Cardiac Rehabilitation

Definition

Cardiac rehabilitation is a medically supervised exercise and education program designed to improve the fitness, health, and well-being of people with heart disease through individualized exercise prescription, risk factor counseling, and attention to the patient's clinical and psychosocial status. Most programs provide exercise monitored by electrocardiograms (EKGs), a variety of exercise equipment, and experienced clinicians to evaluate exercise responses. Most programs also include patient education on many topics designed to improve cardiovascular health and reduce disease progression, such as nutrition, smoking cessation, and stress management.

Medicare and most major insurance providers help pay for cardiac rehabilitation when it is referred by a physician, is an appropriate medical diagnosis, and the program meets guidelines for monitoring and supervision. Eligible patients include those who have had a myocardial infarction (heart attack) within the preceding 12 months, cardiac bypass surgery, heart transplantation, a coronary angioplasty or stenting procedure, and those with a diagnosis of stable angina.

Purpose

Cardiac rehabilitation programs aim to improve quality of life for patients with cardiovascular disease. It reduces the risk of worsening symptoms and another event by improving fitness; controlling risk factors, such as high cholesterol, high blood pressure, and excessive weight; helping the patient remain smoke-free; and paying vigilant attention to signs and symptoms that suggest the patient has become clinically unstable. As of 2016, studies continued to show the success of structured programs in improving physical and mental health of people who complete them. A 2016 study indicated that cardiac rehabilitation reduces risk of death in patients who are depressed following heart surgery.

Cardiac rehabilitation generally includes the following:

Together, these components of cardiac rehabilitation improve physical and mental functioning, promote a return to a quality of life more similar to the one before a heart event, and reduce the risk of subsequent cardiac events.

Description

Phase 1 cardiac rehabilitation begins in the hospital during the patient's admission for a cardiac event. In phase 1, patients often begin with activities such as sitting up in bed or taking short walks. The goals of phase 1 are to minimize the negative effects of bed rest, provide additional medical care, provide education on topics about cardiovascular disease and risk reduction, review activity restrictions, and work on referral of a patient for out-patient cardiac rehabilitation.

A physician referral is required to enter a cardiac rehabilitation program and should clarify requirements, such as the need for an exercise test or office visit before beginning the program. Once the referral is received, the patient might need insurance pre-certification beginning the phase 2 outpatient program.

Patients referred to phase 2 by their physician receive an initial evaluation and orientation, which includes a medical history and physical, a baseline EKG, vital signs, a six-minute walk (or some other form of functional testing), a psychosocial inventory to screen for depression and anxiety, and the development of an individualized treatment plan. The plan is approved by the medical director, supervising physician, or referring physician.

Phase 2 cardiac rehabilitation must include aerobic exercise each day the patient attends. Typically, the patient's EKG is monitored by telemetry before, during, and after exercise. Patients use a variety of exercise equipment, such as treadmills, bikes, stair climbers, ellipticals, and rowers. If a patient has had an exercise test for program entry, this information is used to develop the exercise prescription. If not, the exercise prescription may be based on the following:

Research studies have evaluated the safety and usefulness of high intensity interval training for exercise prescription. In interval training, patients exercise intensely for a few minutes, followed by a few minutes of low-intensity activity. Intensity can be based on heart rate (85%–90% of maximum for work intervals) or RPE. The sequence is then repeated several times. This approach appears to cause equal or greater benefit with less time commitment, can prevent boredom, and appears safe, though more research was needed as of 2016 before it was likely to be widely recommended.

The exercise prescription takes into consideration the patient's fitness level, comfort with exercise, preferences, and goals, as well as any orthopedic limitation or other health concern. Patients with a recent surgical incision might need to adapt their exercise equipment usage because of incision pain or to allow for adequate healing. Patients who have had a pacemaker placed within the previous month should refrain from overhead activity.

A phase 2 session begins with an assessment of the patient's weight, blood pressure, blood glucose (if diabetic), and heart rate and rhythm. The clinician asks the patient about new or concerning symptoms, medication changes, physician appointments, or questions. The patient performs 5–8 minutes of warm up and then exercises at prescribed levels on a variety of equipment for 20–60 minutes. The patient continues cooling down and is free to leave the facility once heart rate, rhythm, blood pressure, and glucose (if applicable) are stable. Typically, patients gradually increase their activity levels at visits based on the center staff monitoring with telemetry.

