Cardiac rehabilitation

What is cardiac rehabilitation?

Cardiac rehabilitation is the process by which a person who has coronary heart disease, or who has had a myocardial infarction, is encouraged to achieve their full potential in terms of physical and psychological health.

Cardiac rehabilitation after an acute myocardial infarction includes communication of the diagnosis and advice, psychological and social support, motivation, and lifestyle changes, as well as drug therapy.^{1 2}

See also the separate Acute Myocardial Infarction Management and Heart Disease and Physical Activity articles.

In order to be successful, cardiac rehabilitation must draw on the skills of many members of the healthcare team and involve a combination of education, psychological support, exercise training and behavioural change.

Although the mechanism by which it occurs is not yet fully understood, cardiac rehabilitation that includes a programme of structured exercise is now generally believed not only to improve morbidity but also to reduce mortality in patients who have had a myocardial infarction.³

For optimal effect, cardiac rehabilitation programmes should be structured and tailored to the individual patient following an initial assessment. Computer support systems have been shown to assist the decision-making process.⁴

Cardiac rehabilitation is one of the National Priority Projects on the NHS's improvement agenda. The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) specifically identifies the cardiac specialist nurse as a core member of the cardiac rehabilitation team.⁵

The National Institute for Health and Care Excellence (NICE) guidance¹

• All people (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component.

• Begin cardiac rehabilitation as soon as possible after admission before discharge from hospital, and invite the person to a cardiac rehabilitation session. This should start within 10 days of their discharge from hospital.

• Contact people who do not start or do not continue to attend the cardiac rehabilitation programme with a further reminder, such as a motivational letter, a prearranged visit from a member of the cardiac rehabilitation team, a telephone call.

• Comprehensive cardiac rehabilitation programmes should include health education and stress management components.

• A home-based programme validated for people who have had an MI that incorporates education, exercise and stress management components with follow ups by a trained facilitator may be used to provide comprehensive cardiac rehabilitation.

Driving and flying: consider the latest Driver and Vehicle Licensing Agency (DVLA) guidelines. After an MI without complications, people who wish to travel by air should seek advice from the Civil Aviation Authority. People who have had a complicated MI need expert individual advice.

Sport: advice on competitive sport may need expert assessment of function and risk, and is dependent on what sport is being discussed and the level of competitiveness.

Stress management: offer stress management in the context of comprehensive cardiac rehabilitation.

Sexual activity: reassure that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI. Advise people who have made an uncomplicated recovery after their MI that they can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks.

Diet: advise to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on plant oils). Do not routinely recommend eating oily fish or omega-3 fatty acid supplements.

Physical activity: advise to undertake regular physical activity sufficient to increase exercise capacity. Advise to be physically active for 20 to 30 minutes a day to the point of slight breathlessness. Advise people who are not active to this level to increase their activity in a gradual, step-by-step way, aiming to increase their exercise capacity.

Smoking: advise all who smoke to stop and offer assistance from a smoking cessation service.

Alcohol: advise maintain alcohol intake within the recommended limits (no more than 14 units of alcohol per week, spread across 3 days or more, and at least 2 alcohol-free days a week).

Weight: offer all people who are overweight or obese advice and support to achieve and maintain a healthy weight.

There is evidence that early identification of, and intervention in, those most at risk of psychological distress can reduce psychological distress, hospital readmission rates and anxiety and depression scores at one year.⁶

Systematic reviews have concluded that the reduction in cardiovascular mortality associated with attending rehabilitation can be attributed to the exercise component. There is no comparable evidence for the efficacy of smoking cessation or dietary intervention. Implicit in an individualised patient-centred approach to rehabilitation, however, is that equal importance should be placed on all lifestyle risk factors, based on an individual assessment of need.⁷

Engaging patients

Although cardiac rehabilitation has been proven to be beneficial, uptake has been suboptimal. Reasons provided by patients are varied and include difficulty in attending the hospital (transport, car parking), a dislike of groups, and work or domestic commitments. There is only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. However, interventions targeting patient-identified barriers may increase the likelihood of success.⁸