Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada
Cardiovascular disease is a broad term that is used to describe diseases of the structure and function of the heart.(1). Atherosclerotic diseases of the cardiac and vascular systems, electrophysiological abnormalities, infections and defects are alluded to within this framework. When we speak of cardiovascular disease we include coronary artery disease, peripheral artery disease, valvular disease, congestive heart failure, cardiomyopathy and congenital heart defects. Coronary artery disease is the most prevalent type which consists of plaque build up inside coronary arteries that then blocks oxygen rich blood from reaching the heart. PAD or peripheral artery disease is the build up of plaque within the arteries in the lower limbs. Damage to one of the four valves in the heart is called valvular heart disease. This type of disease can be present at birth or later on in life and accounts for approximately 1% of all cardiovascular deaths. Congestive Heart Failure is an increasing heart disease. CHF means the heart cannot pump sufficient blood to meet the demands of the body. Currently 600,000 Canadians are living with congestive Heart Failure. Cardiomyopathy is typically inherited or acquired later and refers to diseases of the heart muscle. There are four types of CM: dilated CM, hypertrophic CM, restrictive CM and arrhythmogenic right ventricular dysplasia. Congenital heart defects are characterized by abnormalities or malformations that develop before birth. These can include structural problems of heart chambers, valves and blood vessels near the heart.
Patients with cardiovascular disease have decreased functional ability, increased morbidity and mortality rates, and increased hospitalizations post diagnosis. About 2.4 million Canadian aged 20 years and older live with ischemic heart disease. Heart disease is also the second leading cause of death in Canada, claiming more than 48,000 lives in 2012. The good news is that cardiovascular disease (CVD) deaths have decreased. In 2004 CVD was the leading cause of death of Canadians involving 72,743 deaths or 32% of all deaths. (2) Seven years later in 2011, heart disease and stroke accounted for 46,852 deaths or 20% of all deaths. (3) Costs in treating cardiovascular disease is both expensive and rising. In 2008 the costs for cardiovascular disease was $12 billion dollars. This compares to heart disease cost of$297.7 billion in the United States in 2008 and $312.6 billion dollars in 2009.
Reducing Costs by Decreasing Hospitalization, Morbidity and Mortality through
Cardiovascular disease (CVD) is the leading cause of death and disability for men and women in North America. Although substantial health risks continue following coronary interventions, secondary prevention efforts have beneficial effects on mortality and morbidity. In addition to physiological factors, psychosocial and socio-demographic factors affect the recovery from heart attacks (Myocardial Infarction), unstable angina and other coronary events.(4) Cardiac Rehabilitation reduces the risk of a future cardiac event by stabilizing, slowing or reversing the progression of cardiovascular disease. Patients with other cardiovascular disease including valve repair, congestive heart failure, cardiomyopathy and congenital heart disease also benefit from a cardiac rehabilitation program.(5) (6). Cardiac Rehabilitation typically includes a medical and exercise assessment, an exercise prescription, education on heart health issues including identifying and managing risk factors, symptom management, psychological counselling, vocational rehab and or pharmacological treatment. The goals of cardiac rehabilitation include promoting secondary prevention and improving the quality of life for individuals with heart disease. Cardiac Rehabilitation is a medically supervised program consisting of exercise training, education on heart healthy living, counselling on reducing stress and individual assistance in returning to an active lifestyle including return to work. Cardiac Rehabilitation is offered to individuals with the following conditions (7):
- Recent heart attack( Myocardial Infarction)
- Percutaneous coronary intervention
- Coronary Artery Bypass grafting
- Chronic stable angina
- Heart failure
- Cardiac Transplantation
- Valvular disease
- Anyone with three risk factors for Coronary artery disease. This was approved for Women through Women’s College Hospital Cardiac Rehab program but we think is universally available throughout Ontario
Benefits of Cardiac Rehabilitation Programs include:
- A 20 to 30% reduction in all-cause mortality rates. An Ontario study demonstrated that Cardiac Rehab participation was associated with a 50% lower mortality rate than those who did not particpate(8)
- An Alberta study demonstrated that participating in Cardiac Rehab lowers risk of death, hospitalization and cardiac hospitalization by 31 to 51%.