Education and counseling can occur while the patient exercises, after exercise, or in a class setting. The patient's individual treatment plan helps to guide the education process. Typical educational components include:

The individual treatment plan is updated every 30 days based on the patient's progress. Functional tests, such as the six-minute walk, might be repeated at regular intervals. Progress reports are sent to the referring physician.

KEY TERMS
Angina—
Chest pain.
Bypass surgery—
A surgical procedure that grafts blood vessels onto arteries to reroute the blood flow around blockages in the arteries.
Decompensated heart failure—
Occurs when the heart cannot adequately pump blood through the body and signifies worsening heart failure.
Dysrhythmia—
Irregular heart rhythm.
Heart transplant—
Removal of patient's heart and replacement with a donor heart.
Hypoglycemia—
Low blood sugar.
Intensive cardiac rehabilitation—
New designation for research-proven cardiac rehabilitation, such as the Ornish or Pritikin program.
Metabolic equivalents (METS)—
Energy requirement in terms of oxygen used. One MET is resting energy use. The higher the MET level, the greater the energy cost.
Myocardial infarction—
Heart attack.
Ornish—
An intensive lifestyle program founded by Dean Ornish, proven to reverse cardiovascular disease, which received the designation of intensive cardiac rehabilitation.
Pritikin—
An intensive lifestyle program proven to reverse or reduce several chronic diseases, including cardiovascular disease, which received a designation of intensive cardiac rehabilitation.
Unstable angina—
Chest pain that occurs at rest or a new change in the patient's typical pattern of chest pain.

A new category of cardiac rehabilitation, called intensive cardiac rehabilitation, was designated in 2010. These programs were shown to improve patients' cardiovascular disease through specific outcome measurement, such as reducing the need for cardiac medications, procedures, or surgery. Three programs, Ornish, Pritikin, and the Benson-Henry Institute, were accepted for this designation by the Centers for Medicare and Medicaid Services. These programs rely on intensive lifestyle modification, including very low-fat diets, regular exercise, and daily stress management.

Precautions

To minimize the risks of a cardiac event during exercise, cardiac rehabilitation programs typically follow the American College of Sports Medicine Contraindications to Exercise. The contraindications alert the clinician to withhold or delay exercise until the patient has been evaluated or stabilized. Contraindications include unstable angina, very high pre-exercise blood pressure, acute systemic illness or fever, EKG changes indicating new heart problems, signs or symptoms of uncompensated congestive heart failure, active pericarditis or myocarditis, or uncontrolled diabetes.

To enhance the safety of exercise for the patient with cardiovascular disease, the clinician checks for concerning changes in clinical status before, during, or after exercise. These include a change in symptom pattern; a significant change in heart rate, rhythm, or EKG; a very hypertensive blood pressure response; a significant change in exercise tolerance; or new signs or symptoms that indicate acute exacerbation of heart failure, such as abrupt weight gain, increased edema, and increased breathlessness.

Preparation

Before a patient begins in-patient cardiac rehabilitation, the clinician assesses patient health and reviews medical history and records. Before beginning outpatient rehabilitation, a physician referral and clarification of insurance coverage are needed. A pre-entry exercise test might be required by the referring physician or per program policies. The patient's history, including copies of the recent discharge summary and office notes, should be obtained.

Aftercare

At the completion of phase 2 cardiac rehabilitation, the patient is encouraged to continue exercising on a regular basis. Maintenance cardiac rehabilitation, exercising at home, and joining a community program are recommended. The patient should understand the exercise prescription, including heart rate parameters and symptoms that require withholding exercise and being evaluated by a physician.

Complications

Exercise is generally safe for stable cardiac patients, but complications can arise. The cardiac disease can become worse, or a patient might have a sudden change in health. When patients do not follow clinician recommendations for exercise and prescriptions for medications, they are more likely to have complications. In these cases, especially if they notice symptoms, patients usually are told to stop exercising until evaluated by their physician.

