As the leading cause of death worldwide, cardiovascular diseases leave many individuals with a myriad of functional impairments related to debility and adjustment to their cardiac event. Cardiac rehabilitation provides an integrated process of restoring the person to their maximum potential both physically and emotionally by a combination of secondary prevention through disease management and lifestyle changes, structured progressive physical exercise, and returning to previous social and recreational activities. This has robust support in the medical literature to decrease mortality and morbidity and improve quality of life.
KeywordsCardiac, cardiovascular disease, cardiovascular implants and grafts, rehabilitation
|I21.3||ST elevation (STEMI) myocardial infarction of unspecified site|
|I25.2||Old myocardial infarction|
|I25.9||Chronic ischemic heart disease, unspecified|
|I20.9||Angina pectoris, unspecified|
|I50.9||Heart failure, unspecified|
|I25.10||Atherosclerotic heart disease of native coronary artery without angina pectoris|
|Z95.2||Presence of prosthetic heart valve|
|Z95.812||Presence of fully implantable artificial heart|
|Z95.811||Presence of heart assist device|
|Z95.1||Presence of aortocoronary bypass graft|
Cardiac rehabilitation is the integrated treatment of individuals after cardiac events or procedures with the goals of maximizing physical function, promoting emotional adjustment, modifying cardiac risk factors, and addressing return to previous social roles and responsibilities. The American Heart Association 2015 update estimates cardiovascular disease (CVD) prevalence to be 85.6 million people in the United States; coronary heart disease affects 15.5 million people. Of those with coronary heart disease, 7.6 million have had myocardial infarction, 8.2 million have angina pectoris, 5.7 million have heart failure, and 650,000 to 1,300,000 have congenital cardiovascular defects. CVDs have continued to be the leading cause of mortality in both men and women for more than a century and accounted for 31.3% of all deaths in 2011. The World Health Organization states that worldwide 17.5 million people die each year from CVD, making it the leading cause of death with 75% due to myocardial infarction and stroke. Eighty-two percent of CVD mortality occurs in low- and middle-income countries. Cardiac rehabilitation may benefit individuals after acute coronary syndrome, cardiac surgery (coronary artery bypass graft, valve replacement, transplantation, ventricular reduction surgery, correction of congenital heart defect), compensated congestive heart failure, and ventricular augmentation devices. Cardiac rehabilitation comprehensively addresses risk factor modification and secondary prevention through exercise training, smoking cessation, diet modification, evaluation and treatment of psychosocial stressors, education about the disease process, return to work, and maximizing the medical treatment of comorbidities (such as diabetes mellitus, hypertension, and obesity). In a meta-analysis of cardiac rehabilitation programs, pooled cardiovascular mortality was decreased from 10.4% to 7.6%, hospital readmissions were reduced from 30.7% to 26.1%, and health-related quality of life was increased compared with usual care in patients with myocardial infarction, percutaneous interventions, coronary artery bypass graft, or known cardiac disease.
The individual with a recent cardiac event or procedure frequently complains of decreased endurance for walking or climbing stairs, increased dyspnea during physical activity, and fatigue. If arrhythmia is present, the patient may feel palpitations. Chest pain may accompany physical exertion or emotional stress. Pain due to surgical incisions of the extremities or chest wall may also be present. Symptoms of heart failure, such as orthopnea and paroxysmal nocturnal dyspnea, may also be present. The person may feel anxious about any type of physical exercise, resumption of sexual activities, and return to work. In many cases, the patient may have symptoms suggesting depression, such as emotional lability, listlessness, poor sleep with frequent or early morning awakenings, and lack of interest in previously enjoyed activities.
Observation of the patient should look for signs of depression and anxiety. During the examination of the cardiac patient, the clinician will search for signs of complications after the cardiac event or cardiac procedure. Findings of congestive heart failure or fluid overload, such as dyspnea at rest, rales, decreased basilar lung sounds, pleural or pericardial rub, dependent edema, elevated jugular venous distention, or S 3 gallop, should be evaluated. Palpation of decreased or absent pulses in the extremities may suggest the common comorbidity of peripheral vascular disease. Wounds such as sternotomies, vascular harvest sites, chest tube insertion sites, pacemaker insertion sites, ventricular augmentation lead insertions, and arterial puncture sites should be carefully examined for appropriate healing or signs of infection before exercise programs are prescribed. Manual muscle testing of the extremities provides an indication of the degree of skeletal muscle weakness due to deconditioning and decreased physical activity. Observation of the patient should look for signs of undue dyspnea during standing and ambulation. The recently hospitalized patient should be able to at least walk at a slow comfortable cadence unless there is marked congestive heart failure or lung disease.
Common limitations after cardiac events are fatigue, limited endurance during walking and self-care, anxiety about having another cardiac event, more dyspnea with the same level of exertion, restrictions due to sternotomy, managing leads and lines associated with ventricular augmentation devices, and angina. Functional limitations due to cardiac disease alone are related to the workload the myocardium can sustain before signs of cardiac dysfunction result as well as those related to the procedures and devices themselves. This may manifest as inability to fully participate in the person’s accustomed manner at work, home, and the community. Housekeeping, home improvement projects, intimate relations, sport and recreational activities, and vocations requiring physical exertion may be too demanding on the heart.
The patient may later return to physically demanding activity, such as heavy labor or competitive tennis (both 8 metabolic equivalents, or METs), after rehabilitation that follows uncomplicated coronary angioplasty or stenting without myocardial infarction. However, for the patient who experienced myocardial infarction complicated by congestive heart failure and arrhythmia, the 3 to 5 METs required for walking to a neighbor’s home or performing the household chores may be limited by dyspnea.
