Cardiac Rehabilitation


Article Author:
Joseph Tessler


Article Editor:
Bruno Bordoni


Editors In Chief:
Susan Jeno
Sarah Fabiano


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/4/2019 12:22:06 PM

Introduction

Cardiovascular disease (CVD) is one of the leading causes of death worldwide and is the leading cause of death in the United States.[1][2] Cardiac rehabilitation, or cardiac rehab, is a complex, multidisciplinary intervention customized to individual patients with various cardiovascular diseases such as ischemic heart disease, heart failure, and myocardial infarctions, or patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting.[3] Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, reduce the risk of mortality secondary to CVD, and improve cardiovascular function to help patients achieve their highest quality of life possible.[4] Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence through gradual conditioning.[5]

Several organizations including the American Heart Association (AHA), The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and the Agency for Health Care Policy and Research agree that a comprehensive cardiac rehabilitation program should contain specific core components. These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:

  • Patient assessment nutritional counseling
  • Weight management
  • Blood pressure management
  • Lipid management
  • Diabetes management
  • Tobacco cessation
  • Psychosocial management
  • Physical activity counseling
  • Exercise training[6]

Indications

 The indications for cardiac rehabilitation are [7]:

  • Recent myocardial infarction
  • Acute coronary artery syndrome
  • Chronic stable angina
  • Congestive heart failure
  • After coronary artery bypass surgery
  • After a percutaneous coronary intervention
  • Valvular surgery
  • Cardiac transplantation

Contraindications

Contraindications to cardiac rehabilitation only apply to the exercise aspect. They include [8]:

  • Unstable angina
  • Acute decompensated congestive heart failure
  • Complex ventricular arrhythmias
  • Severe pulmonary hypertension (right ventricular systolic pressure > 60 mm Hg)
  • Intracavitary thrombus
  • Recent thrombophlebitis with or without pulmonary embolism
  • Severe obstructive cardiomyopathies
  • Severe or symptomatic aortic stenosis
  • Uncontrolled inflammatory or infectious pathology
  • Any musculoskeletal condition that prevents adequate participation in exercise

Personnel

Cardiac rehabilitation under a multidisciplinary approach has well-established benefits.[9][10] The cardiac rehabilitation team is made up of members including the following [4]:

  • Patient
  • Patient's family
  • Physicians (surgeons, cardiologists, physiatrists, other specialists)
  • Pharmacists
  • Nurses
  • Physical therapists
  • Occupational therapists
  • Speech and language pathologists
  • Behavioral therapists
  • Dietitian
  • Case managers

Technique

Cardiac rehabilitation consists of three phases.

Phase I: Clinical phase

  • This phase begins in the inpatient setting soon after a cardiovascular event or completion of an intervention. It begins by assessing the patient's physical ability and motivation to tolerate rehabilitation. Therapists and nurses may start by guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a range of motion and limiting hospital deconditioning. The rehabilitation team may also focus on activities of daily living (ADLs) and educate the patient on avoiding excessive stress. Patients are encouraged to remain relatively rested until completion of treatment of comorbid conditions, or post-operative complications. The rehabilitation team assesses patient needs such as assistive devices, patient and family education, as well as discharge planning. 

Phase II: Outpatient cardiac rehab

  • Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts three to six weeks though some may last up to up to twelve weeks. Initially, patients have an assessment with a focus on identifying limitations in physical function, restrictions of participation secondary to comorbidities, and limitations to activities. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice, tailored training program, and a relaxation program. The treatment phase intends to promote independence and lifestyle changes to prepare patients to return to their lives at home. 

Phase III: Post-cardiac rehab

  • This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening, and aerobic conditioning. Patients receive encouragement towards maintaining an active lifestyle and continue exercise. Outpatient visits to physician specialists are recommended to monitor cardiovascular health and medications regimens, promote healthy lifestyle changes and intervene when necessary to prevent relapse.[11][12]

There is also a pre-surgery phase, where the patient starts cardiovascular rehabilitation. A small number of studies demonstrate that the post-surgical pathway is better tolerated by patients.

