heart.¹² Patients should be screened for anxiety and depression at this stage and should be treated with suitable non-cardiotoxic antidepressants if appropriate.

Stage 3 -Structured exercise and rehabilitation

Graded exercise is a vital component of cardiac rehabilitation, although it does not alter morbidity and mortality rates if offered in isolation. Aerobic low to moderate intensity exercise will be suitable for most patients who have been assessed as low to moderate risk. This form of exercise programme may generally be undertaken either at home or under supervision in the community e.g. graded exercise programmes in leisure centres where staff have received basic life support training. Exercise training for high risk patients would normally be carried out in a hospital or other suitable venue able to provide facilities and staff trained in resuscitation should this prove necessary.

Graded exercise should be accompanied at this stage by other interventions tailored to meet the individual patient's requirements. Lifestyle changes should be encouraged and supported where appropriate e.g. weight reduction, smoking cessation, retraining with a view to returning to work. This is likely to be accompanied by education concerning the cardiac condition and the reasons why changes in lifestyle might be desirable.

Stage 4 - Long term maintenance

In order to be effective, physical activity and changes in lifestyle need to be maintained for the long term.
A protocol which allows for the regular review of all patients with ischaemic heart disease and/or heart failure by the primary care team is desirable.¹ Long term review will permit continued support of lifestyle changes in addition to assessment of drug therapy, physical and psychological well being, and will allow early intervention where required in all areas.