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Definition

Cardiac rehabilitation is a multi-disciplinary treatment and secondary prevention program for patients with various cardiac disorders, including recovery from heart attack and bypass surgery, which includes exercise, education, counseling, and lifestyle changes to help the patient return to previous levels of health and functioning and prevent recurrence of cardiac problems.

Purpose

The purpose of cardiac rehabilitation is to provide comprehensive, multifaceted treatment, education, and secondary prevention for cardiac patients and individuals with heart disease risk factors, in order to aid recovery and prevent recurrence of heart problems. Cardiac rehabilitation programs can improve quality of life, help patients return to their previous level of functioning in work and daily life, increase fitness, facilitate heart-healthy behavior changes and management of risk factors, and reduce costs by decreasing frequency and expense of hospital stays.

Precautions

Exercise, or certain kinds of exercise, may be contraindicated in the presence of some medical conditions. Conditions included are acute heart failure, angina at rest, second or third degree heart block, excessively low or high blood pressure, orthopedic problems, continued ischemia, aortic stenosis or mitral valve disease, or other health conditions in addition to the cardiac disorder. Exercise might also need to be discontinued if certain problems or symptoms such as the following occur: failure of monitoring equipment, lightheadedness, confusion, nausea, angina that occurs while exercising, excessive rise in blood pressure, or unusual heart rate. In addition, certain precautions may be taken before any cardiac patient begins an exercise program or session. Some of these include recording heart rate, blood pressure, and cardiac rhythm at each supervised session, and educating the patient in how to prepare for the exercises (proper breathing, dressing appropriately, avoiding smoking, etc.). Any preexisting medical conditions should also be taken into consideration when planning exercise treatments.

Description

Cardiac rehabilitation is a comprehensive, multidisciplinary approach to treatment and secondary prevention

for patients with various forms of cardiac disorders, such as post myocardial infarction (heart attack), bypass surgery, chronic stable angina pectoris, and heart transplant. It involves a cardiac rehabilitation team, which can be comprised of primary care and specialty physicians, nurses, physical therapists, exercise physiologists, occupational therapists, mental health professionals and dieticians. The physician may choose to participate in various roles, or refer patients to physical therapists and other practitioners or hospital departments.

A specially qualified physical therapist or RN may provide or direct cardiac rehabilitation services. At least one member of the physical therapy department or other team of practitioners in charge should be ACLS (Advanced Cardiac Life Support) certified, and a cardiopulmonary specialist should be included. The ACLS certification, which can be obtained during a one-day training course provided by the American Heart Association, is a level higher than CPR, and allows the practitioner to perform intubation and use a defibrillator.

Cardiac rehabilitation can be broken into three phases. Phase I, inpatient treatment in a hospital, can begin as early as 24 hours after a cardiovascular event. Phase II, outpatient treatment, can take place at the hospital, in a community center, in a medical center, or at the patient's home or place of employment. Phase III, referred to as the secondary prevention or maintenance phase, is performed more independently by the patient, with the goal of maintaining benefits and preventing further cardiac problems. An individual patient may participate in cardiac rehabilitation for a few weeks, six months, or longer. Many programs are conducted in groups, but the exercise prescription and other facets of treatment are individually designed to meet the specific medical needs and preferences of each patient.

The main components of a cardiac rehabilitation program are exercise, education, counseling, and behavior modification. Physical therapists may play a large part in the exercise component, as well as some aspects of patient education. Some of the goals of exercise are to restore or improve fitness, increase exercise tolerance and functional capacity, regain levels of functioning equivalent to those prior to the disease or surgery, and improve confidence and mood. Exercise and education by a physical therapist or other qualified practitioner can also help the patient manage and improve other risk factors and associated conditions such as diabetes, obesity, high blood lipids (fats), and stress. Inactivity itself is now recognized as a coronary risk factor, and thus exercise is an essential part of treatment for many reasons. A physical therapist may also be especially appropriate for work with cardiac patients who also have musculoskeletal problems. For example, bypass recipients may have problems with mobility of the shoulder or other joints.

The other components of the rehabilitation program may include education about the heart condition and its risk factors, counseling for psychological aspects of heart disease, stress management, vocational or occupational counseling, and guidance in adopting healthier behaviors. Some of the lifestyle or behavioral changes encouraged include smoking cessation and a lower fat diet, and management of other controllable coronary disease risk factors such as smoking, high blood pressure, high cholesterol, obesity, stress, and a sedentary lifestyle.

Many economic and medical benefits have been associated with cardiac rehabilitation, including decreased disability and improved functional capacity, less likelihood of mortality and recurrent morbidity, and decreased medical costs. Another benefit is that the use of electrocardiograph and other forms of objective and subjective assessment in ongoing supervised rehabilitation can lead to detection of problems and adjustments in the patient's treatment. Reasons for cost effectiveness of this form of treatment include reduction in disability and health care costs, fewer re-hospitalizations, and improved productivity. Despite these benefits, only about 11-38% of qualified candidates generally participate. Although many insurance companies cover all or part of a cardiac rehabilitation program, coverage is not available to all patients, and may be limited in terms of length of treatment or conditions covered.

Preparation

A cardiac rehabilitation program is usually prescribed and overseen by a physician, and generally begins in the hospital, under the direction of appropriate hospital departments, and after exercise testing and other preparatory procedures have been administered. An EKG will likely be given before the rehabilitation program begins, and then be used as an ongoing monitoring method by the physical therapist or other rehabilitation team members.

Aftercare

The patient may continue with a maintenance or secondary prevention program, and should maintain the healthy habits they have gained, including regular exercise to maintain improved fitness and associated physical and psychological benefits.

Complications

Patients are closely monitored for any exercise-related health complications, and the rehabilitation team is equipped to detect and manage possible emergencies. Cardiac rehabilitation is a safe treatment option, and serious problems are rare.

Results

Participation in a cardiac rehabilitation program can help the heart patient return to physical and emotional/social well-being and be able to function in their lives and work as near as possible to their pre-illness level of functioning. In fact, their overall quality of life and health may be improved. Patients also learn new ways of taking care of their health so that recurrence of illness or symptoms and re-hospitalization are minimized, and deterioration of existing conditions is less likely.

Health care team roles

After a prescription is made by the primary care physician or cardiac specialist, various health care professionals are involved in the program, including a physical therapist or exercise physiologist, nurses, an occupational therapist, dietician, and mental health professional. A nurse specializing in cardiac rehabilitation, exercise physiologist or physical therapist, or physical therapy department may manage the patient's rehabilitation program, in consultation with a physician.

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KEY TERMS

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Electrocardiogram (EKG/ECG)—A test that records electrical activity of the heart. It may be used to detect a heart attack, because injured cardiac muscle causes abnormal conduction of electrical impulses.

Ischemia—Shortage of blood supply to a body tissue or organ (to the heart in the case of cardiac ischemia), which can cause tissue death. Cardiac ischemia can lead to heart attack or abnormal cardiac rhythms.

Myocardial infarction (MI)—The medical term for a heart attack. When cardiac ischemia, narrowing of a coronary artery or arteries, decreases blood supply to the heart muscle (myocardium), it can cause muscle tissue death (infarction).

Secondary prevention—The prevention of a recurrence of illness, such as another heart attack.

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Diane Fanucchi, B.A., C.M.T.