Cardiac rehabilitation

Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "The sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life".[1] CR is a comprehensive model of care including established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life while helping to reduce the risk of future heart problems.[2][3][4]

CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are very patient-centered.

Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology[5] and the European Society of Cardiology,[6] among other associations.[7] Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator).[8] CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies.[4]

CR Phases

Inpatient program (phase I)

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms and legs. Heart rate is monitored and continues being monitored as the patient begins to walk.[9]

Outpatient program (phase II)

It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, 4–6 weeks after cardiac surgery or the intervening 6-8 weeks after discharge from hospital.[10][3][11] In order to participate in an outpatient program, the patient generally must first obtain a physician's referral.[12] This period is often very difficult for patients due to fears of overexertion or a recurrence of heart issues.[13][3]

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipid measures, blood pressure, body composition, depression / anxiety, and tobacco use.[4] An exercise stress test is usually performed both to determine if exercise is safe and to allow for the development of a customized exercise program.[12]

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained Registered Nurse, Physiotherapist, or an exercise physiologist who works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.[12]

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered,[14] and it is well-established that the more the better.[15]

After CR is finished, there are long-term maintenance programs (phase III) available to interested patients,[16] as benefits are optimized with long-term adherence; unfortunately however patients generally have to pay out-of-pocket for these services.

Under-use

CR is significantly under-used globally.[17] Rates vary widely.[18]

Under-use is caused by multi-level factors. At the health system level, this includes lack of available programs.[19] At the provider level, there are low referral rates by physicians,[20] who often focus more attention on better reimbursed cardiac intervention procedures than on long-term lifestyle treatments.[21] At the patient level, factors such as transportation, distance, cost, competing responsibilities, lack of awareness and other health conditions are responsible,[22] but most can be mitigated.[23] Women,[24] ethnocultural minorities,[25][26] older patients,[27] those of lower socio-economic status, with comorbidities, and living in rural areas[28] are less likely to access CR, despite the fact that these patients often need it most.[29] Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.

Strategies are now established on how we can mitigate these barriers to CR use.[30] It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR.[31] It is also key for healthcare providers to promote CR to patients at the bedside.[32] The National Institute for Health and Care Excellence (NICE) offer helpful recommendations on encouraging patients to attend CR. Offering programs tailored to under-served groups such as women may also facilitate program adherence[33][34].

Benefits

Participation in cardiac rehabilitation may be associated with many benefits[35]. For acute coronary syndrome patients, cardiac rehabilitation reduces cardiovascular mortality by 25% and readmission rates by 20%.[36][37] The potential benefit in all-cause mortality is not as clear, however there is some evidence that cardiac rehabilitation may lead to significant reductions in all-cause mortality.[38]

Cardiac rehabilitation is associated with improved quality of life, improved psychosocial well-being, and functional capacity,[39] and is cost-effective.[40] In low and middle-income countries, there is some evidence that cardiac rehabilitation is effective at improving functional capacity, risk factors and quality of life robustly in these settings as well.[41]

There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same.[42] Home-based CR is generally safe[43].

Patients in cardiac rehabilitation may experience different benefits depending on the indication for referral. In people with cardiac valve problems, weak and limited evidence suggests that cardiac rehabilitation may improve exercise capacity.[44] For people who are heart transplant recipients, moderate quality evidence suggests that cardiac rehabilitation may be safe and improve exercise capacity, however, it may have no impact on the person's short-term health-related quality of life.[45]

There is moderate-quality evidence that CR participation increases physical activity levels in cardiovascular disease patients.[46] However, it is not effective in increasing physical activity in heart failure.[46] A range of potentially-effective physical activity interventions were evaluated in a review;[47] Exercise combined with behavioural change interventions was found to be effective in promoting physical activity in HF in the short-term. Indeed, CR is recommended as a quality standard for heart failure patients.[48]

CR Societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR. The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, ICCPR seeks to promote CR in low-resource settings, among other aims outlined in their Charter.[49]

