Cardiac Rehabilitation

Guide to Procedures for the Twenty-first Century

Nanette Wenger, Nanette K. Wenger, L. Kent Smith, Erika Sivarajan Froelicher, Patricia McCall Comoss, Nanette Wenger, Nanette K. Wenger, L. Kent Smith, Erika Sivarajan Froelicher, Patricia McCall Comoss

• Publisher: CRC Press
• Year: 1999
• eBook ISBN: 9781135567088
• Topic: Medicine
• Subtopic: Cardiology

This detailed reference provides practical strategies and a scientific foundation for designing and implementing cardiac rehabilitation services to relieve the symptoms of cardiovascular disease patients through exercise training and risk reduction and secondary prevention, improve quality of life, and decrease mortality.
Emphasizes multidisciplinary care that includes exercise training, behavioral interventions, and education and counseling regarding lifestyle changes and other aspects of secondary prevention!
Written by world-renowned physicians, nurses, exercise physiologists, psychologists, dietitians, educators, and counselors in the field, Cardiac Rehabilitation

presents evidence-based medicine as the cornerstone of clinical cardiology practice

discusses interventions that limit the physiological and psychological effects of cardiac illness

offers guidelines that enable elderly patients to maintain self-sufficiency and functional independence

describes means of social and workplace reintegration

evaluates policies for maintaining high-quality care, efficacy, and safety in an atmosphere of diminishing resources

explains the role of managed care in moving rehabilitative care into the home, workplace, and other nontraditional sites

assesses new interactive technologies that aid in tracking patient data

gives pragmatic recommendations for the delivery of cardiac rehabilitative care in the next millenium

and more!
Advocating integrated, high-quality, consistent cardiac rehabilitation services for the well-being of patients recovering from a variety of cardiovascular problems and procedures, Cardiac Rehabilitation is ideally suited for all medical professionals working in this field.

1
Overview: Charting the Course for Cardiac Rehabilitation into the 21st Century

Nanette K.Wenger
Emory University School of Medicine, Grady Memorial Hospital, and Emory Heart and Vascular Center, Atlanta, Georgia

INTRODUCTION

The U.S. Public Health Service definition of cardiac rehabilitation (1) states that:

Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiological and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients.

Simply stated, cardiac rehabilitation is a combination of services that helps patients with cardiovascular disease improve their functional abilities, particularly their tolerance for physical activity; decrease their symptoms; and achieve and maintain optimal health.

Several variables are likely to significantly influence the delivery of cardiac rehabilitative care in the next millennium. Pivotal among these are changes in the demography of the U.S. population, changes in the demography of cardiovascular disease, and changes in the patterns of clinical practice. Each will be addressed in turn.

CHANGES IN THE DEMOGRAPHY OF THE U.S. POPULATION

Since the middle of the nineteenth century, there has been an almost doubling of life expectancy at birth in the United States, from about 40 years to about 80 years. More than half of all individuals who ever lived beyond 65 years of age are alive today. Between 1988 and 2025 the total U.S. population will increase by about 23%; however, the most dramatic increase will occur among the elderly, with the 60-to 74-year age group predicted to increase by 85% and the group older than 75 years of age by 98%. The over-85 population subgroup is the fastest growing segment of the U.S. population. Since cardiovascular disease remains the major health problem in this elderly population, there will be an unprecedented acceleration in the requirement for cardiac rehabilitation services. As well, owing to their greater life expectancy, women will continue to be disproportionately represented among the elderly. A far greater proportion of U.S. inhabitants will be from the populations previously considered as racial and ethnic minorities. Thus, the landscape of patients with cardiovascular disease will increasingly be characterized by elderly age (2), more often women and individuals from minority groups, many of whom are from lower socioeconomic background. There is currently a substantial disparity in the utilization of cardiac rehabilitation, with lower rates documented among older individuals, women, those with less education, and the unemployed; the need for and utilization of cardiac rehabilitation services by these undeserved populations will likely entail a further major expansion.

Arguably, progressive education of the U.S. population regarding the benefits of rehabilitative care and improved patient expectations of favorable outcomes of cardiovascular illness should likewise escalate the demand for cardiac rehabilitation services. Finally, health values of the U.S. population increasingly target a lessening of symptoms and an improvement in functional status (i.e., enhancement of the quality of life). These goals are concordant with those of cardiac rehabilitation (i.e., limitation of the progression of cardiac illness and maintenance of the functional capabilities of the patient).

