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Running Head: CARDIAC REHABILITATION ON MYOCARDIAL INFARCTION
Cardiac rehabilitation on myocardial infarction patient
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CARDIAC REHABILITATION ON MYOCARDIAL INFARCTION PATIENTS
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Abstract
Background- even though many studies have given a report that the cardiac rehabilitation is
normally associated with reduction in the mortality after cases of myocardial infarction, quite
little is known on its association with the mortality after the percutaneous coronary
intervention.
Methods and the results- a retrospective analysis of the data from prospectively collected
registry of the 2395 patients who actually underwent the percutaneous coronary intervention
from 1994 to 2008 in Minnesota. The association of the cardiac rehabilitation with the allcause mortality, the myocardial infarction, revascularization or cardiac mortality was
assessed using three techniques of statistics: propensity score stratification (n=2351),
propensity score matched analysis with (n=14380 and the regression adjustment with the
propensity score in 3 month analysis landmark 9n=2009). Within a median follow up of 6.3
years, there were 503 deaths (with 199 deaths being cardiac), 394 cases of myocardial
infarctions and 755 being revascularization procedures. The participation in the cardiac
rehabilitation, noted in about 40% (964 out of the 2395) of the cohorts, was actually
associated with significant reduction in the all-cause mortality by all the three statistical
techniques. A trend unto the decreased cardiac mortality also was noted in the cardiac
rehabilitation participants. No effect, however, was observed for the subsequent
revascularization and myocardial infarction. This association between the participation of the
cardiac rehabilitation and the reduced rates of mortality was similar for women and men, for
the younger and the older patients, and for the patients that are undergoing the non-elective or
the elective percutaneous coronary intervention.
The conclusion is that it was found that the cardiac rehabilitation after the coronary
intervention was indeed associated with some significant reduction in the rates of mortality.
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Those findings add the support to the published guidelines of clinical practice, the
performance measures and the insurance coverage policies which recommend the cardiac
rehabilitation for the patients after coronary intervention.
Discussion
This data from the cohort provide the evidence for significant relationship between the
participation in the cardiac rehabilitation and the lower rates of mortality for the patients that
are undergoing PCI. With the use of the three different statistical techniques, it was found
that there was 45-47% reduction in the all-cause mortality in the patients who actively
participated in the cardiac rehabilitation after the PCI in comparison with the ones who did
not actually participate. This reduction is consistent with the previous study that was
conducted at Olmsted County which reported 56% reduction in the all-cause mortality that is
associated with the cardiac rehabilitation after the myocardial infarction, but it is even bigger
than the 20-30% decrease in the all-cause mortality that previously reported in some other
observational studies and the meta-analyses of the cardiac rehabilitation after myocardial
infarction (Hammill et al, 2010, pg 67).
This report is an addition to the limited number of the studies which have examined the
association between the cardiac rehabilitation and the mortality after percutaneous coronary
intervention. Although these investigators used the PS analyses to assist in the adjustment of
the potential confounding factors, they just did not adjust for quite a number of the factors
which were included in the analysis such as obesity, smoking, history of disease of the
coronary artery, medication use, hypercholesterolemia, ejection fraction and other variables,
which owe to the limitations in Medicare database. Furthermore, their study was actually
limited to the patients below 65 years and they did not include the data on the cardiac
mortality and the recurrent cardiovascular events (Daly et al, 2012, pg 7).
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In the study, the cardiac mortality was actually reduced by about 39% in the cardiac
rehabilitation participants when the PS stratification analysis method was applied to the entire
study population. No substantial effect on the cardiac mortality however was noted in the
analysis of the matched-pair. Because the autopsy evidence is not actually available in all of
the patients, the confirmatory evidence as regards this cannot be adequately provided. Given
that each patient in this cohort had the coronary artery disease, the cardiac cause should
actually be responsible for most of the deaths. Only about 39.5 percent of all the deaths could
be attributed to the cardiac causes in this study (Daly et al, 2012, pg 8). Such a percentage is
consistent with the prospective registry of the PCIs at the 50 United States centers and pooled
analysis of the four prospective, double-blind and randomized clinical trials which attributed
about 40 percent of total deaths to the cardiac causes. In addition, the cardiac death was
indeed responsible for just 27 percent of all deaths in the PCI patients who were enrolled in
clinical utilizing and aggressive evaluation.
