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THE CARDIAC REHAB TEAM: A HOLISTIC
APPROACH TO RECOVERY AND HEALING
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic
medicine, and medical author. He graduated from Ross
University School of Medicine and has completed his clinical
clerkship training in various teaching hospitals throughout New York, including King’s
County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed
all USMLE medical board exams, and has served as a test prep tutor and instructor for
Kaplan. He has developed several medical courses and curricula for a variety of educational
institutions. Dr. Jouria has also served on multiple levels in the academic field including
faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter
Expert for several continuing education organizations covering multiple basic medical
sciences. He has also developed several continuing medical education courses covering
various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the
University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an emodule training series for trauma patient management. Dr. Jouria is currently authoring an
academic textbook on Human Anatomy & Physiology.
Abstract
Just as a serious limb injury requires rehabilitation to return to optimal
performance, the heart also requires serious rehab in order to function at its
best after a trauma. When a cardiac event occurs, the patient may suffer
emotional difficulties and challenges to accept and overcome events that
caused the condition. Cardiac rehabilitation is a whole-body approach to
restore health that incorporates a multi-dimensional methodology to address
body, mind, and spirit. Exercise, counseling, and physical therapy combine
with medical management to ensure that as much normal function as
possible is restored, and that every patient is able to adapt to lifestyle
changes that reduce the risk of a repeat occurrence. The cardiac
rehabilitation team and program goals for various cardiac diagnoses and
interventions are discussed to support further studies and to increase
knowledge in everyday practice.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Assisting patients to lower their risk of heart disease following a new cardiac
diagnosis often involves specialized health professionals to encourage and
educate them on best practice exercise programs and healthy lifestyle
choices. Nurses are key partners within the health team to support the
patient with heart disease in their progress to heal and to lead a healthy life.
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Course Purpose
To provide nursing professionals with knowledge of a holistic approach for
cardiac rehabilitation to support the patient with heart disease to recover
and heal.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 3/1/2016
Termination Date: 3/17/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1.
In the United States, cardiovascular disorders are:
a. proven to be the leading cause of mortality and morbidity.
b. responsible for approximately 50% of annual deaths in the U.S.
c. present in approximately 14 million people who suffer from some
form of coronary artery disease or its complications.
d. All of the above.
2.
True or False: Overall, modern cardiac rehabilitation is safe and
well tolerated with a very low rate of major complications such
as death, cardiac arrest, myocardial infarction/serious injuries.
a. True.
b. False.
3.
With low intensity exercise training programs,
a. it is essential that staff have current training in cardiopulmonary
resuscitation.
b. the administration of a diuretic should always be given to avoid
constipation caused by exercise.
c. mandatory equipment include resuscitation cart and defibrillator.
d. All of the above.
4.
True or False: Some cardiac rehabilitation programs have been
developed to provide job specific rehabilitation. In these
instances, the patient will only focus on areas that will aid in the
transition back to work.
a. True.
b. False
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Introduction
The primary goal of cardiac rehabilitation is to reverse limitations
experienced by patients who have suffered the adverse pathophysiologic and
psychological consequences of cardiac events. Just as a serious leg injury
requires rehabilitation to return the patient to optimal performance, the
heart also requires major rehabilitation in order to function at its best after a
trauma. Additionally, when a cardiac event occurs, the patient may suffer
emotional difficulties and challenges in accepting and overcoming the events
that caused the issue. Cardiac rehabilitation is a whole-body approach to
restoring health that incorporates a multi-dimensional approach to address
body, mind, and spirit. Exercise, counseling, and physical therapy combine
with medical management to ensure that as much normal function as
possible is restored to each patient, and that every patient is able to adapt
to lifestyle changes that reduce the risk of a repeat occurrence.
Cardiovascular disorders are proven to be the leading cause of mortality and
morbidity in the United States. They are responsible for approximately fifty
percent of annual deaths.1 In addition, those who experience cardiovascular
events and survive require a significant amount of care and lifestyle
modification post-event. Approximately 14 million people in the United
States suffer from some form of coronary artery disease (CAD) or its
complications, including congestive heart failure (CHF), angina, and
arrhythmias. Of this number, approximately one million survivors of acute
myocardial infarction (MI), as well as the more than 300,000 patients who
undergo coronary bypass surgery annually, are candidates for cardiac
rehabilitation.2
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History Of Cardiac Rehabilitation
Cardiac rehabilitation programs appeared in their earliest form in the late
1940’s and early 1950’s. Initially, these programs focused on helping
patients return to work: “At that time, there was an acute manpower
shortage and the possibility of returning unemployed or retired men to the
work force was considered. It was recognized that there were many men
capable of work that had been prematurely retired because of coronary
heart disease. In 1941, the first Work Evaluation Unit was established in
New York under the auspices of the American Heart Association. Many
people with coronary heart disease were medically reviewed and their
capacity for work evaluated. The majority returned to work and were found
to make satisfactory employees in occupations similar to those which they
had previously enjoyed.”12
By the 1970’s, more thorough hospital-based programs were developed to
assist patients with recovery. The programs were more comprehensive in
their approach and focused on more areas than preparing the patient to
return to work. This occurred as health providers recognized the significant
impact mobilization and supervised exercise programs had on all aspects of
recovery, not just on the patient’s ability to return to work. Programs
became more structured, and attempted to promote rehabilitation through a
variety of activities.
“Confirmation that early exercise testing and training could start within
two to three weeks of a myocardial infarction led to exercise training
starting immediately after discharge from hospital. However, because
the exercise was of relatively high intensity, careful monitoring was
necessary. These programs usually lasted up to twelve weeks and
patients attended three times per week during that period. Some
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education was delivered during these programs; partly through the
natural exposure to interested health professionals who could supply
requested information to patients during supervised exercise sessions.
Gradually it was recognized that more formal patient education was
desirable. Therefore, group education was later added to many of the
group exercise programs.”13
Core Components of Cardiac Rehab Programs
Although the specific components will vary from program to program, and
will be tailored to the specific needs of the patient, there are a number of
core components that comprise a cardiac rehabilitation program. In some
instances, only a select few components will be used, while other programs
may utilize all of the components as part of the rehabilitation process. The
following table provides a thorough overview of all of the components that
can be included in a cardiac rehabilitation program:5
Patient Assessment
Evaluation
Medical History:
Review current and prior cardiovascular medical and surgical diagnoses
and procedures (including assessment of left ventricular function);
comorbidities (including peripheral arterial disease, cerebral vascular
disease, pulmonary disease, kidney disease, diabetes mellitus,
musculoskeletal and neuromuscular disorders, depression, and other
pertinent diseases); symptoms of cardiovascular disease; medications
(including dose, frequency, and compliance); date of most recent
influenza vaccination; cardiovascular risk profile; and educational barriers
and preferences. Refer to each core component of care for relevant
assessment measures.
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Physical Examination:
Assess cardiopulmonary systems (including pulse rate and regularity,
blood pressure, auscultation of heart and lungs, palpation and inspection
of lower extremities for edema and presence of arterial pulses); postcardiovascular procedure wound sites; orthopedic and neuromuscular
status; and cognitive function. Refer to each core component for
respective additional physical measures.
Testing: Obtain resting 12-lead ECG; assess patient’s perceived healthrelated quality of life or health status. Refer to each core component for
additional specified tests.
Document the patient assessment information that reflects the patient’s
Interventions current status and guides the development and implementation of (1) a
patient treatment plan that prioritizes goals and outlines intervention
strategies for risk reduction, and (2) a discharge/follow-up plan that
reflects progress toward goals and guides long-term secondary
prevention plans.
Interactively, communicate the treatment and follow-up plans with the
patient and appropriate family members/domestic partners in
collaboration with the primary healthcare provider.
In concert with the primary care provider and/or cardiologist, ensure that
the patient is taking appropriate doses of aspirin, clopidogrel, β-blockers,
lipid-lowering agents, and ACE inhibitors or angiotensin receptor blockers
as per the ACC/AHA, and that the patient has had an annual influenza
vaccination.
Expected
Patient Treatment Plan:
Outcomes
Documented evidence of patient assessment and priority short-term (i.e.,
weeks-months) goals within the core components of care that guide
intervention strategies. Discussion and provision of the initial and followup plans to the patient in collaboration with the primary provider.
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Outcome Report:
Documented evidence of patient outcomes within the core components of
care that reflects progress toward goals, including whether the patient is
taking appropriate doses of aspirin, clopidogrel, β-blockers, and ACE
inhibitors or angiotensin receptor blockers as per the ACC/AHA, and
whether the patient has had an annual influenza vaccination 9 (and if not,
documented evidence for why not), and identifies specific areas that
require further intervention and monitoring.
Discharge Plan:
Documented discharge plan summarizing long-term goals and strategies
for success.
Blood Pressure Management
Measure seated resting blood pressure on ≥2 visits.
Evaluation
Measure blood pressure in both arms at program entry.
To rule out orthostatic hypotension, measure lying, seated, and standing
blood pressure at program entry and after adjustments in
antihypertensive drug therapy.
Assess current treatment and compliance.
Assess use of nonprescription drugs that may adversely affect blood
pressure.
Provide and/or monitor drug therapy in concert with primary healthcare
Interventions provider as follows:
If blood pressure is 120-139 mm Hg systolic or 80-89 mm Hg diastolic:
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Provide lifestyle modifications, including regular physical activity or
exercise; weight management; moderate sodium restriction and
increased consumption of fresh fruits, vegetables, and low-fat dairy
products; alcohol moderation; and smoking cessation.
Provide drug therapy for patients with chronic kidney disease, heart
failure, or diabetes if blood pressure is ≥130/≥80 mm Hg after lifestyle
modification.
If blood pressure is ≥140 mm Hg systolic or ≥90 mm Hg diastolic:
Provide lifestyle modification and drug therapy.
Expected
Short-term: Continue to assess and modify intervention until
Outcomes
normalization of blood pressure in prehypertensive patients; <140 mm
Hg systolic and <90 mm Hg diastolic in hypertensive patients; <130 mm
Hg systolic and <80 mm Hg diastolic in hypertensive patients with
diabetes, heart failure, or chronic kidney disease.
Long-term: Maintain blood pressure at goal levels.
Lipid Management
Obtain fasting measures of total cholesterol, high-density lipoprotein,
Evaluation
low-density lipoprotein, and triglycerides. Obtain a detailed history to
determine whether diet, drug, and/or other conditions that may affect
lipid levels can be altered (for patients with abnormal levels).
Assess current treatment and compliance.
Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months
after initiation or change in lipid-lowering medications. Assess creatine
kinase levels and liver function in patients taking lipid-lowering
medications as recommended by NCEP.12
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Cardiac Rehabilitation Programs
In the past, cardiac rehabilitation was used to treat lower-risk patients who
had the physical capacity to exercise without the risk of additional
complications. However, in recent years, cardiac treatment and management
has evolved, thereby expanding the demographic of patients who can
participate in cardiac rehabilitation programs. A substantial component of
this new demographic includes approximately 400,000 patients who undergo
coronary angioplasty.3 In addition, there are approximately 4.7 million
patients with congestive heart failure who can participate in a modified
program of rehabilitation.4
Cardiac rehabilitation programs have been consistently shown to improve
objective measures of exercise tolerance and psychosocial wellbeing without
increasing the risk of significant complications. According to the U.S. Public
Health Service (USPHS), a cardiac rehabilitation program is defined as a
program that involves the following:5

