Dr Hayley Willacy would like to draw your attention to the latest version of the Scottish Intercollegiate guidelines on cardiac rehabilitation. 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.
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[2, 3]. 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 which 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. It has been thought for many years that all patients, regardless of gender or age, who have coronary heart disease and/or cardiac failure, might benefit from cardiac rehabilitation. 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.
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. Intervention by a specialist nurse can substantially reduce the length of hospital stay, hospital costs and the risk of readmission to hospital for heart failure[8, 9].
- All patients who have had a myocardial infarction 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 particular component or more.
- 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.
- 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.
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.
Home-based programmes have been devised to address these problems and to improve access to, and participation in, cardiac rehabilitation programmes.
- 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 myocardial infarction patients.
- Services should be culturally sensitive. This may mean employing bilingual peer educators or cardiac rehabilitation assistants to 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-myocardial infarction patients, including senior medical staff, should promote cardiac rehabilitation services. Various methods of contact should be considered, including verbal, postal and telephone communication. One study propounded the benefits of 'telehealth' interventions (internet, telephone and video conferencing). Despite its proven benefits, the uptake of cardiac rehabilitation services in the UK is currently poor.
- 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 (eg, 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. One study in Birmingham found no differences in clinical outcomes in patients participating in hospital-based or home-based programmes.
- Most patients who have sustained a myocardial infarction 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).
- 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 involved in competitive sports may need expert advice to assess the level of risk.
Psychological and social support
- Patients should be offered basic stress management advice and may not need more complex treatment such as cognitive behavioural therapy. However, one study found that six components of psychological intervention - usual care, educational, behavioural, cognitive, relaxation and support - offered positive benefits in terms of clinical outcomes.
- 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 National Institute for Health and Care Excellence (NICE) guidance.
Phases in cardiac rehabilitation
Cardiac rehabilitation can be divided into different phases, with each appropriate for the patient's physical and psychological recovery:
Phase 1: the initial stage following myocardial infarction or cardiac event
- Assessment of a patient's physical/psychological condition.
- Assessment of risk factors - eg, diet, smoking, exercise, lipid profile.
- Reassurance and correction of any misconceptions.
- Initial mobilisation.
- Plan for discharge.
Phase 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. Patients should be screened for anxiety and depression at this stage and should be treated with suitable non-cardiotoxic antidepressants if appropriate.
Phase 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 - eg, graded exercise programmes in leisure centres where staff have received basic life support training. One meta-analysis confirmed that light-to-moderate exercise in a group setting offered the greatest benefit in terms of improved quality of life. 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 - eg weight reduction, smoking cessation, and 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.
Phase 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 coronary heart disease and/or heart failure by the primary care team is desirable. Long-term review will permit continued support of lifestyle changes in addition to assessment of drug therapy, and physical and psychological well-being, and will allow early intervention, where required, in all areas.
Further reading and references
Secondary prevention after a myocardial infarction; NICE Quality Standard, September 2015
Cardiac Rehabilitation; British Heart Foundation
Cardiac rehabilitation; Scottish Intercollegiate Guidelines Network (2017)
Myocardial infarction: cardiac rehabilitation and prevention of further MI; NICE Clinical Guideline (November 2013)
Contractor AS; Cardiac rehabilitation after myocardial infarction. J Assoc Physicians India. 2011 Dec59 Suppl:51-5.
Anderson L, Thompson DR, Oldridge N, et al; Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016 Jan 51:CD001800. doi: 10.1002/14651858.CD001800.pub3.
Gordon NF, Gulanick M, Costa F, et al; Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention the Council on Cardiovascular Nursing
Goud R, de Keizer NF, ter Riet G, et al; Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation. BMJ. 2009 Apr 27338:b1440. doi: 10.1136/bmj.b1440.
Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation; British Association for Cardovascular Prevention and Rehabilitation, 2012
Grange J; The role of nurses in the management of heart failure. Heart. 2005 May91 Suppl 2:ii39-42
Blue L, Lang E, McMurray JJ, et al; Randomised controlled trial of specialist nurse intervention in heart failure. BMJ. 2001 Sep 29323(7315):715-8.
Acute coronary syndrome; Scottish Intercollegiate Guidelines Network - SIGN (2016)
Karmali KN, Davies P, Taylor F, et al; Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database Syst Rev. 2014 Jun 256:CD007131. doi: 10.1002/14651858.CD007131.pub3.
Neubeck L, Redfern J, Fernandez R, et al; Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Cardiovasc Prev Rehabil. 2009 Apr 29.
Bethell H, Lewin R, Dalal H; Cardiac rehabilitation in the United Kingdom. Heart. 2009 Feb95(4):271-5. Epub 2008 Jan 20.
Jolly K, Lip GY, Taylor RS, et al; The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart. 2009 Jan95(1):36-42. Epub 2008 Mar 10.
Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency
Welton NJ, Caldwell DM, Adamopoulos E, et al; Mixed treatment comparison meta-analysis of complex interventions: psychological interventions in coronary heart disease. Am J Epidemiol. 2009 May 1169(9):1158-65. Epub 2009 Mar 3.
Depression in adults: recognition and management; NICE Clinical Guideline (April 2018)
Piotrowicz R, Wolszakiewicz J; Cardiac rehabilitation following myocardial infarction. Cardiol J. 200815(5):481-7.
Gillison FB, Skevington SM, Sato A, et al; The effects of exercise interventions on quality of life in clinical and healthy populations a meta-analysis. Soc Sci Med. 2009 May