References

  1. ↑ WHO Expert Committee on Rehabilitation after Cardiovascular Diseases, with Special Emphasis on Developing Countries. Rehabilitation after cardiovascular diseases, with special emphsis on developing countries : report of a WHO expert committee. Geneva. ISBN 9241208317. OCLC 28401958.
  2. ↑ Cowie A, Buckley J, Doherty P, Furze G, Hayward J, Hinton S, et al. (April 2019). "Standards and core components for cardiovascular disease prevention and rehabilitation". Heart. 105 (7): 510–515. doi:10.1136/heartjnl-2018-314206. PMC 6580752. PMID 30700518.
  3. 1 2 3 Shajrawi A, Granat M, Jones I, Astin F (November 2020). "Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study". The Journal of Nursing Research : JNR. 29 (1): e131. doi:10.1097/JNR.0000000000000408. PMC 7808357. PMID 33136697.
  4. 1 2 3 Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell N, Derman W, et al. (September 2016). "Cardiac rehabilitation delivery model for low-resource settings". Heart. 102 (18): 1449–55. doi:10.1136/heartjnl-2015-309209. PMC 5013107. PMID 27181874.
  5. ↑ Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. (November 2011). "AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation". Circulation. 124 (22): 2458–73. doi:10.1161/CIR.0b013e318235eb4d. PMID 22052934.
  6. ↑ Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. (August 2016). "2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)". European Heart Journal. 37 (29): 2315–2381. doi:10.1093/eurheartj/ehw106. PMC 4986030. PMID 27222591.
  7. ↑ Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, et al. (April 2017). "Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India". Indian Heart Journal. 69 (Suppl 1): S63–S97. doi:10.1016/j.ihj.2017.03.006. PMC 5388060. PMID 28400042.
  8. ↑ Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell NR, Derman W, et al. (2016-11-01). "Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement". Progress in Cardiovascular Diseases. Controversies in Hypertension. 59 (3): 303–322. doi:10.1016/j.pcad.2016.08.004. PMID 27542575.
  9. ↑ Zarret BL, Moser M, Cohen LS (1992). "Chapter 28" (PDF). Yale University School of Medicine Heart Book. Yale University School of Medicine. pp. 349–358 [351]. Retrieved 13 January 2012. Cardiac rehabilitation begins during hospitalization, not after discharge. Today’s heart-attack patient who is free of complications is likely to be up and about in a day or two.
  10. ↑ Zhang Y, Cao H, Jiang P, Tang H (February 2018). "Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study". Medicine. 97 (8): e9785. doi:10.1097/MD.0000000000009785. PMC 5841979. PMID 29465559.
  11. ↑ Dafoe W, Arthur H, Stokes H, Morrin L, Beaton L (September 2006). "Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation". The Canadian Journal of Cardiology. 22 (11): 905–11. doi:10.1016/s0828-282x(06)70309-9. PMC 2570237. PMID 16971975.
  12. 1 2 3 Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. (August 2019). "Nature of Cardiac Rehabilitation Around the Globe". EClinicalMedicine. 13: 46–56. doi:10.1016/j.eclinm.2019.06.006. PMC 6733999. PMID 31517262.
  13. ↑ Astin F, Closs SJ, McLenachan J, Hunter S, Priestley C (January 2009). "Primary angioplasty for heart attack: mismatch between expectations and reality?". Journal of Advanced Nursing. 65 (1): 72–83. doi:10.1111/j.1365-2648.2008.04836.x. PMID 19032516.
  14. ↑ Chaves G, Turk-Adawi K, Supervia M, Santiago de Araújo Pio C, Abu-Jeish AH, Mamataz T, et al. (January 2020). "Cardiac Rehabilitation Dose Around the World: Variation and Correlates". Circulation: Cardiovascular Quality and Outcomes. 13 (1): e005453. doi:10.1161/CIRCOUTCOMES.119.005453. PMID 31918580. S2CID 210133397.
  15. ↑ Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL (November 2017). "Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis". Mayo Clinic Proceedings. 92 (11): 1644–1659. doi:10.1016/j.mayocp.2017.07.019. hdl:10315/38072. PMID 29101934. S2CID 40193168.
  16. ↑ Chowdhury M, Heald FA, Sanchez-Delgado JC, Pakosh M, Jacome-Hortua AM, Grace SL (July 2021). "The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex". Heart & Lung. 50 (4): 504–524. doi:10.1016/j.hrtlng.2021.02.016. PMID 33836441.