Medical evaluation

Prescribed exercise

Education

Counseling of patients with cardiac disease
The following is the common definition of cardiac rehabilitation, as developed
by the United States Public Health Service:
“Cardiac rehabilitation services are comprehensive, long term
programs involving medical evaluation, prescribed exercise, cardiac
risk factor modification, education and counselling. These programs
are designed to limit the physiological and psychological effect of
cardiac illness, reduce the risk of sudden death or reinfarction,
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control cardiac symptoms, stabilize or reverse the atherosclerotic
process, and enhance the psychosocial and vocational status of
selected patients. Cardiac rehabilitation services are prescribed for
patients who have had a myocardial infarction, have had coronary
bypass surgery, or have chronic stable angina pectoris.”6
One newer strategy is to use cardiac rehabilitation programs to treat those
at high risk of coronary heart disease, including those with other evidence of
vascular disease or who are at high risk of vascular disease, or any other
form of cardiac disease. With this new strategy in place, the current
definition of cardiac rehabilitation has been modified as follows: “The sum of
interventions required to ensure the best physical, psychological and social
conditions so that patients with chronic or post-acute cardiac disease may,
by their own efforts, preserve or assume their proper place in society.”7
Cardiac rehabilitation has to be comprehensive and, at the same time,
individualized. Patients must be identified and selected to participate in
cardiac rehabilitation, as there are a number of patients who may not benefit
or who are at risk of developing further complications through participation.
Patients generally fall into following categories:8

Lower-risk patients following an acute cardiac event

Patients who have undergone coronary bypass surgery

Patients with chronic, stable angina pectoris

Patients who have undergone heart transplantation

Patients who have had percutaneous coronary angioplasty

Patients who have not had prior events but who are at risk because of
a remarkably unfavorable risk factor profile

Patients with stable heart failure

Patients who have undergone non-coronary cardiac surgery
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
Patients with previously stable heart disease who have become
seriously deconditioned by intercurrent, comorbid illnesses
Part of the identification process requires a determination of the specific
needs and goals of the patient. If these goals align with the primary goals of
cardiac rehabilitation, the patient may be a candidate, assuming there are
no risks of developing secondary complications. The primary goals of cardiac
rehabilitation include:9

Curtail the pathophysiologic and psychosocial effects of heart disease

Limit the risk for reinfarction or sudden death

Relieve cardiac symptoms

Retard or reverse atherosclerosis by instituting programs for exercise
training, education, counseling, and risk factor alteration

Reintegrate heart disease patients into successful functional status in
their families and in society
The primary goals listed above can be further broken down into short term
and long term goals. These goals are as follows:
Short-term goals:

"Reconditioning" the patient sufficiently enough to allow him or her to
resume customary activities

Limiting the physiologic and psychological effects of heart disease

Decreasing the risk of sudden cardiac arrest or reinfarction

Controlling the symptoms of cardiac disease
Long-term goals:10

Identification and treatment of risk factors

Stabilizing or reversing the atherosclerotic process
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
Enhancing the psychological status of the patients
Cardiac rehabilitation programs are incredibly beneficial when properly
administered. The following table provides an overview of the most
significant benefits associated with cardiac rehabilitation:11
Improved
Cardiac rehabilitation exercise training for patients with coronary
exercise
heart disease or congestive heart failure (CHF) leads to objectively
tolerance
verifiable improvement in exercise capacity in men and women,
regardless of age. Adverse outcomes or complications of exercise
are exceedingly rare. The nonfatal infarction rate is 1 patient per
294,000 patient-hours; the cardiac mortality rate is 1 patient per
784,000 patient-hours. The benefits are even greater in patients
with diminished exercise tolerance. This beneficial effect does not
persist long-term after completion of cardiac rehabilitation without a
long-term maintenance program. Therefore, exercise training must
be maintained long-term to sustain the improvement in exercise
capacity.
Control of
In patients with coronary heart disease, angina significantly
symptoms
improves during the cardiac rehabilitation exercise program.
Objective evidence of improvement in ischemia has been seen by
performing interval stress ECG or radionuclide testing. Similarly,
patients with LV failure or dysfunction show improvement in the
symptoms of heart failure. Use of gas analysis (CPX) has shown that
patients' exertional tolerance improves significantly with exercise
training.
Improvement in
Improvements in lipid and lipoprotein levels are observed in patients
the blood levels
undergoing cardiac rehabilitation exercise training and education.
of lipids
Exercise must be combined with dietary and medical interventions
for required lipid control.
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Effect on body
Exercise training as a sole intervention has an inconsistent effect on
weight
controlling excess weight. Optimal management of obesity requires
multifactorial rehabilitation, including nutritional education and
counseling, behavioral modification, and exercise training.
Effect on blood
Rehabilitation exercise training as a sole intervention has minimal
pressure
effect; however, multifactorial intervention has been shown to have
beneficial effects. Inconsistencies with this theory remain
unresolved.
Reduction in
Cardiac rehabilitation services with well-designed educational,
smoking
counseling, and behavioral modification programs result in cessation
of smoking in a significant number of patients. Cessation of smoking
can be expected in 16-26% of patients. This reduction is combined
with the spontaneously high smoking cessation rates following acute
coronary events.
Improved
Cardiac rehabilitation exercise and educational services enhance
psychosocial
measures of psychological and social functioning.
well-being
Reduction of
In multifactorial cardiac rehabilitation programs, improvement in
stress
emotional-stress measurements occurs, as does a reduction of type
A behavior patterns. This reduction of stress is consistent with
improvement in psychosocial outcomes that occurs in
nonrehabilitation settings.
Enhanced social
Cardiac rehabilitation exercise training improves social adjustment
adjustment and
and functioning.
functioning
Return to work
Cardiac rehabilitation exercise training exerts less influence on rates
of return to work than on other aspects of life. Many nonexercise
variables also affect this outcome (i.e., prior employment status,
employer attitude, economic incentives).
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Reduced
Scientific data suggest a survival benefit for patients who participate
mortality
in cardiac rehabilitation exercise training, but it is not attributable to
exercise alone. This survival benefit is due to multifactorial
interventions. A meta-analysis of post–myocardial infarction (MI),
randomized, controlled trials of exercise showed a 25% reduction in
mortality at 3-year follow-up. The magnitude of this benefit is as
large as that seen with the post-MI use of beta blockers or with the
use of ACE inhibitors in LV dysfunction along with MI. Trials that
involve exercise alone still show a 15% mortality reduction.
The scientific evidence pertaining to the relationship between cardiac
rehabilitation exercise training and mortality also includes scientific
reports that have appeared on the U.S. National Institutes of Health
Web site. Among the data in these reports was the finding, through
randomized trial, that 3-year coronary mortality and sudden death
rates were significantly lower (P < .02) in patients who, after
suffering myocardial infarction, underwent multifactorial cardiac
rehabilitation, starting 2 weeks after hospital discharge. This
beneficial outcome persisted at the 10-year follow-up.
Data/Statistics
The benefits achieved with cardiac rehabilitation are the result of the
regarding
combination of all its components. Approximately half of the
benefits
mortality reduction achieved by exercise-based cardiac rehabilitation
(28%) can be attributed to reductions in major risk factors,
particularly smoking.
Other factors may also contribute to the benefits of cardiac
rehabilitation. These include a reduction in inflammation (a decrease
in serum C-reactive protein concentration that is independent of
weight loss and other medical therapies), ischemic preconditioning,
improved endothelial function and a more favorable fibrinolytic
balance. Other important benefits of cardiac rehabilitation include an
increase of tolerated metabolic equivalents by 33% and of maximal
oxygen consumption by 16%.
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This improvement in exercise performance is associated with
beneficial effects on the quality of life and cardiovascular events.
Patient’s life quality benefits are also achieved through the
improvement of symptoms (lessening of chest pain, dyspnea and
fatigue), stress reduction and the enhancement of the overall sense
of psychosocial wellbeing.
The benefits of cardiac rehabilitation in patients with coronary
disease are summarized in two recent meta-analyses. One metaanalysis of 63 randomized trials with a total of 21,295 patients
showed a 17% reduction of recurrent myocardial infarction at 12
months and a 47% reduction of mortality at 2 years with cardiac
rehabilitation.
Another meta-analysis of 48 randomized trials with a total of 8,940
patients with coronary disease showed that cardiac rehabilitation
was associated with a significant reduction in all-cause mortality
(odds ratio [OR] =0.80; 95% [CI] 0.68 to 0.93) and cardiac
mortality (OR =0.74; 95% CI 0.61 to 0.96). There were no
significant differences in the rates of nonfatal myocardial infarction
and revascularization.
In a recent study of more than 600,000 Medicare patients
hospitalized for acute coronary syndrome, percutaneous coronary
intervention, or coronary artery bypass graft surgery, 73,049
patients (12.2%) participated in cardiac rehabilitation. After 1 yr.,
there was a 2.2% mortality rate for cardiac rehabilitation
participants vs. 5.3% for nonparticipants. This benefit was sustained
at 5 yrs. with a mortality rate of 16.3% for participants vs. 24.6%
for nonparticipants.
There was a dose–response relationship with cardiac rehabilitation.
Patients who attended 25 or more sessions had a 20% lower 5-yr
mortality rate than those who attended less than 25 sessions.
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The first studies showing the benefits of cardiac rehabilitation in
heart failure patients were small, monocentric with results that were
disputed.
ExtraMatch, a meta-analysis of 9 randomized studies, confirmed a
35% decrease in mortality for heart failure patients. A large
randomized controlled trial of exercise training in heart failure (HFACTION) involving 2331 patients with an ejection fraction of 35% or
less showed that exercise training can achieve significant reductions
(15%) in all-cause and cardiovascular mortality and heart failure
hospitalization. It should be noted that the initial analysis in
intention to treat did not show a difference between the exercise
training and the standard treatment groups. The positive result was
obtained after adjustment of pre-specified prognostic criteria.
Risks Of Cardiac Rehabilitation
Although cardiac rehabilitation has proven to be extremely beneficial to
patients recovering from cardiac events, there are some risks involved. The
following is an overview of the most common risks associated with cardiac
rehabilitation:14

In a contemporary study of over 25,000 patients participating in 65
cardiac rehabilitation centers in 2003, there was one cardiac event for
every 8484 exercise tests performed, one cardiac event for every
50,000 patient hours of exercise training, and 1.3 cardiac arrests for
every million patient hours of exercise.

The 2007 American Heart Association scientific statement on exercise
and acute cardiovascular events estimated that the risk of any major
cardiovascular complication (cardiac arrest, death or myocardial
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infarction) is one event in 60,000 to 80,000 patient-hours of
supervised exercise.

Patients most at risk are those with residual ischemia, complex
ventricular arrhythmia and severe left ventricular dysfunction (ejection
fraction of less than 35%), especially NYHA III or IV. The respect of
indications and contraindications and proper risk stratification are key
to the safety of cardiac rehabilitation.

