by Christine Haran
Former President Clinton's heart bypass surgery might seem like the all the cardiac treatment he will need, if all goes well. But in fact it's likely that Clinton, like many others with heart disease, will undergo cardiac rehabilitation to get his heart back in shape. Cardiac rehabilitation programs, which involve exercise, along with dietary changes and stress management, are one of the best ways people with heart disease can prevent future heart-related medical problems.
Below, Barry Franklin, PhD, director of cardiac rehabilitation and exercise laboratories at the William Beaumont Hospital in Royal Oak, Michigan, explains how cardiac rehabilitation can strengthen weakened hearts safely and effectively.
How did cardiac rehabilitation evolve?
About 30 years ago, the prescribed treatment after a heart attack was prolonged bed rest. We then realized that prolonged bed rest actually had many adverse consequences on the patient. It resulted in pronounced decreases in fitness and often depression. It also resulted in a tremendous decline in aerobic fitness.
We realized that the heart heals rather rapidly and that low levels of activity soon after a heart attack or bypass surgery prevent blood clots, improve breathing capacity and reduce the decline in fitness that occurs with prolonged bed rest. Today, even people with severely weakened hearts, which we call congestive heart failure, can be involved in progressive, moderate-intensity exercise programs safely and effectively.
Literature tells us that cardiac rehabilitation programs reduce the death rate by 20 percent to 25 percent. That's equivalent to some of the best drugs out there.
When is a cardiac rehabilitation program usually recommended?
Cardiac rehab is best for people who have either had an acute cardiac event, such as a heart attack, or people who have undergone coronary revascularization, which are procedures that restore blood flow to the heart. This includes bypass surgery and angioplasty. Cardiac rehab also an ideal treatment for people who have chest pain or chest pain on exertion.
Ideally, we're looking for people who are clinically stable, who are not having any ongoing symptoms, and who are interested in a combination of lifestyle modification and drug therapy to slow, halt and even reverse the progression of this disease.
How are patients referred to the program?
It could be through their cardiologist, their family physician, their internist or their cardiac surgeon. A patient can't walk in the door with their gym bag and say, "I'm here for cardiac rehab." But if a doctor feels the patient is clinically stable and they fit the criteria for cardiac rehab, they can refer them.
Who makes up the cardiac rehabilitation team?
Our program, which I think is typical, involves nurse clinicians and exercise physiologists. They're involved on a day-to-day basis. We have a medical director, who's a clinical cardiologist, who oversees the entire program, though the staff is highly independent. Most programs have also access to a registered dietician and a psychologist, or have them on staff.
Do patients have a medical evaluation before entering a program?
All patients are evaluated by the nurse clinician and the exercise physiologist. Most programs encourage the patient to undergo an exercise stress test (having them walk on a treadmill, while their heart rates, blood pressures, and any symptoms are observed) in an effort to determine their safe exercise capacity.
What does the rehabilitation process consist of?
There are three phases of cardiac rehab. The program starts while they are still in the hospital recovering from the heart attack. If they're clinically stable, we want to get them up, out of bed, doing self-care activities and low-level walking as soon as possible.
Then the patient comes to an outpatient facility for phase II of cardiac rehab. Some arrive within a week of hospital discharge. More often they come two, three, four, five weeks after a hospital discharge. This portion of rehab includes an electrocardiogram (ECG)-monitored exercise program, where small groups of patients come in three days per week. It typically lasts between 4 and 12 weeks.
Then the long-term maintenance is what we call phase III or phase IV. And we've had patients involved in our long-term maintenance for more than 20 years.
Are all of the phases covered by insurance?
Phase I is covered, and 80 percent or more of phase II is usually covered. Phase III is not covered by insurance, and then the challenge is to provide a weekly or monthly fee that's reasonable to the patient. In our particular case, the cost is about $80 per month.
What is the ultimate goal of a cardiac rehab program?
The ultimate goal is to reduce morbidity and mortality, to improve the quality of life, to reduce subsequent hospitalizations, and to get people back into a meaningful vocational and leisure time activity.