Complications

A study in France reviewing the safety of cardiac rehabilitation found the cardiac arrest rate was 1.3 per million patient hours of exercise.[13] Rakhshan et al. studied the potential complications of heart rhythm device malfunction after eight weeks of cardiac rehabilitation, but the study revealed a decrease in physical complications in patients who received cardiac rehabilitation versus a control group.[14] 

Clinical Significance

Benefits

Overall cardiac rehabilitation increases quality of life and decreases health care costs.[15] Cardiac rehabilitation has many physiologic benefits due to its exercise component. Exercise training has been shown to increase maximal oxygen uptake (VO2max), improve endothelial function, and improve myocardial reserve flow. Additionally, cardiac rehabilitation can reduce smoking, body weight, serum lipids, and blood pressure.[11] Milani et al. found that cardiac rehabilitation decreased depression in heart disease patients who suffered a major coronary event.[16] A Cochrane review noted that cardiac rehabilitation reduced hospital admissions and showed a long-term decrease in all-cause mortality in patients heart failure patients with preserved ejection fraction. However, there was no short-term (less than 12 months) benefit to all-cause mortality.[9]

Goals

As stated above, cardiac rehabilitation goals can be designated into two broad categories [4]:

    • Short-term
      • Control cardiac symptoms
      • Enhance functional capacity
      • Limit unfavorable psychological and physiologic effects of cardiac illness
      • Boost psychosocial and vocational status
    • Long-term
      • Alter natural history of coronary artery disease
      • Stabilize or reverse progression of atherosclerosis
      • Lessen risk of sudden death and reinfarction

Future Research

In a systematic review of 19 random clinical trials, complex e-coaching was found to be an effective method of delivering therapies targeting physical capacity, clinical status, and psychosocial health; however, detailed protocols were not well described. Therefore, determining which aspects of e-coaching have the most benefit and need to be further developed have not been determined. In addition, basic e-coaching was not found to be effective.[17] Studies on the effects of cardiac rehabilitation for congenital heart disease (CHD) patients is lacking. Randomized clinical trials in adult and pediatric populations are needed to establish specific guidelines and the current evidence.[18]

Enhancing Healthcare Team Outcomes

Even though there is an overwhelming body of evidence to support the benefits of cardiac rehabilitation, patient participation is unusually low. Data from Medicare and the CDC reveal 14-35% of heart attack survivors and about 31% coronary bypass grafting surgery patients utilized or enrolled in cardiac rehabilitation or secondary prevention programs.[7] Leon et al. noted that low utilization correlated to a low referral rate, lack of insurance coverage, poor patient motivation, and limited program site accessibility.[19] A 2017 qualitative study on the patients’ perspectives of cardiac rehabilitation revealed psychosocial barriers to attending cardiac rehabilitation were lack of time and fear of exercise. Patients’ perceptions of cardiac rehabilitation (and subsequent participation) were also affected by prior exercise experience, physiotherapist communication, the severity of the cardiovascular disease or event, and the patient's’ future goals after rehabilitation. Therefore, the cardiac rehabilitation team should take these points into consideration when creating rehabilitation programs for patients.[20]


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Cardiac Rehabilitation - Questions

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The first activities that an OT should plan during the acute cardiac rehabilitation should:



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Most patients are on beta blocker medication during cardiac rehabilitation. Which of the following would be best to measure exercise tolerance in this case?



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A patient has coronary artery bypass grafting and has been on bed rest for a prolonged period. The patient is able to tolerate sitting on the edge of the bed. Which of the following activities would be the next step?



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A patient doing cardiac rehabilitation endurance training a patient slows down, doing progressively smaller movements. What should the OT do?



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A patient finishes rehabilitation and has reached a MET level of 6. How much snow can he or she shovel?



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At what point can a patient in cardiac rehabilitation begin to exercise?



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Which phase of cardiac rehabilitation starts to address exercise, stress, and diet?



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During cardiac rehabilitation, which of the following is the most important OT educational goal?



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A 73-year-old female who recently underwent cardiac bypass presents to her primary care provider's office for follow-up examination. She was placed in a rehab facility for two weeks since after her surgery. She currently tolerates her rehab well, can walk up to a half a mile without feeling short of breath. The patient can also transfer on her own from the bed to her chair. She can dress and feed herself though complains of difficulty remembering to take her cholesterol medication sometimes. What is the next appropriate step in planning to continue her care?



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Which of the following is not a recommended core component to cardiac rehabilitation?



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A 72-year-old female with past medical history of chronic obstructive pulmonary disease, congestive heart failure, and history of breast cancer who presents to the hospital with chief complaint of new-onset chest pain that radiates to her right arm. EKG is significant for ST elevations in precordial leads V4-V6. The patient is appropriately treated, and after two days in the hospital, a physical therapy consultation is placed. Select the answer that correctly describes phase 1 of cardiac rehabilitation.



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A 51-year-old male with a past medical history significant for left subclavian and vertebral artery stenosis, coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia presents to the emergency department with chief complaint substernal crushing chest pain for the past 3 hours. The patient undergoes five vessel coronary artery bypass grafting (CABG). Two weeks after surgery, physical therapy evaluates the patient. Which of the following is a potential complication to cardiac rehabilitation?



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A 62-year-old patient with a past medical history of essential hypertension, asthma, and congestive heart failure presents to the emergency department for progressively worsening shortness of breath and lower extremity swelling for the past five days. After admission and stabilization, the patient is transferred to a rehabilitation hospital. The patient is evaluated, and a rehabilitation program is designed. Which of the following is not a result of cardiac rehabilitation?