Overall, modern cardiac rehabilitation is safe and well tolerated with a
very low rate of major complications such as death, cardiac arrest,
myocardial infarction or serious injuries.
The Cardiac Rehabilitation Team
While more than one member of the team can share many tasks, some
tasks require specific skills and training and should be performed by the
appropriate, designated health professional. Team members have different
backgrounds and training and therefore different areas of expertise. It is
important to determine in advance those tasks, which should be undertaken
by a designated team member and those, which may be shared by several
team members. Failure to do so can create tension within the team.7
Activities such as processing referrals, coordinating programs and following
up patients after program discharge may be allocated to any team member
who has good organizational and interpersonal skills and sufficient time
available to carry out these duties.
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Patient Cardiac Rehab Team Member
The patient is not often considered part of the cardiac rehabilitation, but it is
important to consider the patient’s role in the rehabilitation process.
Patients must be fully engaged in their treatment plan, especially with
cardiac rehabilitation programs. These programs require significant lifestyle
and dietary changes, and the patient will not be successful if he or she is not
fully engaged in the process. Therefore, treatment providers will need to
include the patient as part of the team from the beginning. When the patient
feels like an active member of the group, he or she is more apt to be fully
engaged in the process.130
Physician Cardiac Rehab Team Member
There are a number of physicians that may be part of the cardiac
rehabilitation team. The specific physicians involved will be determined by
the specific needs of the patient. In all instances, the patient’s general
practitioner will be a member of the team. However, some situations may
warrant the involvement of other physicians. In most instances, the cardiac
rehabilitation team will involve the following physicians:
General Practitioner
Referral to an ambulatory rehabilitation program should be organized before
the patient is discharged from hospital. However, the general practitioner
should confirm referral to the program at the patient’s first visit and
encourage the patient to attend. Failure of medical practitioners to advise or
encourage patients to attend a cardiac rehabilitation and secondary
prevention program is a major reason for poor participation rates. According
to one study, the strength of the primary physician’s recommendation to
attend a cardiac rehabilitation program was the most powerful predictor of
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attendance. The general practitioner should reinforce the goals of
rehabilitation, ensuring that the patient understands the expected benefits of
the program and the functions of other team members. To fulfill these roles
adequately, the general practitioner needs sufficient information about the
aims and content of cardiac rehabilitation and secondary prevention
programs. Information about available programs should be circulated to
general practitioners.
General practitioners consider that their role in cardiac rehabilitation has
been limited to date and that they are underutilized as a resource. In their
opinion, cardiac rehabilitation offers opportunities for a shared care approach
in which their input could be very valuable. While recognizing that the
cardiologist is in charge of the medical management of patients in hospital,
the general practitioner is in an ideal position to put follow-up plans into
action and to coordinate the patient’s medical management after discharge
from hospital. To maximize the contribution of the general practitioner, the
cardiologist should involve the general practitioner in the early stages of
each patient’s recovery and provide clear guidelines on how to manage
patients following their acute events. Follow-up of patients by the general
practitioner may be further improved if the general practitioner was
informed of the patient’s admission to hospital and was able to visit the
patient in hospital.
The general practitioner is primarily responsible for the long-term medical
follow-up of patients and for assisting patients to maintain healthy lifestyle
changes. Thus, the general practitioner has an important educational role,
especially after the patient completes the ambulatory group program. The
program coordinator should ensure that the general practitioner receives a
discharge summary about what the patient has achieved at the program.
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Any difficulties the patient is experiencing on completion of the program
should also be communicated. This information should be sent to the general
practitioner directly, as well as recorded on a card for the patient to take to
the general practitioner.
A patient held record may encourage patients to take increased
responsibility for their health. Early communication with the general
practitioner should minimize the likelihood of patients receiving conflicting
information. The general practitioner has continuing responsibility for
ensuring that there is long-term satisfactory control of patients’ symptoms,
lipids, smoking habit, blood pressure, diabetes, weight and wellbeing. This
may necessitate intermittent or regular testing, as indicated by national or
other current guidelines.8,11,131
Cardiologist
Cardiac rehabilitation and secondary prevention programs include a
significant component of education concerning medical topics. These topics
include cardiovascular disease risk factors, the development of coronary
heart disease, acute cardiac events, procedures and investigations. It is
essential that patients and family members receive accurate medical
information from team members. Thus, the cardiologist should define the
medical parameters of the program from the outset, reviewing the medical
content at intervals to ensure information is current and accurate.
Some cardiologists have expressed concern that inaccurate medical
information is given by nurses and allied health workers during cardiac
rehabilitation and secondary prevention programs. Further, they maintain
that nurses often give restrictive dietary advice to patients and that
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information provided to patients by general practitioners often conflicts with
advice from cardiologists.
Better communication between cardiologists, general practitioners and other
team members could minimize the amount of conflicting and inappropriate
advice. While cardiologists do not generally play an active role within group
cardiac rehabilitation programs, they can make a significant contribution by
referring patients to programs, encouraging them to attend, enquiring about
the patient’s progress at the program and supporting the roles of other team
members.
Where possible, it is highly desirable for the cardiologist to facilitate an
occasional group discussion during the outpatient program. Occasional brief
visits by the cardiologist to a group discussion or an exercise session are
also much appreciated by patients. Patients perceive the cardiologist as an
authoritative figure. The cardiologist’s participation in, or visit to, the group
enhances patients’ acceptance of the program as being important to their
recovery. Furthermore, the cardiologist should supervise the discharge
review and, if undertaken, the discharge exercise test. In some larger city
hospitals, the registrar or resident may participate in place of the
cardiologist.124,132-138
Nursing Cardiac Rehab Team Members
Nurses are involved in most ambulatory cardiac rehabilitation and secondary
prevention programs. Their primary role is to detect medical and other
problems, and to refer patients to other health care providers, when
required. Nurses are also extensively involved in patient education. They
commonly facilitate group discussions on heart disease, risk factors for
cardiovascular disease and other medical topics.
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In many smaller hospitals and community health centers, nurses are
responsible for a greater range of activities, including conducting exercise
sessions and recruiting patients to programs. Nurses provide continuity for
patients after discharge from hospital and are often perceived by patients to
be the program coordinator.5
Specialist Cardiac Rehab Team Member
Physical Educator
A physical educator may conduct exercise sessions and supervise patients
with cardiovascular disease, providing appropriate additional training has
been obtained. Previous experience with cardiac patients, especially those
who have recently suffered an acute cardiac event or those who are aged
and infirm, is also required.139
Physiotherapist
The physiotherapist is mainly concerned with the physical aspects of the
patient’s recovery. Specific roles of the physiotherapist include assessing the
physical needs and cardiovascular fitness of patients at entry to the
program, prescribing exercise to minimize the deconditioning effects of
physical inactivity and promoting reconditioning. The exercise program
needs to be flexible and adapted to the needs of the individual patient. It
should aim to facilitate recovery to a level necessary for patients to resume
their work and other activities of daily living. The physiotherapist is
considered best equipped to design and conduct exercise sessions.140
While focusing particularly upon the patients’ physical needs, the
physiotherapist will also address emotional concerns of patients and explore
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any perceived barriers to exercise. For those patients who have been almost
totally inactive, the physiotherapist needs to design an acceptable exercise
program, encouraging such patients to initiate and continue the
recommended exercises.11
Other key roles of the physiotherapist include monitoring patients during
exercise sessions. Pain and other physical problems reported by patients
need to be assessed by the physiotherapist. The physiotherapist should
provide practical advice to patients about what they can and cannot do
safely, including any sporting activities. Patients seeking to exercise at high
levels require particular attention and usually require medical clearance.
Such patients may benefit from referral to a trained exercise therapist. The
physiotherapist may play a useful role in addressing the work requirements
of patients, especially if the job is physically demanding. In this respect, the
role of the physiotherapist may overlap to some extent with that of the
occupational therapist.119
Occupational Therapist
The occupational therapist plays in integral role in the cardiac rehabilitation
process. As part of the cardiac rehabilitation team, the occupational therapist
works with the patient to help him or her develop effective and independent
functioning skills related to employment, family, social and recreational
activities. Where this is not possible or appropriate, the occupational
therapist should assist the patient to live as productive a life as possible
within any constraints imposed by the cardiac condition or other
limitations.141
The occupational therapist will provide vocational assessments to determine
the feasibility and capacity of the patient to resume work at a reasonable
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level of physical or other occupational demand. To prepare the patient for
resuming work, the occupational therapist will assist the patient with work
conditioning and, if required, may also conduct simulated work tests and
visit the worksite. The occupational therapist also assesses the patient’s
functional status and potential for resuming usual activities of daily living.
Leisure and social activities are assessed. Realistic goals are set and
activities are prescribed, which are functionally based. The skills acquired by
the patient can then be transferred to the home or work setting.142
While occupational therapists have a particular role in facilitating
occupational recovery of the patient, their training is broadly based and they
can contribute to the program in several areas and back up. For example,
stress management sessions are sometimes conducted by the occupational
therapist. Occupational therapists are involved in patient education and
counseling and are trained in-group dynamics and facilitating groups.
In some programs, the occupational therapist participates in the group
exercise sessions. It is important for other team members to refer patients
to the occupational therapist, if there are perceived occupational
problems.143
Although the roles of the occupational therapist and physiotherapist may
overlap, their primary functions differ, with the physiotherapist using
exercise and physical modalities to improve physical status, while the
occupational therapist’s approach is a functional one, which applies the
patient’s skills to perform a wide range of activities of daily living or at work.
However, as revealed by surveys of cardiac rehabilitation programs, either
team member may undertake many tasks. Typically, however, the
occupational therapist is more involved in the later stages of the patient’s
recovery rather than in hospital.144
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Dietitians/Nutritionists
The dietitian/nutritionist is an integral part of the cardiac rehabilitation team.
His or her primary responsibility involves providing group and individual
counseling about nutrition and appropriate dietary habits. Patients receive
some initial dietary guidelines at the onset of their cardiac condition (either
from the hospital staff or their general practitioner), however, dietary advice
is best provided by the dietitian during the outpatient program when more
time is available. Most nutrition counseling will occur over a period of weeks,
especially for those with limited ability to comprehend dietary information.
For the most part, regularly scheduled dietary sessions are recommended,
as many patients are unable to process all of the necessary information at
once.145
During the preliminary stages of education and counseling, patients will
receive information about healthy dietary habits and explanations about food
labels. This information will help them make informed choices about their
diet. Practical advice about the preparation of food is also vital. Dietary
information needs to be realistic, simply presented and easy to follow. Once
the patient receives the foundational dietary education, the remainder of the
program will be tailored to provide individual advice specific to the patient’s
needs.8
An important function of the dietitian is to clarify misconceptions about diet
and nutrition. There is considerable confusion in the community, among
health care providers, and even among dietitians themselves, about dietary
guidelines. Moreover, guidelines seem to change intermittently. As a result,
patients receive conflicting dietary advice from different health care
providers and are understandably confused about which advice they should
follow.146
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Mental Health Specialists
Many patients will require mental health care as part of the cardiac
rehabilitation process. In some instances, patients will require counseling or
mental health treatment to help them cope with the lifestyle changes
brought about because of the cardiac condition. Other patients may require
mental health treatment to help reduce stress and anxiety levels, which can
further exacerbate cardiac problems. If a patient is already receiving mental
health care for unrelated conditions, the mental health provider will need to
be involved in the treatment process to ensure the treatment does not affect
the patient’s mental health status.135 The following is a list of the types of
mental health providers that may be involved in the treatment
process:5,7,121,132

Psychiatrist
The psychiatrist’s role in cardiac rehabilitation programs is primarily to
manage patients with a psychiatric illness or psychiatric symptoms.
Psychiatric referrals are appropriate only for a minority of patients,
such as those with a premorbid psychiatric illness, which is
exacerbated by the cardiac event, or illness. The social worker,
psychologist and other staff trained or experienced in counseling are
able to help most patients who are experiencing psychological
problems, referring them to a psychiatrist if it is indicated.