The fact that there was a reduction in the mortality rates with no reduction in the recurrent
myocardial infarction or the revascularization rates in the cardiac rehabilitation participants is
consistent with findings of the other studies of the cardiac rehabilitation in the coronary
intervention patients, and the ones that involve cardiac rehabilitation after myocardial
infarction. Explanation for such findings is not very clear, but it may involve some two main
factors. For one, it is very possible that these findings may be associated with effects of the
differential monitoring and the follow up of the cardiac rehabilitation participants. This may
increase the likelihood of identification and the treatment of the recurrent cardiac symptoms
in the cardiac rehabilitation participants when compared with the non participants. Another
possible explanation is that the effects of the cardiac rehabilitation could bring about shifting
from the fatal to the non fatal events (Steg et al, 2012, pg 215). Indeed, the data showed that
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overall composite rates of the events were lower in the cardiac rehabilitation participants in
comparison with the non participants.
Cardiac rehabilitation does increase the physical activity as well as the exercise capacity that
in turn produces important physiological adaptations which indeed improve the
cardiovascular health. Furthermore, the cardiac rehabilitation participation improves the
medication adherence, factor that is likely to be of great importance for the coronary
intervention patients that are prescribed the antiplatelet therapy after the coronary
intervention. In addition, cardiovascular risk factor control, depression identification, reduced
inflammation, treatment and the psychological support have actually reported to be very
superior in the cardiac rehabilitation participants than in the non participants. A close followup of the patients by the CR program staff members as they do interact with the patients a
number of times in a month is helpful in identification of new symptoms, co morbid
conditions and side effects which may need additional evaluations as well as adjustments in
the treatment. Lastly, it is very possible that the treatments that are received during the
cardiac rehabilitation may stimulate some other beneficial physiological adaptations which
include an increase in number of the circulating endothelial cells.
Therefore, the data from the county of Olmsted, Minnesota, reveal that the participation in
the cardiac rehabilitation after the percutaneous coronary intervention is associated with the
significant reduction in the all-cause and the cardiovascular mortality. Though only about 40
percent of the coronary intervention patients in the overall cohort took part in the cardiac
rehabilitation, there was a substantial improvement in the cardiac rehabilitation participation
in the year 2006, when centers for Medicaid and Medicare services started covering the
cardiac rehabilitation after the percutaneous coronary intervention. The results provide some
supportive evidence for decision by the centers to cover the cardiac rehabilitation in
myocardial infarction patients and for recommendations in the clinical practice guidelines
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and the performance measures which support cardiac rehabilitation for all the myocardial
infarction patients (Suaya et al, 2009, pg 25).
Introduction
Cardiac rehabilitation refers to the process in which a person with coronary heart disease or
the person who has history f myocardial infarction is encouraged to have their full potential
as regards psychological and physical health. This cardiac rehabilitation after acute
myocardial infarction does include the communication of diagnosis and also advice, the
psychological and the social support, lifestyle changes, motivation as well as the drug
therapy.
For a cardiac rehabilitation process to be of success, it must draw on skills from many
members of healthcare team and it should also involve combination from the psychological
support, behavioral change, education as well as the exercise training. All these professionals
have a role to play in the entire process of cardiac rehabilitation, and their inputs cannot be
underestimated. This is because the systems of a human body are in a way interconnected,
where if one is affected, the others are affected as well. It is therefore very important to
combine the specialties in this whole process so that the patient can have a full recovery, and
the expertise can help each other in making the critical decisions that pertains this whole
process (Van de Werf et al, 2008, pg 2912).