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Which of the following is not a reason that patient participation in cardiac rehabilitation is unusually low?



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A patient with a recent anterior infarction and a 27% ejection fraction, which physical activity should be avoided?



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The patient has a pressure of 80 and a hemoglobin value of 9.0 g/dL. Due to previous traction of the cable that connects the machine to the batteries, there is a local and systemic infection. Can this patient with a left ventricular assist device (LVAD) implant access a rehabilitation cycle?

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    Contributed by Bruno Bordoni, PhD
Attributed To: Contributed by Bruno Bordoni, PhD



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Cardiac Rehabilitation - References

References

Servey JT,Stephens M, Cardiac Rehabilitation: Improving Function and Reducing Risk. American family physician. 2016 Jul 1     [PubMed]
Dalal HM,Doherty P,Taylor RS, Cardiac rehabilitation. BMJ (Clinical research ed.). 2015 Sep 29     [PubMed]
Naughton J,Lategola MT,Shanbour K, A physical rehabilitation program for cardiac patients: a progress report. The American journal of the medical sciences. 1966 Nov     [PubMed]
Tarride JE,Lim M,DesMeules M,Luo W,Burke N,O'Reilly D,Bowen J,Goeree R, A review of the cost of cardiovascular disease. The Canadian journal of cardiology. 2009 Jun     [PubMed]
Heidenreich PA,Trogdon JG,Khavjou OA,Butler J,Dracup K,Ezekowitz MD,Finkelstein EA,Hong Y,Johnston SC,Khera A,Lloyd-Jones DM,Nelson SA,Nichol G,Orenstein D,Wilson PW,Woo YJ, Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011 Mar 1     [PubMed]
Balady GJ,Williams MA,Ades PA,Bittner V,Comoss P,Foody JM,Franklin B,Sanderson B,Southard D, Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007 May 22     [PubMed]
Rakhshan M,Ansari L,Molazem Z,Zare N, Complications of Heart Rhythm Management Devices After Cardiac Rehabilitation Program. Clinical nurse specialist CNS. 2017 May/Jun     [PubMed]
Pavy B,Iliou MC,Meurin P,Tabet JY,Corone S, Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation. Archives of internal medicine. 2006 Nov 27     [PubMed]
Balady GJ,Ades PA,Bittner VA,Franklin BA,Gordon NF,Thomas RJ,Tomaselli GF,Yancy CW, Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011 Dec 20     [PubMed]
Leon AS,Franklin BA,Costa F,Balady GJ,Berra KA,Stewart KJ,Thompson PD,Williams MA,Lauer MS, Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005 Jan 25     [PubMed]
Mampuya WM, Cardiac rehabilitation past, present and future: an overview. Cardiovascular diagnosis and therapy. 2012 Mar     [PubMed]
Braverman DL, Cardiac rehabilitation: a contemporary review. American journal of physical medicine     [PubMed]
McMahon SR,Ades PA,Thompson PD, The role of cardiac rehabilitation in patients with heart disease. Trends in cardiovascular medicine. 2017 Aug     [PubMed]
Veen EV,Bovendeert JFM,Backx FJG,Huisstede BMA, E-coaching: New future for cardiac rehabilitation? A systematic review. Patient education and counseling. 2017 Dec;     [PubMed]
Taylor RS,Sagar VA,Davies EJ,Briscoe S,Coats AJ,Dalal H,Lough F,Rees K,Singh S, Exercise-based rehabilitation for heart failure. The Cochrane database of systematic reviews. 2014 Apr 27;     [PubMed]
Milani RV,Lavie CJ,Cassidy MM, Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. American heart journal. 1996 Oct;     [PubMed]
Anderson L,Oldridge N,Thompson DR,Zwisler AD,Rees K,Martin N,Taylor RS, Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. Journal of the American College of Cardiology. 2016 Jan 5;     [PubMed]
Amedro P,Gavotto A,Bredy C,Guillaumont S, [Cardiac rehabilitation for children and adults with congenital heart disease]. Presse medicale (Paris, France : 1983). 2017 May;     [PubMed]
Bäck M,Öberg B,Krevers B, Important aspects in relation to patients' attendance at exercise-based cardiac rehabilitation - facilitators, barriers and physiotherapist's role: a qualitative study. BMC cardiovascular disorders. 2017 Mar 14;     [PubMed]
Achttien RJ,Staal JB,van der Voort S,Kemps HM,Koers H,Jongert MW,Hendriks EJ, Exercise-based cardiac rehabilitation in patients with chronic heart failure: a Dutch practice guideline. Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation. 2015 Jan;     [PubMed]

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