Psychologist
Psychologists have a role in conducting relaxation or stress
management sessions. The psychologist may also be trained in
individual and group counseling and can therefore facilitate sessions
with patients and spouses. In undertaking counseling and stress
management, the psychologist’s role overlaps to some extent with that
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of the social worker and the occupational therapist. The roles of the
psychologist may also include assessing the psychological status or
cognitive functioning of cardiac patients and relaying the results to the
doctor and other team members. Such information can be useful in
developing the patient’s rehabilitation plan.
Clinical psychologists can also make a significant contribution by using
behavioral strategies to help patients acquire skills to change and
maintain healthier behaviors. This aspect of secondary prevention
needs further development in cardiac rehabilitation programs.
Psychologists should be more extensively involved in programs to
address this need.
Primary Components Of Cardiac Rehabilitation Programs
Traditionally, cardiac rehabilitation is divided into three phases. All phases of
cardiac rehabilitation aim to facilitate recovery and to prevent further
cardiovascular disease. These are described below:121,140,147,148
Cardiac Rehab: Phase I
Phase I or inpatient phase is initiated while the patient is still in the hospital.
It consists of early progressive mobilization of the stable cardiac patient to
the level of activity required to perform simple household tasks. The shorter
hospital stay with modern cardiology makes it difficult to conduct formal
inpatient education and training programs. Thus inpatient cardiac
rehabilitation programs are mostly limited to early mobilization to make selfcare possible by discharge, and brief counseling about the nature of the
illness, the treatment, risk factors management and follow-up planning.
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Cardiac Rehab: Phase II
In most programs, phase II is a supervised ambulatory outpatient program
of 3 to 6 months duration which consists of outpatient monitored exercise
and aggressive risk factor reduction.
Cardiac Rehab: Phase III
Phase III is a lifetime maintenance phase in which physical fitness and
additional risk-factor reduction are emphasized. It consists of home- or
gymnasium-based exercise with the goal of continuing the risk factor
modification and exercise program learned during phase II. The American
Heart Association, the American College of Cardiology Foundation and the
American Association of Cardiovascular and Pulmonary Rehabilitation have
outlined the core components of contemporary cardiac rehabilitation and
secondary prevention programs and produced guidelines for detection,
management and prevention of cardiovascular disease. These core
components include patient assessment, exercise training, physical activity
counseling, tobacco cessation, nutritional counseling, weight management,
aggressive coronary risk-factor management and psychosocial counseling.
The following table provides a detailed overview of the primary components
of the rehabilitation process:5,10,11,142,149-152
Patient
In order to guide the patient through the different aspects of cardiac
assessment
rehabilitation, to meet his individual needs and to optimize his
benefits, a risk profile of the patient needs to be established through
a complete physical and mental evaluation done at the initiation of
the cardiac rehabilitation program. The goal is to insure a safe
environment for the patient and to facilitate patient care with
minimal risk. This evaluation will help set the goals of cardiac
rehabilitation for the patient.
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Before the exercise training, a symptom-limited exercise test is
undertaken for prognostic, diagnostic, and therapeutic purposes. At
the end of the participation, some centers routinely perform another
evaluation to verify if the goals have been met and to find ways to
ensure a continued patient progress in the long term.
Exercise
The scientific data clearly establish that exercise training results in
Training
improvements in exercise tolerance. Appropriately prescribed and
conducted exercise training is therefore a key component of cardiac
rehabilitation.
Meyers, et al., showed that improvement of 1 metabolic equivalent
in functional capacity imparts a 12% reduction in all-cause mortality.
More recently, Jolly et al., showed that abnormal heart rate
recovery, which is a predictor of mortality, can be normalized with
exercise training with improvement in mortality.
Exercise protocols should include not only endurance but also
resistance training, as improvement in muscle strength could benefit
patients’ performance of activities of daily living. A variety of
material is used for patients’ endurance and resistance training.
These include treadmills, steppers, weights, rowers, elliptical
trainers, exercise bikes, dumbbells, etc. Swimming pools can be
very helpful for the training of highly debilitated patients.
A baseline symptom-limited exercise test is used to stratify patients’
risk for cardiac events before exercise training. An exercise
prescription is developed based on the result of the exercise test and
includes the type, the intensity, the duration, and the frequency of
the exercise.
Patients covered by health insurance, Medicaid or Medicare are
offered exercise training at a frequency of three times weekly for 8
to 12 weeks. Exercise training sessions are usually of 45 minutes
duration.
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In an effort to address the problem of discrepancies in response to
cardiac rehabilitation and the increasing rate of obesity in cardiac
rehabilitation participants, exercise modalities other than the
traditional moderate-intensity protocols have been studied recently.
High-intensity interval aerobic exercise program and high-calorieexpenditure exercise program are two such modalities recently
studied. High-intensity interval aerobic exercise training programs
have shown greater improvements in exercise performance and
hemodynamic benefit when compared to moderate-intensity
exercise training in patients with stable CAD and heart failure with
no significant increase in complications.
Exercise protocols for this modality vary. In one study, the exercise
program consisted of a 10-minute warm-up period at 50 to 60
percent of VO2max followed by four 4-minute intervals at 90 to 95
percent peak heart rate (Rate of Perceived Exertion 17±1), with
intervals separated by three-minute periods of walking at 50 to 70
percent of peak heart rate.
Ades et al., developed another variation called high-calorieexpenditure exercise training, which they compared to the standard
cardiac rehabilitation exercise in participants who were overweight
or obese and who had ischemic heart disease. This program
achieved a much higher exercise-related energy expenditure (30003500 kcal/week) compared to the usual care (700-800 kcal/week)
with patients walking at lower intensities (50-60% peak VO2) for
longer durations and more often.
Ades et al., showed a significantly greater weight loss with
improvement in insulin resistance and lipid profiles.
Physical activity
Regular physical activity has been shown to have many
counseling
cardiovascular benefits including weight loss, blood pressure
reduction, glycemic control and lipid profile improvements.
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A meta-analysis of 11 exercise rehabilitation randomized trials
including 2285 patients showed that regular exercise was associated
with a significant 28% reduction in all-cause mortality (6.2% versus
9.0%, risk ratio 0.72, 95% CI 0.54-0.95) and a possible but
nonsignificant 24% reduction in recurrent myocardial infarction (risk
ratio 0.76, 95% CI 0.57-1.01).
Most guidelines recommend that exercise should be performed for a
minimum of 30 minutes per day at least five days per week and
preferably daily, should involve moderately intensive (target heart
rate of 60 to 75 percent of the average maximum heart rate or the
perception of moderate exercise 12 to 14 on the Borg scale) aerobic
activity such as brisk walking and should be supplemented by an
increase in daily lifestyle activities (i.e., walking breaks at work,
gardening, and household work).
There seems to be a dose-response relation between physical
activity and Health in general and coronary heart disease in
particular. A meta-analysis by Sattlemair, et al., found that “some
physical activity is better than none” and “additional benefits occur
with more physical activity.”
Tobacco
Smoking cessation is the most important and the most cost-effective
cessation
of all the lifestyle modifications recommended to prevent
cardiovascular disease. Several large observational studies and a
meta-analysis showed a substantial reduction in mortality [RR: 0.64
(CI: 0.58-0.71)] in patients with a history of MI, CABG, angioplasty,
or known CHD, who quit smoking compared with patients who
continued to smoke. The overall mortality risk of smokers who quit
decreases by 50% in the first couple of years and tends to approach
that of nonsmokers in approximately 5-15 years of cessation of
smoking. Nevertheless, smoking cessation is often challenging, as
tobacco dependence is a complex phenomenon that includes not
only physical and psychological addiction but also social and
behavioral components.
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A personalized consultation with an emphasis on both smoking
history and the exposure to second-hand smoke is offered to
smokers to enable and consolidate smoking cessation.
Many tools are used for smoking cessation and they include
pharmacologic assistance (nicotine substitutes, bupropion,
varenicline), counseling, education and group support.
Nutritional
The aim of nutritional counseling in cardiac rehabilitation is to help
counseling
patients understand the impact of food on one’s health and make
healthy food choices. For that reason, the dietician gathers baseline
daily caloric intake and dietary information. Recommendations are
given to patients tailored on their individual diet profile. Dieticians
organize practical workshops to teach patients healthy eating habits,
label reading and cooking demonstrations.
General dietary recommendations for cardiac patients include a
reduced intake of saturated fats (<7% of total calories) and
cholesterol (<200 mg/d), increased intake of polyunsaturated (about
10% of total calories) and monounsaturated fats (20% of total
calories), an adequate repartition of calorie sources (about 50-60%
of total calories for carbohydrates, 15% for protein and 25-35% for
fat) and increased fiber intake (about 20-30 g/d).
Based on recent studies in nutrition and cardiovascular disease,
there has been specific recommendations for patients with heart
disease that emphasize moderation and plant-based food.
Weight
The negative effects of overweight and obesity on physical activity
management
and the incidence of hypertension, cholesterol and diabetes have
been confirmed in many studies. Anthropometrics measurements
are taken during visits at cardiac rehabilitation centers. Patients are
instructed on their specific weight issues and on methods that can
help achieve a healthy body weight through a combination of
decreased caloric intake and increased caloric expenditure.
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All the other aspects of cardiac rehabilitation will also have an
impact on weight improvement and maintenance.
The American Heart Association released a Scientific Statement in
2011 regarding weight management strategies for busy ambulatory
settings. The goal of weight management is body mass index of
18.5-24.9 kg/m2 and waist circumference of <40 inches in men and
<35 inches in women. The initial goal of weight loss therapy should
be to reduce body weight by approximately 10% from baseline. With
success, further weight loss can be attempted if indicated through
further assessment.
Lipid
Hypercholesterolemia is the risk factor with the highest percentage
management
of attributable risk post myocardial infarction. Yusuf et al. showed
that every 1 mmol/L (38.7 mg/dL) decline in LDL cholesterol results
in a 21% decrease in cardiovascular events. Unfortunately this risk
factor is often overlooked. Euroaspire studies have shown that this
risk factor is not well controlled and that there have only been weak
improvements in the percent of patients attaining target LDLcholesterol values (33% to 41%). Many aspects of cardiac
rehabilitation will contribute to improve patients' lipid profile. These
include physical exercise, nutritional counseling and weight
management. Pharmacologic treatment is often added to
therapeutic lifestyle changes to achieve LDL-cholesterol targets.
Blood pressure
High blood pressure is very prevalent among patients referred for
management
cardiac rehabilitation. A decrease in systolic blood pressure by 10
mmHg can decrease cardiovascular mortality by 20-40% and a
reduction of diastolic blood pressure by 5-6 mm Hg results in a
reduction of stroke risk by 42% and Coronary heart disease events
by 15%. For many patients at cardiac rehabilitation centers,
medications for high blood pressure will be a new reality they are
dealing with because those medications would have been introduced
only a few weeks earlier at the time of their cardiac event.
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During cardiac rehabilitation sessions, they will learn the importance
of blood pressure control, the medications and their side effects, the
measures of therapeutic life changes that will have an impact on
their blood pressure and the use of blood pressure devices.
Understanding of the disease and its treatment will certainly improve
patients' compliance and reduce the risk associated with high blood
pressure.
Diabetes
About 26% of patients referred to cardiac rehabilitation have
management
diabetes. These patients have a particularly high cardiovascular risk
profile. The majority (93%) will have another associated risk factor
(smoking 16%, hypertension 54%, hypercholesterolemia 51%,
overweight 40%, obesity 34%).
Therapeutic education is a very important tool that helps improve
diabetes control. Because of their multidisciplinary approach and the
use of therapeutic education tools, cardiac rehabilitation programs
can help achieve a better glycemic control. This has been shown to
reduce cardiovascular morbidity and mortality.
The goal of diabetes management is to maintain glycosylated
hemoglobin (HbA1c) concentration of <7%.
Management of
Patients with heart disease are often confronted with psychological
Psychosocial
and social problems that can affect both morbidity and mortality.
and
Depression, anxiety, and denial occur in up to 20% of patients
professional
following myocardial infarction. During cardiac rehabilitation follow-
issues
up, patients undergo a routine screening to identify anxiety,
depression, substance abuse and familial or other social problems.
The social workers and others professionals involved in the
multidisciplinary team in cardiac rehabilitation centers provide
patients with the information and the help they need to plan for their
return to work and to a normal life.
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Medical, psychological and social interventions tailored to individual
problems are offered and have been shown to improve outcomes.
The INTERHEART Study quite clearly demonstrated that stress was
the third most important risk factor for coronary events, following
lipids and smoking, and accounts for approximately 30% of the
population’s attributable risk of acute MI.
Psychosocial stress affect cardiovascular disease process through the
increase in blood pressure, blood glucose, lipid levels and body
weight. It also promotes the progression of atherosclerosis,
inflammation and endothelial dysfunction. Exercise training has been
associated with reductions in stress and its related mortality. Many
cardiac rehabilitation programs also offer stress management
workshops to help patients identify, avoid and deal with stressful
situations.
Cardiac rehabilitation is therefore an important therapeutic tool for
distressed cardiac patients. Besides exercise training, many cardiac
rehabilitation centers offer other stress reduction techniques training
including meditation, relaxation breathing, yoga, etc.
Alcohol drinking
Moderate alcohol consumption (1-2 drinks per day) is associated
with a reduced cardiovascular and all-cause mortality compared with
both abstinence and heavy drinking. In a pooled estimate from five
prospective cohort studies of patients with coronary heart disease,
patients who consumed small to moderate amounts of alcohol daily
had a 20 percent reduction in cardiovascular mortality (relative risk
0.80, 95% confidence interval [CI] 0.78-0.83) compared to
nondrinkers. A meta-analysis by Costanzo, et al., found J-shaped
curves for alcohol consumption and mortality, with a significant
maximal protection against cardiovascular mortality with
consumption of approximately 26 g/d and maximal protection
against mortality from any cause in the range of 5-10 g/d.
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The pattern and amount of alcohol intake appears to be more
important than the type. Possible explanations for moderate alcohol
consumption benefits include: HDL increase by stimulating the
hepatic production of apo A-I and A-II, fibrinogen levels reduction,
fibrinolysis stimulation, inflammation reduction and inhibition of
platelet activation.
Medical Evaluation
Prior to beginning a cardiac rehabilitation program, patients will require a
thorough medical assessment and evaluation to determine eligibility. This
assessment will also be used to determine the level of programming required
for the patient. The rehabilitation program will be tailored to meet the
specific needs of the patient.
The following is a list of key points to keep in mind regarding the initial
patient assessment:153