Although the actual mechanism by which this occurs is yet to be discovered in full, the
cardiac rehabilitation that includes a program of the structured exercise is at present now
generally believed not just to improve on morbidity, but also to reduce the mortality in the
patients who in the past have had this condition of myocardial infarction. For many years, it
has been thought that all the patients, regardless of age or gender, who have the coronary
heart disease or/and cardiac failure may actually benefit from the cardiac rehabilitation.
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However, in order to achieve the optimal effects, these cardiac programs should indeed be
tailored and structured to a particular individual patient after an initial assessment has given
the proper indication. In addition to this, systems that support computers have also been
shown to help in this process of making decisions.
Cardiac rehabilitation is among the national priority projects on the agenda of National
Health Services improvement. The BACPR (British Association for the cardiovascular
prevention & Rehabilitation) particularly identifies cardiac specialist nurse as a major or the
core player of the team that is involved in the cardiac rehabilitation. The intervention by a
cardiac specialist nurse is able to substantially reduce length of the stay in hospital, the
hospital costs as well as the risks that are associated with the readmission to the hospital for
the heart failure (Van de Werf et al, 2008, pg 2916).
In general, all the patients who have the history of myocardial infarction should indeed be
given a cardiac rehabilitation program that is inclusive of an exercise component. Options
should be offered to the patient in a wide range. They should be encouraged to actually attend
to the options that have been offered to them, but which are appropriate to their particular
needs. However, in case they would not like to take up one of the components, they should
not be totally excluded. If some patient has got a cardiac and or any other condition that
limits the physical exercise, then this one condition should actually be treated first before the
patient is given the component. A suitably qualified practitioner and a professional in the
healthcare sector should be in a position to make the component somehow adapted to suit the
condition of this patient. The patients who have stable left ventricular dysfunction are able to
be given the physical component as well. Evidence exist that early identification and
intervention in the patients who are at the risk of the psychological distress may help reduce
this distress, the rates of hospital readmission and also the anxiety and depression scores in a
year (Van de Werf et al, 2008, pg 2918)
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Although the cardiac rehabilitation has actually been currently proved to be very beneficial,
the uptake has really been suboptimal. The reasons that are given by the patients are very
varied and they include the difficulty in attending the hospital, domestic and work
commitments as well as dislike of the groups. Only weak evidence exists that supports the
idea that the uptake of the cardiac rehabilitation is effective (Suaya et al, 2009, pg 27). The
interventions that target the patient-identified problems and challenges can increase
likelihood of this success.
Engaging the patients
The home-based programs nowadays have been devised that addresses such challenges and
also to improve the access to, and the participation in the cardiac rehabilitation programs.
After the cardiac rehabilitation services are actually planned, needs of that local community
have to be taken into consideration, which includes the social and health factors as well as
deprivation. It will go an extra mile and ensure that maximum engagement is there with the
people with the biggest need, thus ensuring that the services are actually accessible and are
relevant to all the patients of myocardial infarction. The services that are offered should be
sensitive to the culture of the patients. This may translate into employing cardiac
rehabilitation assistants and bilingual peer educators in order to reflect diversity of local
population. This physical component should actually be adapted in order to meet needs of the
older patients as well as those with substantial co morbidities. Provision of the transport to
this service may also need to be put into account. The patients need to be given single-sex or
mixed-sex classes. It’s essential for the patients’ basic level of the health literacy and health
beliefs to actually be established prior to the offering the lifestyle advice. All the healthcare
professionals that come in contact with the post-myocardial infarction patients, with the
senior medical staff included should try to promote the cardiac rehabilitation services. There
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are several means of contact that can be considered. These include telephone communication,
verbal, postal and the ‘telehealth’ interventions (Cortés & Arthur, 2006, p 251)
Health education
The programs should include the general health education and the information on how to
actually deal with stress. A coordinated and integrated approach from the primary as well as
the secondary care teams in this stage, for example using validated structured plan like the
Heart manual, may improve the psychological overall and well being outcome. Such may be
specifically appropriate for the patients that are not willing or are unable to access the
secondary care-based service. Many of the patients that have sustained myocardial infarction
are able to go back to their work. However, consideration should be taken on which type of
the work, and the environment, psychological and physical states of the patient. The patients
are able to fly within 2 to 3 weeks. In case of any complications, advice should be sought
from experts. The patients who have the license to pilot a plane should first seek advice from
the Civil Aviation authority before returning to their normal flies. In general, on the basis of
the physical and psychological status, majority of the patients are able to resume their normal
day to day activities. The patients that are involved in the competitive sports will need some
advice from experts in order to assess the level of the risks (Cortés & Arthur, 2006, p 253).