- Decreased mortality at up to 5years post participation
- Reduced symptoms of angina, dyspnoea(difficulty breathing) and fatigue
- Reduction in nonfatal myocardial infarction over a follow up of 12 months
- Improved adherence with preventive medications
- Increased exercise performance, oxygen levels
- Improved health factors including lipids (LDL-C, HDL-C, Triglycerides)
- Increased knowledge about cardiac disease and its management
- Increased ability to perform daily living activities
- Improved health related quality of life
- Improved psychosocial symptoms including reduced levels of anxiety and depression
- Reduced hospitalizations and medical resources
- Increased ability to return to work or engage in leisure activities
- Cardiac Rehabilitation has been shown to be both cost effective and a good value for money (8)
Problems with referral and participation rates in Cardiac Rehabilitation Programs
Despite the above mentioned benefits, referrals and participation rates for cardiac rehabilitation programs remain low. These rates range from a low of 14% (9) for a Medicare study of those eligible to a recent high of 50% (10) as reported by the British Heart Foundation in its National Audit of Cardiac Rehabilitation Annual Statistical Report 2016. In a 2012 United States national study of 884 Cardiac Rehabilitation Programs it was found that only 28% of patients with indications for CR were served. In a 2016 report on home based cardiac rehab programs for Veterans it was found that from 2000 to 2007 56% of Medicare patients hospitalized for CABG or MI was referred for cardiac rehab. This compares to between 73 to 81% of patients being referred from 2007 to 2012. However the actual participation rate of both groups was less than 20%. (11) In Canada we do not have a National Referral or usage rate. In 1999 an Ontario wide Cardiac Rehab Pilot study was undertaken showing that 22% of eligible patients attend a cardiac rehab program. In New Brunswick an evaluation of cardiac rehabilitation use in 2005/2006 revealed that only 8.8% of eligible patients attended cardiac rehabilitation. A regional analysis in Alberta showed that of those referred to cardiac rehab 50% completed the program, with 40% not attending and 10% who did not complete the program. (12) In a more recent analysis in Ontario it was revealed that 52% of patients who have had revascularization are referred to cardiac rehab programs. This compares to 39% of Albertans who have had cardiac catheterization being referred to cardiac rehabilitation programs. Before exploring reasons for non referral to cardiac rehab programs, the reader should be aware that in Ontario even if we do increase referrals we simply do not have sufficient space to accommodate these added numbers. This is primarily due to lack of funding and consequently lack of capacity. In Canada this same paper revealed that we only have capacity for 34% of revascularization patients and in the 2012 United States study the US capacity was 37%.
In reviewing this discussion, we know from other outcome and cost effectiveness studies that Cardiac Rehabilitation is both effective and cost effective and we also know that it has value. In responding to the outcome studies on efficacy and cost effectiveness of cardiac rehabilitation programs, the National Societies in Canada, Great Britain and the United States have set 85% as the target rate to be achieved for referrals to cardiac rehab of those who are eligible. In achieving this most provinces now have an automatic referral system whereby patients are referred to cardiac rehab before they leave hospital.
The question which needs to be answered is why have referrals to cardiac rehab programs been problematic? Firstly we know that Family Physicians just do not refer individuals to cardiac rehabilitation. Secondly we know that women, minorities, individuals living with lower socioeconomic income levels and those who are older simply do not get referred, nor do they attend. We also know from recent studies that transportation costs, time to attend and a need to either take care of family responsibilities including a return to work act as barriers for individuals attending and or completing cardiac rehabilitation programs.
Given this information, what can we do to both expand cardiac rehab programs and increase referrals and participation in these programs?
The answer might be a combination of strategies and could include home based cardiac rehabilitation programs.
We do know that Home Based cardiac rehab programming has been introduced in Canada, the United States and Great Britain. In a recent study by Grace et al, in Ontario we know that 70% of existing cardiac rehab programs offer home-based cardiac rehabilitation programs. The question is how effective are these and do these become one of the ways for increasing patient referrals and completion rates for cardiac rehabilitation?
Effectiveness of Home Based Cardiac Rehabilitation Programs
In Great Britain, United States and in Canada the Heart Manual developed in Scotland and adopted by the British Heart Foundation has been utilized to deliver home based cardiac rehab programming. The services delivered at home usually begin with a hospital based program medical and exercise capacity assessment. The individual is then provided with an exercise prescription and an accompanying workbook from which to begin their home based cardiac rehabilitation program. By using telehealth/internet based care systems individual’s monitor and provide BP readings, pulse rate and maximum heart rate levels achieved. Other risk factors monitored include Lipid levels, blood glucose levels and potentially creatinine levels. Depending on the program oxygen levels may also be recorded. The exercise sessions are supplemented with education on heart health, nutrition, managing and reducing risk factors, medication compliance and psychosocial counselling. Motivational counselling strategies including goal setting are also components of the program. Follow up is maintained either through skype, or by having a public health nurse visit or call the home for follow up. The delivery of these home based programs is different depending on the country or region delivering the program. The United States uses telehealth/internet based services with patient workbooks. In Ontario another home based system called CardioFit was developed with tutorials on fitness, nutrition, and risk factor management.
The Office of Veterans Affairs in the United States has just launched a home based cardiac rehab program which has the following components (M. Whooley M.D.):
- An automatic referral for eligible patients post CABG or post PCI
- Bedside visit by cardiac rehabilitation nurse
- Exercise prescription and physical activity monitoring
- Motivational interviewing and goal setting
- Provision of home based exercise equipment if needed
- Medication reconciliation and tracking
- Nutrition and weight management
- Stress reduction ( including peer group support calls)
- Risk factor management (blood pressure, lipids, smoking)
Benefits of Home Based Cardiac Rehab Programs include:
- No wait list or capacity issues to contend with
- Customizable and individually tailored
- Flexible scheduling
- No travel expenses/ transportation issues
- Greater privacy
- Somewhat lower cost
- Integrated with patients home routine
- Greater adherence and sustainability
How Effective are these Home Based Programs?