Before patients are enrolled into the program, an interview and
assessment are required, either individually or together with another
family member (usually the spouse).

Approximately 30 minutes are required for assessment of each patient.
Either, or both, of the health professionals conducting the exercise
class can undertake this enrolment interview.

A referral note from the patient’s medical practitioner will best support
the entry assessment, preferably with relevant clinical information.
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
Hospital records should be sought to provide in-hospital data including
diagnosis, symptoms, medications, advised restrictions and perceived
patient difficulties.

The entry assessment should address the patient’s specific goals
regarding resumption of work and activities of daily living, since these
may influence the duration and pace of the exercise training. It should
also clarify needs for specific muscle strengthening related to work,
social or leisure activities.
Physical Activity Program
The physical activity program will be categorized into three groups based
upon the intensity level of the programming. In most instances,
categorization will be done using Berg’s scale, or by heart rate.
Categorization can also be based upon correlating activities with metabolic
equivalents (METs). However, when METs are used, it is important to factor
in age and cardiovascular disease status of the patient, for example:

1 MET is the oxygen consumption at rest, measured as 3.5ml
O2/Kg/min.

2 METs would be equivalent to strolling at about 3kms/hour for a
healthy person.

3.5 METs should be equivalent to walking at about 5kms/hour (the
usual walking pace for a middle-aged male).120
One could therefore suggest that 3.5 METs is light exercise; that would be so
for a healthy male. It may well be a high level of activity for an elderly
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woman, for a patient with controlled or compensated heart failure or for a
patient deconditioned by a long period of immobilization in hospital. The
chart below outlines an exercise program with patient perceptions and
physical responses to varied levels of exercise.139
Exercise
Training
Level
Rate of Perceived Exertion
(BORG)
Very, very light
% of Maximal
Heart Rate on
Test
Increment over
Resting Heart
Rate
50 – 65%
10 – 25
60 – 75%
20 – 35
70 – 85%
30 - 55
6
7
8
Very light
9
10
LOW
Light
11
12
MODERATE
Somewhat hard
13
14
HIGH
Hard
15
16
Very hard
17
18
Very, very hard
19
20
The following table provides an explanation of the appropriateness of the
three categories of intensity, as well as a recommendation for a standard
program:13,77,154-157
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Low intensity
Low intensity exercise is acceptable to almost all patients. It can
exercise
be managed by the elderly and by patients with incipient or actual
heart failure. It is associated with little risk and requires little
supervision. However, some monitoring is needed for the disabled
and those with congestive heart failure.
Moderate intensity
Moderate intensity exercise is acceptable to many patients. It
exercise
may prove difficult to incorporate into daily living activities on a
long-term basis and can lead to musculoskeletal injury in the
elderly. It may not initially be within the capacity of many older
patients and probably should not be attempted by those with
heart failure except with careful supervision.
High intensity
Only a small minority of patients embraces high intensity
exercise
exercise. It is a barrier to participation in cardiac rehabilitation for
the elderly, the obese and for most middle aged or older women.
It is beyond the capacity of those with heart failure or significantly
impaired left ventricular function and requires prior testing for
safety and determination of a training heart rate. High intensity
exercise requires monitoring. Further, it is unlikely to be
subsequently incorporated into the life activities of most patients.
For some patients, however, high intensity exercise training is a
desired level of activity, particularly for younger males who are
usually of higher socioeconomic status and who are in a position
to continue such activity in a social or gymnasium environment. It
may also be desirable for rapid reconditioning of those in
physically demanding work. The need for high intensity exercise
has now been questioned in and many programs now offer
moderate intensity exercise training. While high intensity exercise
represents the quickest method of achieving or regaining fitness,
it is the most demanding on resources and costs. Further, it
delivers a program with limited appeal and with poor equity of
access.
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Recommendation
Low to moderate levels of physical exercise training, coupled with
regular physical activity at home, approaches that of high
intensity exercise training as a mode of enhancing physical
working capacity. High intensity and low intensity exercise
training appear to be equally effective in accelerating psychosocial
recovery. Thus, low to moderate intensity exercise is
recommended as best practice for cardiac rehabilitation programs.
As well as producing comparable physical benefits to those
achieved through high intensity exercise, it is acceptable to a
larger proportion of the population with greater safety. Further,
because of the reduced need for technology and medical
supervision, low to moderate intensity exercise training programs
can be delivered at low cost.
Currently, most authorities recommend supervised exercise of
high or moderate intensity three times weekly (preferably not on
consecutive days) for 12 weeks. This is based upon acceptance
that improvement in physical working capacity tends to plateau
from 10 to 21 weeks in such programs. It has been accepted that
if high intensity exercise training lasts for longer than half an
hour, the chance of musculo-skeletal injury is increased. Further,
it has also been confirmed that the risk of injury is greater if
exercise training occurs more frequently than on alternate days.
The concept of exercising three times per week for 12 weeks (36
training sessions), with electrocardiographic monitoring, either
with telemetry or other methods (limited leads or defibrillator
paddles), has been the basis of programs throughout the United
States. It is recognized that this requirement needs to be changed
(for example, there has been no defined insurance funding for
non-ECG monitored programs, nor for education programs or
psychosocial support of individual patients who may well require
additional personal attention).
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Exercise programs should be structured with the following components in
place:
Safety Protocols
With low intensity exercise training programs, risk of a cardiac event is very
small. However, it is essential that staff have current training in
cardiopulmonary resuscitation. A written emergency protocol is required,
together with a telephone accessible to staff to generate assistance if
required.
Access to medical and pharmaceutical support is dependent upon the
availability of either an ambulance or a medical practitioner. A simple
manually controlled ventilator and plastic airways are desirable. Nitroglycerin
should be available for patients who may develop chest pain and it is
desirable to have an oral diuretic (furosemide) on site for patients with heart
failure. However, the administration of a diuretic should only be after
medical advice. Healthcare staff requires knowledge of the indications for
and use of nitrates for patients with angina and of diuretics for heart failure.
Additional equipment and training are mandatory for high intensity exercise
programs. The equipment includes a resuscitation cart and a defibrillator,
which must be regularly maintained and checked. Healthcare staff requires
training in the use of the defibrillator and the contents of the resuscitation
cart. Monitoring may be by heart rate, intermittent rhythm strips by
electrocardiography or use of the defibrillator panels. This applies
particularly to those assessed as being at high risk. Telemetered
electrocardiography may be required for monitoring of the occasional patient
who is thought to be subject to serious arrhythmias.
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Equipment
It is possible to conduct cardiac rehabilitation exercise programs with little
equipment and maintain the principles of best practice at low cost. The
decision regarding equipment is partly secondary to the decision regarding
the level of exercise training. For low to moderate level exercise, it is
necessary to have a stethoscope and sphygmomanometer.
Exercise equipment may be limited to simple items such as buckets, bricks,
boxes, baskets, cases or weights. A set of steps to accommodate several
patients, or sets of steps to be used by individual patients, can be useful.
Treadmills for walking are expensive and unnecessary. Stationary cycles
with air or mechanical resistance occupy relatively little space and are not
expensive. An indoor walking area is desirable, but outdoor walking, if
feasible, may be preferred. High intensity exercise may be undertaken using
similar equipment, but additional safety equipment is required, as noted
above.
Content of Exercise Classes
Low to moderate intensity exercise may be undertaken without the warm up
and cool down periods required for high intensity exercise. However, it is
generally desirable, particularly with older, obese or unfit patients who may
have reduced flexibility, to start with a warm up period of light calisthenics
and stretching of major muscle groups. Stretching may be largely limited to
the legs and spine if the activity program is based upon walking, use of
steps or stationary cycling. Patients after sternotomy should include upper
body flexibility exercise as a part of their warm-up. It is desirable to take
patients through a series of activities before starting dynamic exercise or
strength training exercise, particularly if using the arms with cranking,
pushing, pulling or lifting.
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The program may be largely based upon walking, which may be maintained
for 20 to 30 minutes. A circuit of different activities may also be performed
at levels short of breathlessness, with monitoring of perceived exertion
and/or heart rate after each station where activities may be maintained for
up to five minutes at a level acceptable to the patient. Patients should be
observed and should also be requested to report any symptoms or
difficulties in performance of individual exercises.
Blood pressure should be checked during pauses between exercises in new
patients to note possible fall of blood pressure during activity. Blood
pressure should also be checked in those patients known to have, or who are
found in the class to have, elevated blood pressure. If significant variation of
blood pressure is noted, exertion should cease until medical clearance is
obtained.
A record of the exercise intensity, duration, heart rate or perceived exertion
should be charted for each patient at each attendance. Any problems
encountered by patients or staff related to symptoms, abnormal blood
pressure or heart rate should be reported to the patient’s doctor. A cool
down period with gradually lessening levels of activity, followed by a period
of rest, relaxation and breathing exercises, is commonly practiced and
appreciated by patients. The total duration of a low to moderate intensity
exercise training session should be between 45 to 60 minutes, including
rests between activities. For high intensity exercise, usually continuous, the
exercise time is usually 20–30 minutes.
Staffing
While a multidisciplinary team of health professionals may conduct education
groups, physiotherapists, exercise physiologists or appropriately trained
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nurses, occupational therapists or other health professionals are best trained
to conduct exercise classes. Nurses and physiotherapists conduct most
exercise programs, with the exercise program usually designed by a
physiotherapist.
Low to moderate intensity exercise programs may be conducted by a single
health professional, provided there is another health professional available
as back up and provided patients have no medical contraindications to
exercise. Such programs are suitable for small communities with a small
number of patients. This represents a “basic facility.” The key to such
programs is adequate staff training and the development of a support
network for the health professional involved. Such supports are most readily
available through a community health center or local hospital.77.154.158-163
Counseling and Education
Exercise training has traditionally been the primary focus of cardiac
rehabilitation programs. However, education and counseling are now
considered as important as exercise training in facilitating recovery from
acute cardiac events and for secondary prevention of cardiovascular disease.
Exercise training, education and counseling are now universally recognized
as integral components of comprehensive cardiac rehabilitation.164
To facilitate a return to normal living, patients require guidelines about
resuming driving, sexual activity, work and other activities. In addition,
information and advice about lifestyle change are necessary for secondary
prevention of cardiovascular disease. Motivation to adhere to advice and
prescribed medication is strongly influenced by the patient’s understanding
of the disease, the acute event and the need for risk factor modification.
Behavioral and psychosocial counseling may be delivered effectively in-group
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settings. However, specific instruction regarding behavior change should also
be offered on an individual basis so that interventions can be tailored to the
specific needs of each patient. Individual counseling may be required for
some patients.165
The educational level of patients will have a significant impact on their ability
to retain information. Many patients are unable to comprehend or retain
information due to a limited education or literacy skills. Age may also
influence retention of information. The specific needs of patients and their
receptivity to information must be considered, since some information may
not be thought important by individual patients. It is important for the
educator and the patient to engage in joint goal and priority setting at the
beginning of the rehabilitation process. This will help the patient maximize
the benefits of the program.166
The quality of the intervention and education program will play a crucial role
in the success of the patient. For example, educational strategies may be
unsuccessful because the information given was too advanced or too
general. In other instances, the educational counseling may be ineffective
because different health professionals often give contradictory information
and advice. If the educator is giving different information and
recommendations than the general physician, the patient will be confused
and unsure of which guidelines to follow. Clarification is therefore required to
reduce confusion. Information needs to be repeated and reinforced.160
Education and counseling programs should cover several specific, defined
topics. However, depending upon the particular groups of patients attending
and their specific needs, some subjects may be omitted, addressed only
briefly or expanded. Topics should address questions commonly asked by
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patients. The following subjects represent the core content of a typical
education and counseling program for patients with cardiovascular
disease:167