Most patients with uncomplicated cardiac disease are able to ambulate and perform their self-care on discharge from the hospital. A slow stroll and being able to perform basic activities of daily living are not adequate for most individuals and do not predict excellent quality of life for the individual not referred to rehabilitation.
Emotional stress and an individual’s response to it may also produce functional limitations when return to social roles and responsibilities is considered. This may range from anxiety about physical exertion to major reactive depression. Dysfunction such as ischemia, arrhythmia, or even sudden death may be produced by emotional demands such as anxiety. This is likely to be due to increased sympathetic drive in the autonomic nervous system, which predisposes the individual to more endothelial damage and cardiac arrhythmias mediated by catecholamines.
A symptom-limited functional exercise test with a metabolic cart is administered 2 to 6 weeks after adequate time for healing and provides the best guide to exercise prescription, but is uncommonly performed. The specific timing of exercise testing depends on the amount of myocardium damage, the amount of time needed for healing of surgical sites, the need for return to work, and the practice pattern of the clinician administering the test. As opposed to commonly performed diagnostic exercise test protocols, such as the Bruce protocol, that seek to elicit cardiac symptoms, functional exercise testing documents work capacity and cardiopulmonary function. Functional exercise testing protocols start at a lower exercise intensity level than common diagnostic protocols do and increase fewer METs per stage. Treadmill testing following a ramp, modified Naughton, or Naughton-Balke protocol is especially well suited to guide cardiac rehabilitation exercise training because these protocols use smaller increments of intensity that more accurately portray functional capacity. Alternatively, bicycle ergometer protocols may also use smaller gradations of exercise intensity. Bicycle ergometry protocols should be considered for individuals with balance deficits, mild neurologic impairment, or orthopedic limitations.
Echocardiographic, pharmacologic, or nuclear medicine exercise stress testing should be considered for patients with marked lower extremity limitations, severe debility, or electrocardiograms that are difficult to interpret. Most patients have had many electrocardiograms during their hospital stay or evaluation. In the outpatient setting, electrocardiograms should be ordered if there is a change in clinical status, such as new symptoms (e.g., the resumption of angina). For the most part, patients are also monitored by telemetry during at least the initial part of their cardiac rehabilitation.
The clinician should evaluate the patient’s lipid profile to guide pharmacologic and dietary management of hyperlipidemia and hypercholesterolemia. Tight diabetes control may decrease the rate of atheroma formation, and glycosylated hemoglobin (HbA 1c ) level is used to ascertain the recent success of blood glucose control. Calculation of body mass index assists in targeting ideal body weight.
For the individual with dyspnea on exertion and the comorbidity of lung disease, pulmonary function testing will clarify the contribution of obstructive or restrictive lung disease to the symptoms. Treatable conditions, such as reactive airways and hypoxia during exercise, should be addressed before beginning of cardiac rehabilitation for maximal benefit. Combined ventilatory gas analysis by use of a metabolic cart and electrocardiographic monitoring may differentiate cardiac versus pulmonary exercise-induced dyspnea, chest pain, or fatigue. This may be especially useful in patients with congestive heart failure.
Patients should be screened for psychosocial stressors, such as anxiety and depression. Besides asking the patient about the symptoms of anxiety, anger, persistent sadness, excessive fatigue, and abnormal sleep architecture, commonly used questionnaires that are easy to administer in an office setting are the Beck Depression Inventory and the State-Trait Anxiety Inventory. Both take only a few minutes to complete and can be used to monitor the effectiveness of treatment.
Cardiac rehabilitation begins with risk factor reduction. Fully integrated cardiac rehabilitation programs enroll the individual into exercise training, dietary interventions, and psychosocial interventions. The referring physician then becomes the supporter of the patient, shifting the patient’s lifestyle to making responsible health choices. Each cardiac patient has choices about smoking, diet, exercise, and stress management. Smoking cessation has the highest rates of success by combining participation in a smoking cessation support group with pharmacologic management of the craving due to nicotine addiction. Bupropion combined with a nicotine patch, gum, or lozenges works well. Have the patient begin taking the bupropion hydrochloride (150 mg every day for the first 3 days, then 150 mg twice daily) 1 to 2 weeks before the chosen date to quit smoking and begin using the nicotine supplement at the time of smoking cessation. This should coincide with the first smoking cessation support group meeting.
Dietary modification has been documented to improve the lipid profile. Ask the patient to keep a food diary for at least 3 days to bring to the cardiac rehabilitation program or refer the patient to a registered dietitian for evaluation and education on appropriate heart-healthy dietary choices. The American Heart Association revised cardiac diet recommendations of 2006 are substantially more stringent on the saturated fat intake ( Table 123.1 ). The dietitian may recommend the American Heart Association diet, but other choices could be the Mediterranean diet or the lacto-ovovegetarian diet. None of these three diets has been shown to be superior, and the choice of diet is based primarily on the patient’s ability to follow the diet.
|Balance calorie intake and physical activity to achieve or maintain a healthy body weight.|
|Consume a diet rich in vegetables and fruits.|
|Choose whole-grain, high-fiber foods.|
|Consume fish, especially oily fish, at least twice a week.|
|Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to <300 mg/day by choosing lean meats and vegetable alternatives; selecting fat-free (skim), 1% fat, and low-fat dairy products; and minimizing intake of partially hydrogenated fats.|
|Minimize your intake of beverages and foods with added sugars.|
|Choose and prepare foods with little or no salt.|
|If you consume alcohol, do so in moderation.|
|When you eat food that is prepared outside of the home, follow the American Heart Association Diet and Lifestyle Recommendations.|