CHANGES IN THE DEMOGRAPHY OF CARDIOVASCULAR DISEASE

During the past two decades, unprecedented medical and surgical advances have increased the survival and limited the physiological morbidity of many cardiac patients. Owing to the increased effectiveness of medical and surgical management of cardiovascular disease, two polar patient populations are likely to be encountered for cardiac rehabilitation care. The first are patients who have benefited from the newest medical and surgical therapies, who bring a lesser burden of illness to rehabilitation, and who are at low risk of subsequent cardiovascular complications; for these individuals, preventive therapies must be highlighted. At the other end of the spectrum are patients whose survival has been enhanced by advanced technologies, but who now present, often at elderly age, with end-stage disease, particularly with serious residual myocardial ischemia and congestive heart failure. Heart failure has increased in prevalence related both to the growth of the elderly population and to improved heart failure therapies that have enhanced the duration of survival. Heart failure remains the major hospital discharge diagnosis at elderly age; overall, hospital discharges for heart failure have increased from 377,000 in 1979 to more than 800,000 in 1992 (3). The rehabilitative goals for these latter patients, rather than improvement in survival and return to work and an active lifestyle typical for their younger counterparts, should be diminution of symptoms, improvement in functional capabilities, and, particularly valued by these individuals, maintenance of self-sufficiency and functional independence, characterized by the ability to perform self-care and activities of daily living; and achievement of a personally satisfying lifestyle.

CHANGES IN THE PATTERNS OF CLINICAL PRACTICE

A cornerstone of the clinical practice of cardiology in the next millennium will be evidence-based medicine. The Clinical Practice Guideline Cardiac Rehabilitation (4) of the U.S. Agency for Health Care Policy and Research and the National Heart, Lung and Blood Institute is such a landmark document, providing the first comprehensive and objective examination of the specific outcomes of the delivery of cardiac rehabilitation. It documents the most substantial benefits or outcomes of cardiac rehabilitation as improvement in exercise tolerance, improvement in symptoms, improvement in blood lipid levels, reduction in cigarette smoking, improvement in psychosocial well-being and stress reduction, and reduction in mortality. Particular benefit of exercise training is recognized for patients with a decreased functional capacity at baseline. This evidence-based model defines that elderly patients attain improvement in functional capacity from exercise training comparable to their younger counterparts. Improvement in functional status occurs equally in elderly women and elderly men. Initially in observational studies and subsequently in randomized clinical trials, patients with compensated heart failure, including those with significant cardiac enlargement and following myocardial infarction, improved their functional capacity with exercise training (with this benefit additive to that of pharmacotherapy), without exercise training adversely affecting myocardial function. Similar evidence-based models will likely subsequently address the previously understudied patient subgroups—the elderly, women, and those with serious and advanced cardiovascular illness.

During the past three decades, progressive changes have occurred in the delivery of rehabilitative care for cardiac patients. These have included an expansion of the spectrum of cardiovascular illnesses considered eligible for and likely to benefit from cardiac rehabilitation in general and exercise rehabilitation in particular (5). Whereas in the early years of cardiac rehabilitation most patients were those recovered from uncomplicated myocardial infarction, included today are patients with complications of myocardial infarction including residual myocardial ischemia, heart failure, and arrhythmias; those recovering from myocardial revascularization procedures; elderly patients; patients with valvular heart disease with and without surgical correction; patients with cardiac enlargement and compensated heart failure; patients with surgically “corrected” congenital heart disease; medically complex patients with significant comorbidity, often receiving multiple cardiac medications; those with implanted cardiac pacemakers; and those following cardiac transplantation, among others. Many of these categories of patients were initially arbitrarily excluded from exercise rehabilitation regimens. The optimal modes, duration, and needs for surveillance of the exercise training of these severely ill patients have yet to be determined.

Changes in patterns of cardiac clinical care and changes in policies for insurance reimbursement also have altered substantially the components and timing of cardiac rehabilitation. Rehabilitative care is initiated earlier, particularly for coronary patients who received acute interventions designed to salvage myocardium and subsequent revascularization preocedures to improve outcomes; there is abbreviation of the intensity and duration of professional surveillance, with earlier transition to independence in rehabilitative activities, and with an escalating emphasis on return-to-work as an economic imperative.

A concomitant occurrence has been major evidence-based changes in the recommendations for and application of exercise training (4). Prominent among these are the decreased level of supervision for low-risk patients, a lower intensity of exercise compensated for by an increase in exercise duration, and the application of resistance exercises for appropriately selected patients. Because economic constraints and logistics often limit the availability of supervised cardiac rehabilitation, home-based rehabilitation will likely prove attractive to a variety of low-to moderate-risk cardiac patients, who may also participate in rehabilitation regimens in the workplace. Randomized clinical trial data have shown comparable benefit from supervised and home-based exercise training. The cost-saving aspects of this alteration in the delivery of cardiac rehabilitation services is currently being ascertained.