Medical topics
o Anatomy, physiology and pathology of cardiovascular disease
o Coronary heart disease/ischemic heart disease
o Acute cardiac events
o Investigations and procedures
o Symptoms and their management
o Cardiac medications

Modifiable risk factors
o Smoking
o Raised lipids, nutrition and dietary fat
o High blood pressure
o Overweight, obesity and diabetes
o Physical inactivity
o Other risk factors

Non-modifiable risk factors
o Older age
o Male gender
o Positive family history

Behavioral and psychosocial topics
o Behavior change and adherence to medication and advice
o Mood and emotions
o Psychosocial risk factors and social support
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o Stress
o Impact upon the spouse and family
o Sexual activity and activities of daily living
o Return to work
Many patients will require an education program that provides clear
explanations of the disease process and potential risk factors. When
describing acute cardiac events (such as acute myocardial infarction,
coronary artery bypass surgery and percutaneous transluminal coronary
angioplasty), it is important to use clear and concise language that is free
from medical jargon. This approach is also necessary when discussing
investigations and procedures including coronary angiogram, exercise tests,
electrocardiography, echocardiography and nuclear cardiography.168
It is necessary for facilitators to be aware of the benefits of frequently
prescribed drugs so that they can answer questions commonly asked by
patients. Cardiac medications, their purpose and beneficial effects should be
explained simply, noting common side effects and stressing the need for
taking prescribed medication. Patients should be encouraged to report side
effects to their doctors so that alternative medication may be prescribed.
Patients often ask for additional information concerning the following:117

Aspirin

Beta blocking drugs

Calcium channel blocking drugs
– Dihydropyridines
– Diltiazem and verapamil

Angiotensin converting enzyme inhibitors and angiotensin II
antagonists
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
Diuretics
– Frusemide (furosemide)
– Thiazides
– Others

Nitrates (tablets, sprays, patches)

