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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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 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: nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 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, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 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). nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 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%. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 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). nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 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, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 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. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 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 and THE CARDIAC REHAB TEAM: A HOLISTIC APPROACH TO RECOVERY AND HEALING. 1. Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C. Coronary heart disease statistics 2010 edition. Br Hear Found. 2010;21. 2. Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular Heart Disease: Diagnosis and Management. Mayo Clinic Proceedings. 2010. p. 483–500. 3. Leon AS, Franklin B a, Costa F, Balady GJ, Berra K a, Stewart KJ, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation. 2005;111:369–76. 4. Wenger NK. Current Status of Cardiac Rehabilitation. Journal of the American College of Cardiology. 2008. p. 1619–31. 5. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al. 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Improving cardiac rehabilitation services--challenges for cardiac rehabilitation coordinators. Eur J Cardiovasc Nurs. 2011;10:37–43. 185. Henderson I, vanLohuizen K, Fenske T. Remote cardiac rehabilitation. J Telemed Telecare. 2000;6 Suppl 2:S28–30. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. 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