Education and counseling for patients and their family members is a cornerstone of cardiac rehabilitation (4), designed to provide the information needed to assume responsibility for personal health care and the skills needed to insure attainment and maintenance of optimal cardiovascular health. Skill building and motivation are integral components of rehabilitative education and counseling. Modification of lifestyle and other risk factors in patients with cardiovascular disease can reduce cardiac events and deaths, improve symptoms, and enhance the quality of life. Clinical practice pathways are likely to encourage the application of preventive services and thus the utilization of rehabilitative care. The application of behavioral intervention techniques to encourage patients to adopt and systematically implement new healthy behaviors is likely to constitute an important component of the cost-effectiveness of the delivery of these rehabilitation services. Home-based programs of education and counseling involve planned communication and guidance by specially trained rehabilitation personnel. Newer and interactive technologies (6) have potential advantages in effectively tracking and following patient data; in enabling high-quality and more readily available instruction distant from a medical care setting; and in extending the influence of health professionals.

Psychosocial consequences of cardiac illness often impair the cardiac patient’s functional capabilities to a greater extent than do their residual physical limitations. Interventions must be designed to limit emotional and social disability.

Although secondary preventive services for cardiovascular risk reduction are routinely recommended for patients with cardiovascular disease, many high-risk populations including older individuals, women, those with less education and the unemployed are less likely to utilize cardiac rehabilitation (7). Changes in managed care will most likely focus increasingly on preventive and rehabilitative care, with this care often being delivered in the home, in the workplace, or in other previously nontraditional care sites.

There will be increased emphasis both on multidisciplinary care and on the individualization of services, such that the assessment, enhancement, and maintenance of physiological, psychosocial, and vocational status will be appropriate for an individual patient’s medical needs, goals, and personal preferences. Individualization of rehabilitative care should affect favorably a patient’s coping skills, perceptions of personal health status, and functional capabilities and thereby improve the quality of the patient’s life. Cost-effectiveness will also require increased diversity in the delivery of rehabilitative care to meet the needs and desires of diverse cardiac populations, diverse as to age, severity of illness, symptoms, comorbidity, and expectations of outcomes. The increased requirement for the diversity of provision of services and the diversity of sites for ambulatory care provides a major opportunity for the creative delivery of cardiac rehabilitation. The challenge to health care professionals is to maintain quality care, efficacy, and safety in a setting of diminishing resources. Patient care guidelines involving physician–nonphysician collaboration continue to proliferate (8); this is the model of care on which cardiac rehabilitation services have traditionally been built.

Cost utility analyses have shown the costs of cardiac rehabilitation to be comparable to those of other routinely offered treatments (9). As well, cardiac rehabilitation can produce financial savings by lessening rates of hospital readmission and potentially by improving rates of reemployment.

SUMMARY

Given the prominent benefits documented from the application of cardiac rehabilitation, of concern is that fewer than one-third of cardiac patients in the United States eligible for cardiac rehabilitation currently participate. The challenge is to overcome barriers to such participation for this sizeable population of cardiac patients; barriers include lack of access, lack of physician referral, reimbursement issues, and personal reluctance to modify lifestyle habits.

A further challenge for the twenty-first century will be to select, develop, and provide appropriate rehabilitation services for individual cardiac patients; this includes tailoring the method of delivery of these services. The selection strategy should incorporate both the recommendations of health care providers and patient preferences and should be designed to facilitate progressive independence in cardiac rehabilitation and long-term comprehensive care.

REFERENCES

1. Feigenbaum E, Carter E. Cardiac rehabilitation services. Health technology assessment report, 1987, No 6. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Care Technology Assessment. DHHS publication No. PHS 88–3427, August 1988.

2. Projections of the Population of the United States by Age, Sex, and Race: 1983–Washington, DC: U.S. Bureau of the Census; 1984: Table 2, middle series.

3. Fatality from congestive heart failure—United States 1980–1990. MMWR 1994; 43: 77–81.

4. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CME, Dattilo AM, Davis D, DeBusk RF, Drozda JP, Jr, Fletcher BJ, Franklin BA, Gaston H, Greenland P, McBride PE, McGregor CGA, Oldridge NB, Piscatella JC, Rogers FJ. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung and Blood Institute. AHCPR Publication No. 96–0672, October 1995.

5. World Health Organization Expert Committee. Rehabilitation after cardiovascular dis-eases, with special emphasis on developing countries. Technical Report Series No. 831. Geneva: World Health Organization, 1993.