Digoxin

Lipid lowering drugs
– Statins
– Others

Antiarrhythmic agents

Anti-inflammatory drugs

Psychotropic drugs

Hormone replacement therapy
It is important to limit discussions regarding medication to only those that a
patient is taking, or will be taking. The education process can be quite
confusing to a patient, and it is important to ensure that the patient only
receives the information that pertains to him or her. Additional medical
topics may also be discussed during groups, depending upon the medical
and surgical problems of the patients that are present.128
All major risk factors should be covered, either in separate sessions or
together with discussion of several risk factors. Both modifiable and nonmodifiable risk factors need to be addressed. The compounding of risk if
several risk factors are present should be highlighted and the possibility of
reversal of risk, coupled with stabilization or reversal of disease, explained.
Further, it should be pointed out that other common diseases, including
stroke, peripheral vascular disease and diabetes, share many of the same
risk factors as those for coronary heart disease. Providing patients with
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information about heart disease and explaining risk factors will help patients
understand the importance of changing their habits and adhering to advice
in order to reduce their risk of further events.169
In addition to providing an overview of the disease and medications,
educators should also provide a comprehensive educational program on the
following topics:14,157,168-176
Diet
Education and counseling programs should provide information,
explanation and practical advice regarding nutritional aspects of coronary
heart disease. Unfortunately, nutritional education presents a common
problem for many patients who are exposed to conflicting and confusing
information from advertising and the media. They also receive conflicting
advice from professional sources, including different members of the
rehabilitation team. Nutritional advice given by nurses and general
practitioners, in particular, often conflicts with advice given by dietitians.
It is therefore most important for team members to achieve consensus
regarding what constitutes accurate nutritional information. They should
also develop guidelines for specific groups of patients, such as the
elderly, the overweight and those with hypercholesterolemia, so that
advice can be individualized. Since dietary advice changes over time (for
example, the shifts between recommending polyunsaturated or
monosaturated oils), periodic expert review of nutritional guidelines is
particularly necessary.
Sessions should include discussion of total cholesterol, LDL and HDL
cholesterol levels, the nature of fat in food, hidden fat in food, the
distinction between saturated, polyunsaturated and monosaturated fats,
the importance of fruit, vegetables and fiber and the protective effects of
“traditional” diets.
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Patients and families have little understanding of the role of saturated fat
in raising total and LDL cholesterol or of the difference between fat,
lipoproteins and cholesterol. They also have a poor understanding of the
role of blood lipid levels in deposition of cholesterol in the arterial
subintimal layer, the development of atheroma and its progress to
atherosclerotic cardiovascular disease. These aspects should be clearly
and simply explained, supported by visual aids. It is important to avoid
unnecessary detail and complex terminology during sessions dealing with
nutrition.
Most cardiac patients leave hospital on a low salt diet. This is usually
advised because of the desire to prevent fluid retention in those who had
had acute myocardial infarction or coronary artery bypass surgery.
Patients need to understand that a balance should be struck so that, if
they are not found to have high blood pressure or incipient heart failure,
then it is reasonable for them to consume a moderate amount of salt. A
moderate amount of salt is already present in many foods. Hence, the
general advice for all should be to avoid adding salt at the table and to
minimize the addition of salt during cooking. For those who are
hypertensive and found to be salt sensitive, then persistence with a low
salt diet is desirable. Salt excretion may be increased by diuretic
treatments, but if the intake of salt is reduced, the dose of diuretic can
be less.
Smoking
Patients must be made aware of the considerable risks of continued
smoking, particularly the increased likelihood of further cardiac events
and death. The hazards of continued cigarette smoking amongst patients
with cardiovascular disease are well reported in powerful observational
studies. Patients need to understand that many benefits accrue from
stopping smoking, including a marked reduction in morbidity and the
halving of mortality from coronary heart disease and stroke. While
smoking usually ceases with acute events and hospital admission,
resumption of smoking commonly occurs soon after hospital discharge
and occasionally before the patients leave hospital.
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In some patients, relapses occur after months or even years. The
proportion of patients who continue to smoke, or who lapse after initially
ceasing, has been reported to be as low as 10–20% in some studies and
as high as 60% in others.
Continued advice and support should be offered to current or former
smokers. The effect of the culture to which the patient returns is likely to
be an important influence upon adherence to non-smoking advice.
Encouragement to stop smoking is especially important during
convalescence when patients are most motivated. In addition to
providing information about the dangers of smoking and the potential
benefits of ceasing, patients should also be shown how to use simple
behavioral strategies for stopping smoking and for maintaining the
status of a non-smoker.
Patients should be encouraged to discuss any barriers they perceive to
stopping smoking and techniques for quitting which they may have
found helpful in the past. The use and benefits of nicotine replacement
therapy should be explained. Information should be provided about
sources of further assistance and counseling. Referral to smoking
cessation programs should be recommended for those unable to stop
smoking on their own.
High blood
Education and counseling sessions should include explanations of the
pressure
role of high blood pressure in causing coronary heart disease and stroke.
The added risk from hypertension in patients with established
cardiovascular disease should be discussed. The considerable benefits
arising from good blood pressure control in these patients should be
emphasized.
Many patients with previously raised blood pressure have a fall in both
systolic blood pressure and diastolic blood pressure following acute
myocardial infarction and coronary artery bypass graft surgery. A
gradual recovery towards previous or higher levels then occurs over
some months.
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This rise in blood pressure is most marked amongst those patients
whose hypotensive medication was changed or stopped while they were
in hospital. The most effective method of controlling this rising blood
pressure is resumption of medication. Additional lowering of blood
pressure, possibly with lesser dosage of medication, may be achieved
through weight reduction, exercise, salt restriction and dietary change
with the addition of fruit and vegetables.
The importance of adherence to advice regarding hypotensive
medication and the need for regular blood pressure checks should be
stressed. The benefits of blood pressure control through physical activity,
weight control and salt restriction should also be pointed out. Further,
patients should understand that it is possible that the lower the blood
pressure, the better. Since stress, especially work-related stress, is
thought by many patients to cause high blood pressure, this issue also
needs to be addressed.
Physical
A sedentary lifestyle, with little or no physical activity during leisure or at
inactivity
work, is a risk factor for the development and progress of cardiovascular
disease, almost as potent as raised blood pressure or lipid levels. The
role of a sedentary lifestyle as a risk factor for the development and
progression of cardiovascular disease should be explained and the
benefits of physical activity emphasized. Education is required
concerning the need for lifetime physical activity, in addition to
participation in exercise sessions during the rehabilitation program.
Patients should be reassured regarding the safety and ease of
undertaking physical activity outside the rehabilitation class. It should be
emphasized that major health benefits can be achieved through light to
moderate activity and that high intensity exercise is not necessary.
Weekly utilization of 1,500 to 2,200 kilocalories above the caloric
utilization of sedentary living achieves considerable protective benefit.
Patients readily embrace low or moderate levels of daily activity during
convalescence after acute cardiac events, as well as by patients with
past or controlled heart failure, the obese and older men and women.
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Alcohol
Excessive consumption of alcohol should be recognized as a contributor
to hypertension and therefore as a risk factor for stroke. Patients also
need to understand that alcohol may adversely affect myocardial
function, particularly amongst those who are hypertensive and those
who have suffered myocardial infarction. Further, alcohol may be a basis
for resumption of smoking, physical inactivity or a previously
unsatisfactory diet. Patients who are aware that alcohol (whether it be
red wine or any other alcoholic drink) protects against subsequent
myocardial infarction may use that information to increase their alcohol
consumption.
It is important to emphasize the multiple other hazards of exceeding the
recommended daily maximum of two to four standard alcoholic drinks for
men and one to two drinks for women.
Age,
Education and counseling sessions should address non-modifiable risk
gender,
factors, including the increased risks of age, male gender and positive
family
family history. The older the patient with cardiovascular disease,
history and
irrespective of gender, the greater the risk of death and disability from
existing
cardiovascular disease. The hazards of premature cardiovascular disease
disease
are greater amongst males than females. However, late onset
cardiovascular disease and death from cardiovascular disease are now
more common amongst females
A positive family history of cardiovascular disease is a powerful marker
of risk for the development and accelerated progress of cardiovascular
disease. It has been clearly demonstrated that those with a positive
family history for cardiovascular disease commonly have worse risk
factor profiles in terms of lipids, blood pressure, obesity, diabetes and
smoking habit, in addition to their non-modifiable genetic background.
Hence, risk factor modification is of greater importance in patients with a
positive family history than it is for those with identified modifiable risk
factors without a family history.
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A past history of stroke, other vascular disease or diabetes mellitus is
also a powerful marker of risk for coronary heart disease and an
indicator of the need for attention to all risk factors.
Facilitators should define overweight and obesity and explain their role in
the etiology of cardiovascular disease and diabetes. They should also
explain their role as risk factors for further cardiovascular events and
mortality, the development of Type II diabetes and raised cholesterol
and blood pressure. Reduced caloric intake, particularly reduced fat
intake, together with regular, maintained or increased physical activity,
has been shown to be effective and should be encouraged for all
overweight patients and those with non-insulin dependent diabetes.
In some patients, obesity may be coupled more with physical inactivity
than with a high caloric intake. However, weight loss is hard to achieve,
especially in those who have a long history of obesity. The difficulties
faced by overweight and obese patients in achieving and maintaining
lower weight should be recognized and discussed. Gradual weight loss
should be recommended, with limited targets over time. Psychological
factors associated with overweight and obesity should be explored and
the development of a supportive environment encouraged for those
seeking to lose weight.
Depression,
Patients need to understand the typical emotional responses to an acute
anger,
cardiac event. It is usual for patients to pass through a period of anxiety
stress
after their acute event, especially upon transfer to the ward and on
discharge from hospital. Common concerns include a fear of death, a
further cardiac event, physical disability and unemployment. Physical
symptoms such as palpitations, breathlessness and chest pain may be
caused by anxiety, although patients may not recognize such symptoms
as manifestations of anxiety. Anxious patients usually have little
concentration and often fail to comprehend, accept or recall information
provided in hospital. Further, anxiety may lead to a delay in resuming
activities.
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Depression is also common after an acute cardiac event and has been
associated with increased mortality and morbidity and increased costs
associated with rehospitalization. In most cardiac patients, such
depression is more a grief or bereavement reaction rather than a
depressive illness. It is best referred to as a “depressed mood” in which
a sense of real or imagined loss is experienced. Symptoms are mostly
mild and transient and their manifestations are usually subtle. A
depressed mood may be experienced first in hospital. However, it
typically peaks during convalescence. Common symptoms of a depressed
mood include an inability to concentrate, restlessness, disturbed sleep,
early waking, irritability, a sense of fatigue, loss of interest and
motivation, sentimentality or even tearfulness. Patients may become
pessimistic about their recovery and fearful of a recurrence. They may
equate fatigue and weakness with heart damage greater than
anticipated.
They may then become preoccupied with the supposed limitations of the
illness. Withdrawal and irritability during convalescence are frequent
symptoms of a depressed mood. Concerns are increased if there is
awareness of heart action, ectopic beats or palpitation, non-cardiac or
cardiac chest pains, breathlessness from hyperventilation or unfitness or
of any other symptoms of physical and psychosomatic origin. It is
important to explain and discuss such symptoms during group sessions.
Forewarning patients that a depressed mood commonly occurs during
convalescence can also be most valuable. Anxiety and depression often
coexist. Several symptoms, including irritability, reduced concentration
and sleep disturbances, are common to both conditions.
Patients may cope with their anxiety, depression or other symptoms by
denial, convincing themselves that any problems they have are not
serious and that they are not at risk of future problems. While denial
may be a useful defense mechanism in the short-term for coping with
anxiety and a depressed mood it can exert a negative influence upon
outcomes if patients cease to adhere to regimens regarding lifestyle,
medication and other advice.
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It is usual for anxiety and depression to decrease spontaneously during
the months after the event, although they may persist for up to a year
or more. Studies suggest women have poorer psychological outcomes
than male patients. Early detection and management of psychological
difficulties can prevent persisting disturbances. Facilitators of group
sessions need to identify those at risk of continuing psychological
problems and, if necessary, refer them to appropriate team members for
individual assistance.
Psychological difficulties persisting for several months are usually
attributable to an unrecognized and untreated depressed mood, which
can lead to nonadherence with advice, occupational difficulties, and
marital and sexual dysfunction. Moreover, as already stated, depression
is a powerful predictor of mortality after acute myocardial infarction. A
further loss or crisis can intensify or prolong the depressed mood. In
some patients, the onset of depression may be delayed. In these cases,
the acceptance of loss and the need for change have usually been denied
earlier. Those who do not display some signs of depressed mood early
will often become depressed at a later stage of their recovery.
Psychological responses can be effectively addressed during group
sessions by a skillful facilitator. When patients are able to disclose
feelings during group sessions, identification with others who are
experiencing similar problems can be a major benefit. Recognition that
problems are not unique is reassuring. Facilitators of group discussions
should explain that anxiety and a depressed mood are typical after acute
cardiac events but that they are usually mild and transient. Fear of
further cardiac episodes, anxiety about resuming work and concern
about overprotectiveness in spouses may be successfully shared with
others in the group. In addition to identifying with others who have
similar problems, patients also gain from observing positive changes and
a rapid recovery in others. Thus, a group should ideally contain patients
at all stages of recovery, including “elders” who often adopt a preceptor
role for the newer group members.
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Discussion groups for patients can also benefit from the occasional
attendance of former patients who have made a favorable adjustment.
The practice of introducing successfully rehabilitated postsurgical
patients to those awaiting the operation is based on the same premise.
Patients commonly attribute their cardiac illness to stress. Stress and
perceptions of the causal role of stress in the patient’s illness should be
explicitly addressed during group sessions, possibly together with
discussion of mood and emotions. While life stress, as discussed above,
has been shown to be a factor leading to adverse outcomes, this type of
stress is not necessarily that which most concerns many patients. The
perceived stress, which patients typically describe, arises from external
pressures and demands, time constraints, work problems or adverse
personal interactions and low levels of control over these stresses.
There is some evidence that such stress may worsen prognosis.
Patients often perceive such “job stress” to be the main cause of their
disease. However, there is no substantial scientific evidence to support
these views. While “strain” may not be a significant risk, poor “control”
may be so. Such poor “job control” may be another reflection of less
education, reduced job opportunities and lower socioeconomic status.
Nevertheless, since these concerns regarding occupational stresses are
so widely held by patients, the topic needs to be discussed during group
sessions.
Failure to address the issue can have adverse consequences. Concern
about the effects of “work stress” may lead to unemployment, whether it
is the concern of the patient, spouse, other family members, workmates,
foreman or employer. Patients should be encouraged to talk about how
they feel about resuming work and to raise any anticipated problems.
Many problems can be resolved by discussion with the patient and close
family members or in the group where others may have similar concerns
about their work.
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Facilitators should explain the two aspects of stress: the stressor and the
response to the stressor. Most important is recognition that the response
to the stress may influence the progression of the patient’s disease.
Thus, for some, occupational or domestic stress may lead to resumption
of smoking or consumption of more cigarettes, food and alcohol and to
physical inactivity. Alternatively, patients may handle such stress by
walking or exercising during work breaks, pacing up and down rather
than sitting while working and by increasing leisure time physical
activity. Some patients can face stress by “switching off” or by avoiding
situations, which they are aware, will induce a sense of stress.
Patients need to understand that the evidence for stress being directly
harmful is insecure. There is some evidence that it does not contribute
directly and independently to the progression of cardiovascular disease.
Patients may therefore accept the presence of stress, but be led to
modify their responses to embrace favorable rather than harmful