Social and psychological support
The patients need to be given some basic advice on management of stress and may not
actually need more of the complex treatments like the cognitive, support and relaxation. The
careers and the partners should be actively involved if the patient wishes to do so. The
patients with depression or anxiety should be managed in accordance to the appropriate NICE
guidance.
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The phases in the cardiac rehabilitation for patients with myocardial infarction
The process of cardiac rehabilitation can be subdivided into various phases. Each of the
phases is appropriate for patient’s psychological and physical recovery:
a) Initial stage after the myocardial infarction or the cardiac event- this involves

Education

Correction and reassurance of any misconceptions

Initial mobilization

Assessment of the risk factors such as smoking, lipid profile, diet and exercise

Plan for discharge
b) Post-discharge stage- this early discharge period is the period in which the patient is
mostly vulnerable and the psychological stress in this level is a predictor of the poor
outcome and also increased use of the hospital services independent of physical
damage to the patient’s heart. The patients should be actually screened for the
depression and anxiety at this level, and they should be treated with antidepressants or
anxiolytics as appropriate (Cortés & Arthur, 2006, p 255).
c) Rehabilitation and structured exercise- a graded exercise is a very vital component of
the cardiac rehabilitation, though it doesn’t alter mortality and morbidity if it is given
in isolation. The graded exercise should be accompanied in this level by some more
interventions that are tailored in order to meet the individual requirements of a
particular patient. The lifestyle changes need to be encouraged and where appropriate
supported, for example, smoking cessation, reducing weight as well as retraining with
view of returning to the work. All these will be accompanied by the education that
concerns the condition of the heart and the various reasons why the changes in
lifestyle are desirable (Suaya et al, 2009, pg 30).
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d) Long-term maintenance- for it to be very effective, the changes in the lifestyle of the
patient and the physical activity need to be maintained for such a very long time. The
protocol that allows for regular review of each patient with the coronary heart failure
or/and heart disease by primary care team is very desirable (Cortés & Arthur, 2006, p
259). The long-term review will allow for continued support of the lifestyle changes
on top of the drug therapy assessment, and psychological and physical well-being, and
this will permit early intervention, where necessary, in every area.
Conclusion
Cardiac rehabilitation over time has been proven to be effective and safe in the improvement
of the cardiovascular patients’ quality of life and in reducing the mortality and morbidity.
However, despite all the evidences of its benefits, this method remains underused in most
parts of this world. Many patients would benefit from such a cost effective tool by the
improvement of the referral and the participation to the cardiac rehabilitation programs and
the individualizing services taking into consideration the profile of the patient. Many new
research areas are coming up, including the exploration of new ways of the cardiac
rehabilitation delivery in order to improve the referral and also participation rates and
developing some new exercise regimens which are more effective and also versatile and
which incorporates the new technologies in the cardiac rehabilitation in order to maximize its
benefits. For a very effective outcome in the process of managing the patients with
myocardial infarction using the method of cardiac rehabilitation, it is very important that
many professionals from the healthcare sector bring together their skills and knowledge. This
is because all these professions have some very important inputs which will eventually
translate to the total outcome of the entire process.
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Bibliography
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