DID YOU KNOW...
Cardiac Rehabilitation Programs Have Many Benefits?

Written by: John A. Sawdon, Public Education & Special Projects Director

Cardiac Rehabilitation programs have been promoted as aides in enhancing recovery following acute cardiac events while encouraging lifestyle behaviour change aimed at the secondary prevention of coronary artery disease. The Canadian Association of Cardiovascular Prevention and Rehabilitation (CACPR) has defined Cardiac rehabilitation as “the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status. This process includes the facilitation and delivery of secondary prevention through heart hazard (risk factor) identification and modification in an effort to prevent disease progression and the recurrence of cardiac events.” (1)

Cardiac rehabilitation has evolved over the years from a simple monitoring for safe return to physical activities to a multidisciplinary approach that focuses on patient education, individually tailored exercise training, modification of the risk factors and overall well being of the cardiac patients. This shift from a single focus on physical exercise to a multi disciplinary program including post operative individual care, the optimization of medical treatment, nutrition

counselling, smoking cessation, risk stratification, stress management, hypertension management, and control of diabetes or dyslipidemia( abnormal lipids in the blood) has had far reaching effects. It has proven itself as an effective tool in the care of patients with heart disease. Recent research in cardiac rehabilitation in individuals with various cardiac pathologies including ischemic heart disease (blockage of the arteries), heart failure (usually problems with enlarged heart muscle or ventricles), and post heart surgery have all shown to be effective.

The shift to secondary prevention relies on the early detection of the disease process and the application of interventions to prevent the progression of the disease. These interventions include education, counselling and behavioural strategies to promote lifestyle change and modification of risk factors. Clinical trials have proven that strategies for the early detection and the modification of the risk factors can slow, stabilize and even modestly reverse the progression of atherosclerosis and reduce future cardiovascular events. (2)

The World Health Organization offers a definition of cardiac rehabilitation that summarizes the objectives of this definition as follows: ‘The sum of activities required to influence favourably the underlying cause of the disease, as well as to ensure the individual the best possible physical, mental and social conditions, so that they may, by their own efforts, preserve or resume when lost, as normal a place as possible in the life of the community (1993).” (3)

The benefits of cardiac rehabilitation and exercise training include:

  • In a study of 601,099 Medicare participants who were hospitalized for coronary conditions when comparing those who attended cardiac rehab with those who did not found a reduction of mortality from 21% to 34%. (4)
  • Patients who attended 36 sessions ( usually 3 sessions a week for 12 weeks) had a 47% lower risk of mortality and a 31% lower risk of heart attack compared to those who only attended 1 session
  • A study from Alberta demonstrated that participation in a cardiac rehab program lowers risk of death, hospitalization and cardiac hospitalization by 31 to 51%. Additionally an Ontario study demonstrated that cardiac rehab participation was associated with a 50% lower mortality rate when compared to population matched controls (5)
  • Reduction in frequency and severity of angina as well as increased functional capacity in heart failure
  • Regular physical activity improves HDL-cholesterol by 17%, decreases LDL-C by 11%, decreases visceral fat and reduces glycemia as well as blood pressure, There is evidence to suggest that women completing cardiac Rehab programs experience greater improvements in HDL-C.
  • Therapeutic education is aimed at controlling modifiable risk factors through smoking cessation ( a 16 to 25% reduction), the optimization of medication for blood pressure, diabetes and cholesterol control. The overall mortality risk for smokers who quit decreases by 50% in the first two years and approximate non-smokers within 5 to 15 years of cessation
  • Psychiatric troubles like anxiety and depression are quite frequent following coronary events and are associated with lower exercise capacity, fatigue and a reduced quality of life and sense of wellbeing. Individuals in cardiac rehab learn stress management and other self-control tools which in turn affect the control of risk factors. In a study of 522 patients there was a 30% mortality rate in depressed subjects compared to 8% for those who chose to participate in cardiac rehab. Furthermore those who did not improve peak Vo2 after cardiac rehab had a higher prevalence of depression and mortality risk.
  • In Heart failure patients the findings were even more startling with 59% of patients completing cardiac rehab having lower mortality compared to heart failure subjects who did not complete Cardiac rehab
  • Individuals with peripheral artery disease (PAD) benefit from individualized exercise training programs since PAD often co-exists with coronary artery disease. 50% of individuals with PAD have coronary artery disease and 33% of individuals with coronary artery disease have co-existing PAD
  • A reduction in inflammation, ischemic preconditioning, improved endothelial function
  • Those who attend at least 25 sessions have an improved mortality rate by 25% compared to those attend less than 25 times
  • Reduces the chance of individuals going back to hospital for cardiovascular disease
  • Improved quality of Life in returning to work, taking part in social activities and exercise.

With such impressive results we would expect that referral rates to and participation rates of cardiac rehab programs would be high. Unfortunately this is not the case. Referral rates have been as low as 12% along with high drop out rates. Much of this is related to poor Family Physician referral rates and psycho-social pressures including economics. Women, the poor, ethno-racial populations are referred less often than white males. Additionally transportation costs and geographical distances often play a role in limiting involvement in programs. The United Kingdom, Australia and the United States have all taken steps to increase referrals to cardiac rehab programs. In future Did You Know articles we will look at what needs to occur to increase both referrals and completion rates for cardiac rehab programs in Canada (6)

The next section is written for those of you who are fortunate enough to either be referred or are contemplating attending a cardiac rehab program.