  17. ↑ Santiago de Araújo Pio C, Beckie TM, Varnfield M, Sarrafzadegan N, Babu AS, Baidya S, et al. (January 2020). "Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement". International Journal of Cardiology. 298: 1–7. doi:10.1016/j.ijcard.2019.06.064. PMID 31405584.
  18. ↑ Grace SL, Kotseva K, Whooley MA (July 2021). "Cardiac Rehabilitation: Under-Utilized Globally". Current Cardiology Reports. 23 (9): 118. doi:10.1007/s11886-021-01543-x. PMID 34269894.
  19. ↑ Turk-Adawi K, Supervia M, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. (August 2019). "Cardiac Rehabilitation Availability and Density around the Globe". EClinicalMedicine. 13: 31–45. doi:10.1016/j.eclinm.2019.06.007. PMC 6737209. PMID 31517261.
  20. ↑ Ghisi GL, Polyzotis P, Oh P, Pakosh M, Grace SL (June 2013). "Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review". Clinical Cardiology. 36 (6): 323–35. doi:10.1002/clc.22126. PMC 3736151. PMID 23640785.
  21. ↑ Ghanbari-Firoozabadi M, Mirzaei M, Nasiriani K, Hemati M, Entezari J, Vafaeinasab M, Grace SL, Jafary H, Sadrbafghi SM (2020-01-01). "Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting". Rehabilitation Process and Outcome. 9: 1–7. doi:10.1177/1179572720936648. PMC 8282146.
  22. ↑ Shanmugasegaram S, Gagliese L, Oh P, Stewart DE, Brister SJ, Chan V, Grace SL (February 2012). "Psychometric validation of the cardiac rehabilitation barriers scale". Clinical Rehabilitation. 26 (2): 152–64. doi:10.1177/0269215511410579. PMC 3351783. PMID 21937522.
  23. ↑ Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL (February 2019). "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 2019 (2): CD007131. doi:10.1002/14651858.CD007131.pub4. PMC 6360920. PMID 30706942.
  24. ↑ Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ (July 2014). "Sex differences in cardiac rehabilitation enrollment: a meta-analysis". The Canadian Journal of Cardiology. 30 (7): 793–800. doi:10.1016/j.cjca.2013.11.007. PMID 24726052.
  25. ↑ Midence L, Mola A, Terzic CM, Thomas RJ, Grace SL (November–December 2014). "Ethnocultural diversity in cardiac rehabilitation". Journal of Cardiopulmonary Rehabilitation and Prevention. 34 (6): 437–44. doi:10.1097/HCR.0000000000000089. PMID 25357126.
  26. ↑ Koehler AN, Hodgson JL, et al. (September 2016). "Biopsychosocial-Spiritual Factors Impacting African American Patients' Cardiac Rehabilitation Referral and Participation". Journal of Cardiopulmonary Rehabilitation and Prevention. 36 (5): 320–330. doi:10.1097/HCR.0000000000000183. PMID 27496250. S2CID 10829735.
  27. ↑ Grace SL, Shanmugasegaram S, Gravely-Witte S, Brual J, Suskin N, Stewart DE (2009). "Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE?". Journal of Cardiopulmonary Rehabilitation and Prevention. 29 (3): 183–7. doi:10.1097/HCR.0b013e3181a3333c. PMC 2928243. PMID 19471138.
  28. ↑ Leung YW, Brual J, Macpherson A, Grace SL (November 2010). "Geographic issues in cardiac rehabilitation utilization: a narrative review". Health & Place. 16 (6): 1196–205. doi:10.1016/j.healthplace.2010.08.004. PMC 4474644. PMID 20724208.
  29. ↑ Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, Bossano Prescott EI, González-Juanatey JR (November 2016). "Participation and adherence to cardiac rehabilitation programs. A systematic review". International Journal of Cardiology. 223: 436–443. doi:10.1016/j.ijcard.2016.08.120. PMID 27557484.
  30. ↑ Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL (February 2019). "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 2019 (2): CD007131. doi:10.1002/14651858.cd007131.pub4. PMC 6360920. PMID 30706942.
  31. ↑ Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, et al. (February 2011). "Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study". Archives of Internal Medicine. 171 (3): 235–41. doi:10.1001/archinternmed.2010.501. PMID 21325114.
  32. ↑ Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL (August 2020). "Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course". BMC Health Services Research. 20 (1): 768. doi:10.1186/s12913-020-05619-2. PMC 7439558. PMID 32819388.