Patients with diabetes can develop hypoglycemia during or after exercise. Sometimes, the patient's referring physician has to modify insulin or medication doses. Some patients experience worsening of arthritis or other musculoskeletal issues, and exercise may need to be adjusted or withheld.

Results

People who participate in cardiac rehabilitation can expect an improvement in exercise and activity tolerance, sometimes assessed by a repeat stress test or six-minute walk. Exercise tolerance is usually described both in terms of how long a person can tolerate exercise and how intense the activity is.

Other outcomes are monitored according to patients' individual treatment plan. These usually include changes in weight, waist circumference, blood pressure, heart rate, blood glucose, and cholesterol, as well as their progress with smoking cessation, home exercise, symptom-free activity, or dietary changes.

Health care team roles

A cardiac rehabilitation program has one or more medical directors who oversee the program. The medical director must be a licensed physician with expertise in the care of cardiovascular diseases. The cardiac rehabilitation program also must have a physician immediately available in case of emergency. This physician does not have to be in the room but must be close enough to provide immediate emergency care if needed.

Cardiac rehabilitation programs typically have a staff that includes specially trained exercise physiologists, registered nurses or nurse practitioners, registered dietitians, and physical therapists. In some programs these clinicians have distinct roles; in others, there is considerable overlap in duties and responsibilities. Core Competencies for Cardiopulmonary Rehabilitation/Secondary Prevention Professionals, published by the American Association of Cardiopulmonary Rehabilitation, provides specific guidelines regarding necessary knowledge and skills for clinicians working in cardiac rehabilitation.

QUESTIONS TO ASK YOUR DOCTOR

See also Cardiovascular disease ; Cardiorespiratory fitness tests .

Resources

BOOKS

ACSM's Guidelines for Exercise Testing and Prescription, 10th ed. Philadelphia: Wolters Kluwer, 2017.

PERIODICALS

Balady, Gary J., et al. “Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update: A Scientific Statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.” Circulation 115 (2007): 2675–82.

Blumenthal, J. A., et al. “Enhancing Cardiac Rehabilitation with Stress Management Training: A Randomized, Clinical Efficacy Trial.” Circulation 133, no. 14 (2016): 1341–50.

Rosendorf, C., et al. “Treatment of Hypertension in Patients with Coronary Artery Disease: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension.” Circulation 131, no. 19 (2015).

Thorup C., et al. “Cardiac Patients' Walking Activity Determined by a Step Counter in Cardiac Telerehabilitation: Data from the Intervention Arm of a Randomized Controlled Trial.” Journal of Medical Internet Research 18, no. 4 (2016): e69.

WEBSITES

American Association of Cardiovascular and Pulmonary Rehabilitation. “Cardiac Rehabilitation Patient Resources.” https://www.aacvpr.org/Resources/Resources-for-Patients/Cardiac-Rehab-PatientResources (accessed January 17, 2017).

American Heart Association. “Facts: Cardiac Rehabiliation.” https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_482300.pdf

Intermountain Medical Center. “Cardiac Rehabilitation May Play Role in Reducing Risk for Death in Depressed Heart Patients after Surgery.” News-Medical.net . http://www.news-medical.net/news/20161114/Cardiacrehabilitation-may-play-role-in-reducing-risk-for-deathin-depressed-heart-patients-after-surgery.aspx (accessed November 28, 2016).

National Heart, Lung, and Blood Institute. “Cardiac Rehabilitation.” https://www.nhlbi.nih.gov/health/health-topics/topics/rehab (accessedJanuary 17, 2017).

ORGANIZATIONS

American Association of Cardiopulmonary Rehabilitation, 330 N. Wabash Avenue, Suite 2000, Chicago, IL, 60611, (312) 321-5146, Fax: (312) 673-6924, aacvpr@ aacvpr.org, http://www.aacvpr.org .

American Heart Association, 7272 Greenville Avenue, Dallas, TX, 75231, (800) 242-8721, Review.personal. info@heart.org, http://www.heart.org .

Lisa S. Womack, PhD
Revised by Teresa G. Odle, BA, ELS

  This information is not a tool for self-diagnosis or a substitute for professional care.