It is also to reduce major risk factors for coronary artery disease such as cigarette smoking, hypertension, high cholesterol, obesity, physical inactivity and diabetes. Because one of the major risk factors for coronary artery disease is physical inactivity, all programs are exercise-based. We have good evidence that regular exercise has a global effect on many different risk factors such as cholesterol and blood pressure and improves psychosocial well-being. We also have compelling new data that the higher the patient's cardiac or aerobic fitness, the longer they live.
We're also trying to focus on a series of very provocative psychosocial risk factors, including anger and hostility, social isolation, high levels of stress and depression.
What are the different components of rehab?
First and foremost, cardiac rehab involves aggressive efforts at risk factor modification. That is, working with the attending physician or referring physician and implementing lifestyle change such as diet and exercise and, if necessary, complementary drug therapy such as statin drugs to lower elevated cholesterol levels.
Another component is psychosocial counseling. Many cardiac patients tend to have high levels of stress and anxiety, or anger and hostility. They tend to be depressed and socially isolated. We attempt to identify these characteristics when people enter these programs and attend to them via counseling and group therapy.
Medical surveillance is a third component of cardiac rehabilitation. We typically see these patients three days a week for their exercise sessions. If the patient suddenly has gained a great deal of weight, if their ankles are swollen (which would indicate heart failure), if we're finding that they're developing chest discomfort at low levels of exertion, we typically call the referring physician that day or fax them ECGs or other information. We feel that ongoing surveillance information unequivocally helps the physician better medically manage the patient.
Last but not least, we do vocational counseling. There was a very provocative article several years ago that bypass patients bypass work. That is, people who are approaching retirement often don't get back to work if they have bypass surgery. We believe very strongly that work is beneficial for the patient, though maybe a laborer can't go back to lifting heavy items.
Are the programs individualized?
Yes, for example, a higher risk patient may be involved in 12 weeks of ECG-monitored exercise, whereas a lower-risk patient might be involved in four to six weeks of it. Risk factors are individually tailored. Most programs have access to a dietician and a smoking cessation support group. Increasingly, we try to get family members involved, particularly the spouse or partner. You've got to focus on getting support of these interventions if you're going to have optimal success.
What type of exercise is recommended?
Aerobic exercise, such as jogging and biking, predominates as the benefits of aerobic exercise are unequivocal. Increasingly, we believe that resistance training or weight lifting—and I'm not talking about the Arnold Schwarzenegger lifting 300 pounds, but workloads that the patient can handle for 10 to 15 repetitions—is very beneficial.
Resistance training, unlike aerobic exercise, can maintain or increase muscle mass or lean body mass and also favorably affects many of the risk factors that are commonly associated with heart disease such as blood pressure and the way our bodies handle sugars. And the stronger the patient's muscles are, when he or she goes to lift any given object, the lower the heart rate and blood pressure response when lifting that object.
Is diet part of risk factor modification?
Diet is a critically important of cardiac rehab. The traditional American Heart Association recommendation has been that patients adopt a diet in which 30 percent of the total calories are from fat. Based on a number of research studies, I believe that the diet should probably contain less than 20 percent of calories from fat.
Is the formal program more likely to be successful?
I'm a believer in a formal program, although some of my colleagues are big proponents of home-based rehab because they say it's cheaper, and they're right. They also say it's more convenient. Yes, that's true. Some patients say the program is too far from their home or they have other medical problems or work-related stresses, and they'll say they simply can't attend.
And you will find people who say, "I've got other things to do, and I'll do this at home or I'll buy a bike at home." You can go down in your basement and pedal a bicycle. But my experience is, the bicycle in your basement oftentimes ends up being an extension of the ironing board. It's boring sitting on one bicycle for 30 minutes day in and day out. You don't have the camaraderie. You don't have the ongoing medical surveillance. So if it's accessible to you, you're better off in a group program supervised by exercise physiologists and nurse clinicians.
How is quality of life improved?
For one thing, self-efficacy is improved and the patients' perception that they can accomplish physical tasks. They're less worried. We have people come in initially that think, "Geez, if I start to walk fast, I'm going to get another heart attack." Then they come in here day after day, and as their fitness improves, they're walking fast, they're less out of breath, they feel fine.
So from that perspective, I think it's very reassuring. I think it's also reassuring to be surrounded with people who have heart disease just like them and who are thriving. I think seeing others succeed helps one develop the mindset that, "I can succeed as well."
©2007 Healthology, Inc.