Individuals who are referred to and attend a cardiac rehab program often arrive with some trepidation, hope and inquisitiveness. Hopefully their Family Doctor has filled out the application form , provided a quick overview of the program that should help them recover from their particular heart procedure or in addressing the risk factors that place this person at risk of cardiovascular disease and potential heart attack. The first meeting usually involves a stress test and an electrocardiogram (EKG), followed by blood pressure and oxygen levels. This test allows the cardiologist to prescribe the starting exercise regimen along with identifying the schedule for the individual to follow. Some programs offer cardiac rehab three times a week for an hour for 8 weeks while others offer one day a week for six months and still others offer twice a week for three months. During the exercise portion individuals may be on a tread mill, coupled with a bike which has handles for moving the arms while peddling or still others may be assigned to a rowing machine. During the activity blood pressure and oxygen levels are constantly monitored and recorded. Additionally some may use heart monitor holster which is worn for 24 to 48 hours in monitoring the heart rate and rhythm of the heart. In addition to individual counselling individuals are encouraged to develop a support network amongst the other members who are attending the cardiac rehab program with them. Some programs may include special events to promote networking such as golfing and or family sessions on nutrition along with cardiac rehab members.

All cardiac rehab programs offer nutrition counselling focusing on sodium intake, cholesterol and trans-fats. Smoking cessations are also available and symptom management sessions are also scheduled. Most cardiac rehab programs also utilize goal setting, stages of change and motivational interviewing in facilitating individual buy in and motivation to continue program and to maintain the changes after the program ends. The drop out rate is much higher for women which are due to the psycho social pressures that occur within a care givers role. Additional pressures contributing to dropping out of cardiac rehab programs include transportation costs or non existent transportation. Time and family pressures that resist change can also lead to dropping out of the cardiac rehab program. The benefits of cardiac rehabilitation come with being able to move freely without pain and discomfort. This early relief provides a base of motivation to continue the program. With these early gains additional benefits including increased lung capacity emerges that affects the emotional outlook and wellbeing of the individual. These incremental gains are usually visible and become the motivators themselves for continuing. Once the program is over the individual may continue but will have to pay a fee that is similar in amount to joining a gym. For those who can attend this program it addresses the frequent feeling of vulnerability that individuals experience who have had heart attacks or have had major interventions such as bypass surgery or valve replacement surgery. This sense of vulnerability emerges from the shaken confidence and belief “That if it happened once, it could happen again".

Cardiac Rehabilitation offers hope, promotes lifestyle change and reduces both hospitalization and mortality. We encourage everyone to get a referral from your Family Doctor or a walk in clinic in gaining the benefits of a program that offers hope. The benefits of these programs include fewer complications, greater confidence, increased vocational pursuits along with increased energy, and fitness capacity. If you have coronary heart disease, heart failure or have 3 risk factors for heart disease, discuss a referral with your Doctor. You will not be disappointed.

References:

  1. Brown A. , Noorani H. , Taylor R, Stone J., Skidmore B., “ A comprehensive and economic review of exercise based cardiac rehabilitation programs for coronary artery disease” Ottawa: Canadian Coordianting Office for Health Technology Assessment 2003. Technology Overview No.11 www.ccohta.ca ISBN 1203-9012
  2. Menzies Arthur R., Lavie Carl J., Milani Richard V., Forman Danile E., King Marjorie, William Mark A., “ Cardiac Rehabilitation in the United States, Progress in Cardiovascular Diseases 56 (2014) 522-529 http://dx.doi.org/10.1016/j.pcad.2013
  3. Zwislen Ann-Dorthe O., SchouLone, Sorensen Lotle V., “Cardiac Rehabilitation Rationale, Methods and Exeperince from Bisebjerg Hospital 2004 www.cardiacrehabilitation.dk.
  4. Menzies Arthur R. MD, Lavie Carl J. MD, DeSchutter Alban MD, Milani Richard V. MD< Gender, Race and Cardiac Rehabilitation in the United States: Is there a Difference In Care? American Journal of Medical Sciences Volume 0, Number 0, Month 2014
  5. Grace Sherry L., Bennett Stephanie, Arden Chris I., Clark Alexander M., Cardiac Rehabilitation Series: Canada http://dx.doi.org/10.1016.j.pcad.2013.09.010
  6. Alter David A., Oh Paul I., Chong Alice “ Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system” European Journal of cardiovascular Prevention & Rehabilitation 2009 16:102 http://cpr.sagepub.com/content/16/1/102
  7. Hughes Sue July 28th 2011 Cardiac Rehabilitation: What works, what doesn’t and why http://www.medscape.com/viewarticle/790982_print
  8. Silberman A., Banthia R., Estay IS., KempC., StudleyJ., Hareras D., Ornish D., “The Effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites American Journal Health Promotion 2010 Mar-April:24(4): 260-6.doi:10.4278/ajhp.24.4arb http://www.ncbi.nlm.nih.gov/pubmed/20232608
  9. Anderson Lindsey PhD, Oldridge Neil PhD, Thompson David R. Zwisler Ann-Dorthe MD, Rees Karen PhD., Martin Nicole MA., Taylor Rod S. PhD. “Exercise-Based Cardiac rehabilitation for Coronary heart Disease Cochrane Systematic Review and Meta-Analysis http://content.onlinejacc.org/ by Carl Lavie on 01/04/2016

The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.