6. Wenger NK, ed. The Education of the Patient with Cardiac Disease in the Twenty-first Century. New York: Le Jacq Publishing...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• FUNDAMENTAL AND CLINICAL CARDIOLOGY
• SERIES INTRODUCTION
• PREFACE
• CONTRIBUTORS
• CARDIAC REHABILITATION
• 1: OVERVIEW: CHARTING THE COURSE FOR CARDIAC REHABILITATION INTO THE 21ST CENTURY
• 2: BENEFITS OF EXERCISE TRAINING
• 3: THE NATIONAL INSTITUTES OF HEALTH CONSENSUS CONFERENCE STATEMENT ON PHYSICAL ACTIVITY AND CARDIOVASCULAR HEALTH
• 4: REHABILITATION CONSIDERATIONS IN EXERCISE TESTING
• 5: EXERCISE PRESCRIPTION
• 6: ASSESSMENT FOR EXERCISE TRAINING: CONTRAINDICATIONS, RISK STRATIFICATION, AND SAFETY ISSUES
• 7: COMPONENTS OF EXERCISE TRAINING
• 8: LIFE-LONG EXERCISE: COUNSELING FOR EXERCISE MAINTENANCE
• 9: SUPERVISED VERSUS UNSUPERVISED EXERCISE TRAINING: RISKS AND BENEFITS
• 10: EXERCISE TRAINING IN SPECIAL POPULATIONS: THE ELDERLY
• 11: EXERCISE TRAINING IN SPECIAL POPULATIONS: WOMEN
• 12: EXERCISE TRAINING IN SPECIAL POPULATIONS: HEART FAILURE AND POST-TRANSPLANTATION PATIENTS
• 13: EXERCISE TRAINING IN SPECIAL POPULATIONS: DIABETES
• 14: EXERCISE TRAINING IN SPECIAL POPULATIONS: OBESITY
• 15: EXERCISE TRAINING IN SPECIAL POPULATIONS: VALVULAR HEART DISEASE
• 16: EXERCISE TRAINING IN SPECIAL POPULATIONS: PACEMAKERS AND IMPLANTABLE CARDIOVERTER- DEFIBRILLATORS
• 17: EXERCISE TRAINING IN SPECIAL POPULATIONS: PERIPHERAL ARTERIAL DISEASE
• 18: EXERCISE TRAINING IN SPECIAL POPULATIONS: ASSOCIATED NONCARDIAC MORBIDITIES
• 19: MULTIFACTORIAL CARDIAC REHABILITATION: EDUCATION, COUNSELING, AND BEHAVIORAL INTERVENTIONS
• 20: MATCHING THE INTENSITY OF RISK FACTOR MODIFICATION WITH THE HAZARD FOR CORONARY DISEASE EVENTS
• 21: SCIENTIFIC BASIS FOR MULTIFACTORIAL RISK REDUCTION: OVERVIEW WITH EMPHASIS ON NATIONAL GUIDELINES
• 22: SMOKING CESSATION AND RELAPSE PREVENTION: CASE MANAGEMENT APPROACHES
• 23: LIPID LOWERING FOR CORONARY RISK REDUCTION
• 24: MANAGEMENT OF HYPERTENSION
• 25: WEIGHT MANAGEMENT AND EXERCISE IN THE TREATMENT OF OBESITY
• 26: PSYCHOSOCIAL RISK FACTORS: OVERVIEW, ASSESSMENT, AND INTERVENTION FOR ANGER AND HOSTILITY
• 27: PSYCHOSOCIAL RISK FACTORS: ASSESSMENT AND INTERVENTION FOR DEPRESSION
• 28: PSYCHOSOCIAL RISK FACTORS: ASSESSMENT AND INTERVENTION FOR SOCIAL ISOLATION
• 29: STRESS MANAGEMENT
• 30: RETURN TO WORK: FACTORS AND ISSUES OF VOCATIONAL COUNSELING
• 31: EDUCATION FOR SPECIAL POPULATIONS
• 32: QUALITY-OF-LIFE ASSESSMENT IN SECONDARY PREVENTION
• 33: THE NEW INFRASTRUCTURE FOR CARDIAC REHABILITATION PRACTICE
• 34: CASE MANAGEMENT IN CARDIAC REHABILITATION
• 35: HOME-BASED CARDIAC REHABILITATION: VARIATIONS ON A THEME
• 36: BEHAVIORAL CHANGE0—GETTING STARTED AND BEING SUCCESSFUL
• 37: MOTIVATING AND EMPOWERING PATIENTS FOR SELF-LEARNING
• 38: ADHERENCE TO A HEART-HEALTHY LLFESTYLE— WHAT MAKES THE DIFFERENCE?
• 39: MEASURING PROGRAM QUALITY—APPLYING STANDARDS AND GUIDELINES
• 40: STREAMLINING AND COMPUTERIZING CARDIAC REHABILITATION CHARTING
• 41: PATIENT OUTCOMES IN CARDIAC REHABILITATION: WHAT, WHY, AND WHEN TO MEASURE
• 42: MEDICOLEGAL ISSUES: PRACTICE GUIDELINES— FRIEND OR FOE?
• 43: ECONOMIC ISSUES: THE VALUE AND EFFECTIVENESS OF CARDIAC REHABILITATION
• 44: CHALLENGES AND OPPORTUNITIES FOR ADDITIONAL RESEARCH
• ABOUT THE EDITORS