Although home based cardiac rehab programs were recommended as long ago as 1983 they were not available until 1998. At that time the Heart Manual which was the most widely researched document provided the means from which to train facilitators and launch home based cardiac rehab. The Heart Manual was initially developed in Scotland in the 1980’s. Recent systematic reviews have found that home-based cardiac rehab programs are just as effective as hospital based programs.(Dalal MD et al) The most recent Cochrane Library review in 2015, issue 8 found that in a review of 12 controlled randomized studies involving 2,000 patients of hospital based CR programs versus home-based CR programs concluded “ Home and centre based cardiac rehabilitation appears equally effective in improving the clinical and health related quality of life outcomes in acute myocardial infarction and revascularization patients”. In Mary Whooley MD’s presentation to the Veterans Affairs she provided the following quote “ Home and Center based forms of cardiac rehabilitation seem to be equally effective for improving clinical and health related quality of life outcomes. This finding supports continued expansion of Home based programs”. In the Birmingham Rehabilitation Uptake Maximisation (BRUM) study found that adherence rates of home based participants was 96.1% compared to hospital based participants who had a 56.1% adherence rate. This study found that home based cardiac rehab appears to be more effective in maintenance of physical fitness than hospital based programs. Current evidence also suggests that home-based programs in a variety of forms are effective in reducing hospital re-admissions and of patients admitted stays are of shorter duration. The Cochrane review, supports the BRUM and Cornwall Heart Attack Rehabilitation Management Study( CHARMS) which found no significant difference between home based and hospital based cardiac rehab programs on mortality, cardiac events, exercise capacity, modifiable risk factors, blood pressure, total cholesterol and health related quality of life.(J. Blair et al). Thus the evidence suggests that home based cardiac rehab can be both safe and effective for those patients who find that they cannot attend hospital based programs.
This finding should be part of a larger strategy for expanding participation in cardiovascular rehabilitation programs in Canada. We need to increase participation for women, visible minorities including those population subgroups that are at high risk for cardiovascular disease. We need to lobby the Provinces and Territories to expand and fund cardiac rehab programs appropriately. We have a proven method that is cost effective in extending the Lives of Canadians affected Heart Disease. It’s time to both alert your MPP’s and to actively advocate for this service.
- Tameler, Whitney, University of Montana “Cardiac Rehabilitation Enrolment Rates and Different Referral Strategies”(2014) Theses, Dissertations, Professional Papers. Paper 4283
- Public Health Agency of Canada, 2009 “Tracking Heart Disease and Stroke In Canada” http://www.phac-aspc.gc.ca/publicat/2009/cvd-avc/report-rapport-eng.php
- Government of Canada, “Heart Disease In Canada in Canada” Public Health Agency of Canada February 2017. https://www.canada.ca/content/canadasite/en/public-health/services/publications/diseases-conditions/heart-disease-canada.html
- Stephens, Mark Captain MC, USN 2009, Cardiac Rehabilitation American Family Physician Nov 2009 http://www.aafp.org/afp/2009/1101/p955.html
- 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
- Blair J, Corrigall H, Angus NJ, Thompson DR, Leslie S. 2011 “Home Versus Hospital Based Cardiac Rehabilitation: a Systematic Review, Rural and Remote Health 11:1532. http://www.rrh.org.au
- American Heart Association, “Facts Cardiac Rehabilitation: Putting more patients on the road to recovery http://www.heart.org/policyfactsheets
- Grace Sherry L.PhD., Truk-Adawi Karam PhD., Santiago De AraujoPio Carolina PT, MSc. , Alter David A. MD, PhD. “Ensuring cardiac Rehabilitation Access for the majority of those in need: A call to Action for Canadians” Canadian Journal of Cardiology 32 (2016) S358-S364 http://dx.doi.org/10.1016/j.cjca.2016.07.001
- American Heart Association, “Facts Cardiac Rehabilitation: Putting more patients on the road to recovery http://www.heart.org/policyfactsheets
- British Heart Foundation 2016 “The National Audit of Cardiac Rehabilitation : Annual Statistical Report 2016 http://www.bhf.org.uk
- Whooley Mary, MD, FACP, FAHA, FACC, University of California, San Francisco May 10th 2016; “ Delivering Home based Cardiac rehabilitation to Veterans; Department of Veteran Affairs United States
- Grace Sherry L PhD, Abbey Susan E PhD, Shnek Zachary M PhD, Irvine Jane PhD, Franche Renee-Louise PhD, Stewart Donna E. PhD, Cardiac Rehabilitation II: Referral and Participation
- Dalal Hasnain M, Zawada Anna , Jolly Kate, Moxham Tiffany, Taylor Rod S, “Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis BMJ 2010;340:b5631 doi:10.1136/bmj.b5631 Online First/ bmj.com
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.