behaviors. Some may also be able to modify their perception of stress
and their responses to stress through stress management techniques.
Cardiac Rehabilitation Timeline
There are three distinct phases of cardiac rehabilitation. Each phase has
specific activities and guidelines associated with it. While there are
suggested and estimated amounts for the duration the patient should spend
in each phase, it is important to note that the actual amount of time spent
will depend on the individual patient. Some patients will only require a brief
period on one or more of the phases, while other patients may require more
intensive treatment as part of one or more phase. The physician will work
with the individual patient to determine an adequate timeline, with the
understanding that the timeline may change as the patient progresses. The
phases of cardiac rehabilitation are outlined below.
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Inpatient Rehabilitation: Phase 1
Rehabilitation begins in hospital and consists of early mobilization and
education. It is delivered on an individual basis and, additionally, in some
hospitals, to groups of patients. The degree of structure of inpatient
programs varies from one hospital to another. The shorter hospital stay
(now commonly four to six days after acute myocardial infarction, five to
seven days after coronary bypass surgery, and one day after coronary
angioplasty) makes it extremely difficult to conduct formal inpatient
education programs. Further, inpatients commonly undergo time consuming
comprehensive investigations. Thus, inpatient cardiac rehabilitation
programs are now much more limited in scope than in the past. Moreover, it
is recognized that inpatient education may be ineffective because of the
psychological state and concerns of patients soon after their acute event.
Inpatient rehabilitation is now mostly limited to early mobilization, so that
self-care is possible by discharge, and brief counseling to explain the nature
of the illness or intervention, to increase the patient’s awareness of his or
her risk factors and to reassure the patient about future progress and followup. A discharge plan usually incorporates a discharge letter to the general
practitioner and/or cardiologist or cardiac surgeon and assurance that the
patient is aware of the need for continued medication. Appointments are
usually made for follow-up review and, ideally, referral to a formal
outpatient cardiac rehabilitation program. The effects of such restricted
inpatient programs upon patient outcomes have been little studied.177,178
Ambulatory Outpatient Rehabilitation: Phase 2
Most cardiac rehabilitation is based upon supervised ambulatory outpatient
programs conducted during convalescence. Attendance begins soon after
discharge from hospital, ideally within the first few days. In most instances,
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ambulatory cardiac rehabilitation programs usually end within two to three
months of the acute event. Formal outpatient cardiac rehabilitation
programs vary widely in content. Almost all contain an element of group
exercise, which is conducted by allied health professionals. Therefore, an
educational and supportive element is inevitably delivered together with the
exercise.
The duration of ambulatory exercise programs during convalescence also
varies. In some programs, funding is available for exercise classes
conducted three times per week for 12 weeks for those who are covered by
health insurance, Medicare or Medicaid. In other programs, the usual
duration of programs is six to eight weeks, although in some places it may
be as short as four weeks.
Sessions may be offered once, twice or occasionally three times per week.
Many programs offer exercise of a moderate or high intensity level, although
some will offer low or moderate intensity. Most programs include group
education, but the content and method of the delivery of such education
programs varies greatly. Different facilitators in the one program also vary
considerably in their approach to running group discussions. Psychological
and social support may be given on an individual basis, as required, or may
be provided to groups of patients and family members.179-181
Maintenance: Phase 3
A lifetime, maintenance stage will follow the ambulatory program in which
physical fitness and risk factor control are supported in a minimally
supervised or unsupervised setting. Maintenance programs are even more
varied in content and structure than ambulatory programs. The exact
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content of maintenance programs is often not clearly defined. They may
consist of regular recall and review by physician or nurse.
Patients may receive additional medication, further education, social
support, exercise classes and behavioral intervention, as required. Some
patients may be enrolled in special groups for specific reasons (for example,
diabetes, obesity, smoking, lipid disorder, hypertension, heart failure) if
clinics are established for the management of these particular risk factors or
conditions. In other programs, patients may be enrolled in an ongoing
exercise class. Relatively few maintenance programs have been established
or adequately evaluated. Most of the evidence for improved prognosis is
derived from combined ambulatory and maintenance programs, which have
been hospital-based. Individual studies and meta-analyses have reported
benefits in terms of reduced mortality, recurrent events and
readmissions.77,127,166,180
Innovations In Cardiac Rehabilitation
In recent years, some innovative programs have emerged with the intent of
providing patients with a wider range of cardiac rehabilitation options.
These programs are provided as alternatives to traditional cardiac
rehabilitation programs, and are not suitable for all patients. Prior to utilizing
one of these alternative options, the physician must assess the patient to
determine if it is appropriate.
In-Home Exercise
In recent years, some doctors have begun allowing patients to engage in
home-based exercise programs. These programs are offered in place of
facility-based programs, not in addition to them. Patients complete their
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exercises within their own home. This new option provides a more feasible
option for patients who do not have access to regular transportation, or for
those who have difficulty leaving their homes. However, these programs
must be closely monitored to ensure that the patient is performing the
exercises properly, and completely.182 The following is the recommendation
that has been established for home-based exercise programs:
“A home exercise program is recommended for those patients who
are unable to attend a group exercise program. A daily home
walking program is recommended as a supplementary activity for
all patients enrolled in a group program.
Trials have compared home versus hospital ambulatory group
exercise. These have shown benefits in physical working capacity
and psychosocial outcomes approaching those achieved by patients
randomly allocated to a hospital based group program. While
home-based programs reduce patient travelling time, patients who
undertake exercise training at home may still require careful
assessment before an exercise prescription is offered them, if they
are to undertake moderate or high intensity exercise. Further, in
the reported trials, patients had a cycle ergometer at home for
their prescribed exercise session, telephone communication with
the
nurse
program
electrocardiographic
coordinator
transmission
and
facilities
during
for
exercise.
telephone
While
this
extends the opportunities for individual patients to participate in
supervised high or moderate intensity exercise, it is not of low
cost. Further, it could be irrelevant. If lower levels of exercise are
accepted, telephonic monitoring would become unnecessary for the
great majority of patients. It may not be possible for all patients to
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attend a group cardiac rehabilitation program. Such patients
require guidance regarding exercise, education and behavior
change, as well as support. Simple verbal and written instructions
to such patients are required, together with discussion about
activity and behavior while in hospital (inpatient rehabilitation) and
as part of discharge planning. Follow-up by telephone may be
possible. General practitioner follow-up should be assured.
Ideally, patients receiving a home-based program should attend at
least one group exercise session for guidance regarding home
exercise and to learn the level of exercise recommended for them.
They should learn self-monitoring based upon observation of heart
rate during activities or recognition of symptoms to the level of
awareness of breathing. They should be advised to continue
activity at that level on a daily basis, preferably for half an hour
each day.
Home exercise programs generally involve daily walking at a low or
moderate intensity, as well as other physical activities with gradual
progression to achieve an increase in muscular strength for
activities of daily living. Patients who are enrolled in a group
exercise program should also follow a home activity program,
accumulating at least 30 minutes of activity daily at a similar level
of perceived exertion or heart rate. To date, most cardiac
rehabilitation exercise programs have been developed in the
outpatient areas of hospitals.
Referral to such programs should be organized prior to the
patient’s discharge from hospital. Monitoring of attendance and
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follow-up should be readily achieved. A further advantage of
hospital-based programs is the potential for continued support
from the health professionals involved in both inpatient care and
ambulatory rehabilitation, with a heightened sense of security for
both staff and patients.”148
Disadvantages
A potential disadvantage is the possibility of patients considering that they
need to be closely linked to the hospital upon which some may develop a
sense of dependence. Another disadvantage is the centralization of services
at the hospital, with consequent problems for patient attendance, transport
and distance. Thus, there is a good case for programs being sited in
community centers. This latter case becomes more feasible if the intensity of
exercise is at a low to moderate level.183
Job-specific Rehab
Some cardiac rehabilitation programs have been developed to provide job
specific rehabilitation. In these instances, the patient will only focus on
areas that will aid in the transition back to work. These programs will not
include the components that are not relevant to the patient’s occupation.
However, job-specific rehabilitation programs will still include a variety of
components that address the physical, lifestyle, and emotional needs of the
patient.184
Web-based Programs
Web-based programs are a new development in the field of cardiac
rehabilitation. They are currently being limited to a very specific set of
patients who can benefit the most from the program. They are most suited
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for patients who are self-sufficient enough to manage the different
components of their rehabilitation program.
Web-based programs provide the content remotely to the patient, thereby
reducing the amount of time the patient will have to spend in doctor’s offices
and therapy centers. With a web-based program, all treatment guidelines
and activities are delivered electronically to the patient. The patient tracks
progress electronically and provides regular updates to the treatment
provider.185
Summary
Approximately 14 million persons suffer from some form of coronary artery
disease. In the past, cardiac rehabilitation was used to treat lower-risk
patients who had the physical capacity to exercise without the risk of
additional complications. However, in recent years, cardiac treatment and
management has evolved, thereby expanding the demographic of patients
who can participate in cardiac rehabilitation programs. A substantial
component of this new demographic includes approximately 400,000
patients who undergo coronary angioplasty. In addition, there are
approximately 4.7 million patients with congestive heart failure who can
participate in a modified program of rehabilitation.
The primary goal of cardiac rehabilitation is to reverse limitations
experienced by patients who have suffered the adverse pathophysiologic and
psychological consequences of cardiac events. Just as a serious leg injury
requires rehabilitation to return the patient to optimal performance, the
heart also requires serious rehab in order to function at its best after a
trauma. Additionally, when a cardiac event occurs, the patient may suffer
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emotional difficulties and challenges in accepting and overcoming the events
that caused the issue.
Cardiac rehabilitation is a whole-body approach to restoring health that
incorporates a multi-dimensional approach to address body, mind, and spirit.
Exercise, counseling, and physical therapy combine with medical
management to ensure that as much normal function as possible is restored
to each patient, and that every patient is able to adapt to lifestyle changes
that reduce the risk of a repeat occurrence.
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1.
In the United States, cardiovascular disorders are:
a. proven to be the leading cause of mortality and morbidity.
b. responsible for approximately fifty percent of annual deaths in the
United States.
c. present in approximately 14 million people who suffer from some
form of coronary artery disease or its complications.
d. All of the above.
2.
True or False: Overall, modern cardiac rehabilitation is safe and
well tolerated with a very low rate of major complications such
as death, cardiac arrest, myocardial infarction or serious
injuries.
a. True.
b. False.
3.
The following is/are true about cardiac rehabilitation exercise
training for patients with coronary heart disease or congestive
heart failure (CHF):
a. Adverse outcomes or complications of rehabilitation exercise
training are common.
b. Cardiac rehabilitation exercise training for patients with CHF leads
to objectively verifiable improvement in exercise capacity in men
and women, regardless of age.
c. The benefits decrease in patients with diminished exercise
tolerance.
d. The benefits persist long-term after completion of cardiac
rehabilitation even without a long-term maintenance program.
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4.
The American Heart Association and other organizations have
outlined the core components of contemporary cardiac
rehabilitation and secondary prevention programs. They include
which of the following?
a. exercise training and physical activity counseling
b. tobacco cessation
c. nutritional counseling and weight management
d. All of the above.
5.
Healthcare team members have different tasks related to
cardiac rehabilitation. The task of the nurse is:
a. to confirm referral to the program at the patient’s first visit and
encourage the patient to attend.
b. define the medical parameters of the rehabilitation program from
the outset.
c. detect medical and other problems, and to refer patients to other
health care providers, when required.
d. prepare the patient for resuming work by assisting the patient with
work conditioning and, if required, conducting simulated work tests
and visit the worksite.
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6.
When categorizing the intensity level of a physical activity
program, it is important to factor in age and cardiovascular
disease status of the patient when:
a. using the Berg’s scale.
b. metabolic equivalents (“METs”) are used.
c. categorization is done using heart rate.
d. All of the above.
7.
With low intensity exercise training programs,
a. it is essential that staff have current training in cardiopulmonary
resuscitation.
b. the administration of a diuretic should always be given to avoid
constipation caused by exercise.
c. the mandatory equipment includes a resuscitation cart and a
defibrillator.
d. All of the above.
8.
Blood pressure should be checked during pauses between
exercises:
a. in patients after a significant variation in blood pressure is noted.
b. in all patients during low to moderate intensity exercise.
c. in new patients to note possible fall of blood pressure during
activity.
d. but only during the cool down period.
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9.
Home-based exercise programs are a new option for heart
patients:
a. They are usually in addition to and in conjunction with facility-based
programs.
b. One of the benefits of home-based exercise programs is the
program does not need to be closely monitored since the patient
self-monitors the program.
c. Patients receiving a home-based program should attend at least
one group exercise session for guidance and to learn the level of
exercise recommended for them.
d. Home-based exercise programs do not require careful assessment
before an exercise prescription is offered to the patient.
10. True or False: Some cardiac rehabilitation programs have been
developed to provide job specific rehabilitation. In these
instances, the patient will only focus on areas that will aid in the
transition back to work.
a. True.
b. False.
11. After hospitalization, repeat lipid profiles should occur at
_________ weeks
a. 2 - 4
b. *4 – 6
c. 6 – 8
d. 12
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12. Repeat lipid profiles should occur at _______________ after
initiation or change in lipid-lowering medications.
a. 4 weeks
b. *2 months
c. 3 - 4 months
d. 4 – 6 months
13. True or False. A core component of the evaluation of a patient
for a cardiac rehab program includes most recent influenza
vaccination.
a. *True
b. False
14. A high risk factor for heart disease, almost much as raised blood
pressure or lipid levels, is _______________________.
a. Alcohol consumption > 5 drinks/day
b. High blood glucose levels
c. *Sedentary lifestyle
d. Stressful environment
15. With low intensity exercise training programs, risk of a cardiac
event is ___________________.
a. moderate
b. none
c. *very small
d. none of the above
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16. True or False. Denial is a normal emotion that needs to be
factored into patient care but generally has no influence on the
care outcome.
a. True
b. *False
17. Key roles of the physiotherapist include monitoring patient’s:
a. exercise sessions
b. pain
c. dietary needs
d. *answers a and b above.
18. Phase III is a ________________ phase in which physical
fitness and additional risk-factor reduction are emphasized.
a. *lifetime maintenance
b. one year maintenance
c. 6 month maintenance
d. post cardiac infarction, initial
19. True or False. The education process can be quite confusing to
patients. It is important to ensure patients only receive the
information that pertains to them, leaving additional medical
topics to settings such as group discussion.
a. *True
b. False
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20. Cardiac Rehab Phase II involves:
a. a supervised ambulatory outpatient program
b. 3 to 6 months duration
c. outpatient monitored exercise and aggressive risk factor reduction
d. *all of the above
21. Cardiac rehabilitation has to be comprehensive and, at the same
time, __________________.
a. standardized according to age and gender
b. *individualized
c. based on obesity factor
d. designed for the short-term
22. Cardiac rehab programs may be
a. home-based
b. facility-based
c. only offered in hospitals not outpatient settings
d. *answers a and b above
23. The total duration of a low to moderate intensity exercise
training session should be between ______________ including
rests between activities.
a. 20 – 30
b. 30 – 45
c. *45 – 60
d. one hour
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24. For high intensity exercise, usually continuous, the exercise
time is usually ____________________________.
a. 15 – 20 minutes
b. *20 – 30 minutes
c. 30 – 45 minutes
d. generally not recommended, and only in special cases
25. The INTERHEART Study quite clearly demonstrated that
_______________ was the third most important risk factor for
coronary events, following lipids and smoking, and accounts for
approximately 30% of the population’s attributable risk of acute
MI.
a. *stress
b. obesity
c. male gender
d. racial origin
Correct Answers:
1. d
6.
b
11. b
16. b
21. b
2. a
7.
a
12. b
17. d
22. d
3. b
8.
c
13. a
18. a
23. c
4. d
9.
c
14. c
19. a
24. b
5. c
10. a
15. c
20. d
25. a
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Reference Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
The following citations pertain to the course series on cardiac rehabilitation,
which include: CARDIAC CONDITIONS, INTERVENTIONS & REHABILITATION
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