  33. ↑ Mamataz T, Ghisi GL, Pakosh M, Grace SL (2022-06-01). "Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis". Maturitas. 160: 32–60. doi:10.1016/j.maturitas.2022.01.008. ISSN 0378-5122.
  34. ↑ Mamataz T, Ghisi GL, Pakosh M, Grace SL (September 2021). "Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review". BMC Cardiovascular Disorders. 21 (1): 459. doi:10.1186/s12872-021-02267-0. PMC 8458788. PMID 34556036.
  35. ↑ Taylor RS, Dalal HM, McDonagh ST (September 2021). "The role of cardiac rehabilitation in improving cardiovascular outcomes". Nature Reviews. Cardiology: 1–15. doi:10.1038/s41569-021-00611-7. PMID 34531576.
  36. ↑ Anderson L, Taylor RS (December 2014). "Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews". The Cochrane Database of Systematic Reviews (12): CD011273. doi:10.1002/14651858.CD011273.pub2. hdl:10871/19152. PMC 7087435. PMID 25503364.
  37. ↑ Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. (June 2017). "Home-based versus centre-based cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 6: CD007130. doi:10.1002/14651858.CD007130.pub4. PMC 4160096. PMID 28665511.
  38. ↑ Kabboul NN, Tomlinson G, Francis TA, Grace SL, Chaves G, Rac V, et al. (December 2018). "Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis". Journal of Clinical Medicine. 7 (12): 514. doi:10.3390/jcm7120514. PMC 6306907. PMID 30518047.
  39. ↑ Francis T, Kabboul N, Rac V, Mitsakakis N, Pechlivanoglou P, Bielecki J, et al. (March 2019). "The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis". The Canadian Journal of Cardiology. 35 (3): 352–364. doi:10.1016/j.cjca.2018.11.013. PMID 30825955.
  40. ↑ Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM (September 2018). "Cost-effectiveness of cardiac rehabilitation: a systematic review". Heart. 104 (17): 1403–1410. doi:10.1136/heartjnl-2017-312809. PMC 6109236. PMID 29654096.
  41. ↑ "Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials". Progress in Cardiovascular Diseases. 2021-07-13. doi:10.1016/j.pcad.2021.07.004. ISSN 0033-0620.
  42. ↑ Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. (June 2017). "Home-based versus centre-based cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 6 (6): CD007130. doi:10.1002/14651858.CD007130.pub4. PMC 6481471. PMID 28665511.
  43. ↑ Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. (July 2019). "Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology". Circulation. 140 (1): e69–e89. doi:10.1161/CIR.0000000000000663. PMID 31082266.
  44. ↑ Abraham LN, Sibilitz KL, Berg SK, Tang LH, Risom SS, Lindschou J, et al. (May 2021). "Exercise-based cardiac rehabilitation for adults after heart valve surgery". The Cochrane Database of Systematic Reviews. 5: CD010876. doi:10.1002/14651858.CD010876.pub3. PMC 8105032. PMID 33962483.
  45. ↑ Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS (April 2017). "Exercise-based cardiac rehabilitation in heart transplant recipients". The Cochrane Database of Systematic Reviews. 4 (4): CD012264. doi:10.1002/14651858.CD012264.pub2. PMC 6478176. PMID 28375548.
  46. 1 2 Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M (September 2018). "Cardiac rehabilitation and physical activity: systematic review and meta-analysis". Heart. 104 (17): 1394–1402. doi:10.1136/heartjnl-2017-312832. PMC 6109237. PMID 29654095.
  47. ↑ Amirova A, Fteropoulli T, Williams P, Haddad M (June 2021). "Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis". Open Heart. 8 (1): e001687. doi:10.1136/openhrt-2021-001687. PMC 8191629. PMID 34108272.
  48. ↑ "Quality statement 6: Programme of cardiac rehabilitation | Chronic heart failure in adults | Quality standards | NICE". www.nice.org.uk. Retrieved 2021-08-04.
  49. ↑ Grace SL, Warburton DR, Stone JA, Sanderson BK, Oldridge N, Jones J, et al. (March–April 2013). "International Charter on Cardiovascular Prevention and Rehabilitation: a call for action". Journal of Cardiopulmonary Rehabilitation and Prevention. 33 (2): 128–31. doi:10.1097/HCR.0b013e318284ec82. PMC 4559455. PMID 23399847.
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