Advances & Insights: Heart Health
What the news means for you
Alison Bailey, MD
Cardiac rehab enhances patients’ quality of life
Whether the elderly benefit from cardiac rehabilitation has been an issue of debate in the past because of their pre-existing conditions and lower exercise capacity. But it makes sense that older patients also receive benefits because a significant proportion of acute coronary syndromes are lifestyle mediated.
Cardiac rehab is more than just exercises. It’s a comprehensive lifestyle modification program. Every patient gets an individualized exercise prescription tailored to his or her baseline exercise capacity and is encouraged to exercise daily. All patients also receive a dietary consultation and a personalized group of classes based on the individual’s unique risk factors for cardiovascular disease.
Historically, one of the reasons many people didn’t take advantage of cardiac rehab has been lack of access to these programs. Luckily, that’s not as much of a problem today as most areas in Kentucky have some sort of program. The Kentucky Cardiopulmonary Rehabilitation Association lists all of the available rehab facilities in the state on their website.
Unfortunately, many doctors do not adequately stress the importance of rehab while the patient is hospitalized with a cardiac event. Studies in various fields of medicine have shown that people are more likely to follow recommendations if a physician tells them during the hospital stay that it’s important. And programs that are successful in improving their referral rate to rehab generally do so from the inpatient setting.
UK’s cardiac rehab program
UK Cardiopulmonary Rehabilitation offers Phase 2 rehab for patients who have had a coronary event in the past year, including myocardial infarction, percutaneous coronary intervention, heart bypass surgery, heart valve surgery, heart or heart-lung transplant or who have chronic stable angina.
Our Optimal Health (OH!) Program, also known as Phase 3 rehab, is available to anyone for a nominal monthly fee and incorporates the same concepts as Phase 2 rehab. Participants receive an individual exercise prescription as well as education regarding cardiovascular risk and ways to lower their own risk. Exercise sessions are generally three times weekly with classes based on the participant’s schedule. Patients who have completed the initial Phase 2 program frequently join this program to continue improving their health.
Part of the advantage of attending a structured rehab program is the interpersonal connections that develop. A lot of patients meet new people and find friends in rehab who help develop an unofficial support group. There’s really no scientific data to support the notion that this improves their outcomes, but it’s been my observation that people seem to exercise better if they have the support of friends. Patients also build a rapport with our staff, and they can get help if they have questions or are experiencing some sort of health problem.
It’s frequently harder to motivate patients to make lifestyle changes than it is to simply have them take a pill. But the Duke study shows an almost 50 percent greater survival rate at five years in patients attending 36 sessions of rehab versus those who attended only one. If we had a pill that could do that, it would be all over the news. Unfortunately, despite the proven benefits, patients often drop out of rehab early.
Here at UK, they can come three times a week for 12 weeks. After six weeks they may be back to a normal life and able to work. However, the more sessions a patient completes, the better he or she can expect to do, and we encourage everyone to complete the program if possible.
“Studies have shown that in patients who remain depressed, the mortality rate is higher, and rehab can be instrumental in improving depression.”
Rehab helps raise quality of life
It’s amazing how rehab can improve a patient’s quality of life. They’re able to do things they couldn’t do before - walk to the mailbox, go shopping, climb two flights of stairs. Rehab also improves a person’s mood. Depression is common after a cardiac event. Studies have shown that in patients who remain depressed, the mortality rate is higher, and rehab can be instrumental in improving depression. Cardiac rehab can also aid patients in achieving target levels of weight, blood pressure and cholesterol.
Our society is becoming more focused on prevention. I tell my patients I’d love to have met them 40 years ago when this process was really beginning. We know that cardiovascular disease is a progression that occurs over the lifetime and is driven primarily by our lifestyle.
Making changes in the way we eat to increase our fruit and vegetable consumption and decrease our body weight, increasing the time we exercise and stopping our bad habits like smoking can make a huge change in our lifetime risk for cardiovascular disease. Anytime you can reach patients and change their lifestyle, you lower their risk of these cardiovascular events. And as physicians, that’s what we all want to do: help people live longer, happier lives free from disease.
Dr. Bailey is medical director of the UK Cardiac Rehabilitation Program and an assistant professor of medicine (cardiology) in the UK College of Medicine.
Despite benefits, few patients receive cardiac rehabilitation
Exercise-based cardiac rehabilitation has long been recognized as integral to the survival of patients with cardiovascular disease. It involves medical evaluation, prescriptive exercise, cardiac risk factor modification, education, counseling and behavioral interventions.
“Fewer than 20 percent of the patients eligible for cardiac rehabilitation ever receive it.”
Most patients undergoing cardiac rehab have had a myocardial infarction (MI) or coronary artery bypass graft (CABG). Medicare now considers those who have had the following conditions to also be eligible:
- Percutaneous coronary interventions.
- Heart or heart-lung transplantation.
- Stable angina.
- Cardiac surgical procedures for heart valve repair or replacement.
Cardiac rehab is underutilized
Despite the proven benefits, fewer than 20 percent of the patients eligible for cardiac rehabilitation ever receive it. Women and elderly patients are even less likely to go to rehab. Barriers to participation in cardiac rehabilitation include low patient referrals from physicians, a lack of motivation among patients who don’t see the benefit, limited insurance reimbursement and geographic restrictions.
Medicare and most insurers reimburse eligible patients for 36 sessions of rehab. However, the relationship between the number of sessions attended and long-term outcomes has not been established until recently.
How much rehab is optimal?
A group of researchers led by Bradley G. Hammill of Duke University last fall published a study addressing the issue of the number of cardiac rehabilitation sessions necessary to lower a patient’s risk of MI or death. They looked at 30,161 elderly Medicare patients with at least one claim for early outpatient cardiac rehabilitation services, from Jan. 1, 2000, to Dec. 31, 2005. Most of the patients were white males, with an average age of 74, who had undergone CABG. Forty percent had been diagnosed with congestive heart failure in the previous year, and 36 percent had diabetes.
To estimate the relationship between the number of sessions attended and death or MI after four years, researchers used a Cox proportional hazards model. They then adjusted subjects for demographic characteristics, comorbid conditions and subsequent hospitalizations. The study is published in the Dec. 21, 2009, issue of Circulation.
“The rate of MI was consistently lower among those who attended more than 24 sessions and highest among those attending fewer than 12.”
Results of study
Patients who attended more than 36 sessions of rehabilitation had a 22 percent lower risk of death than those who attended 12 and a 47 percent lower risk of death than those attending only one session. The rate of MI was also consistently lower among those who attended more than 24 sessions and highest among those attending fewer than 12.
The authors note that their study has limitations. For example, patients who attended more rehabilitation sessions might have done so because they were generally more active, had previously exercised or did not smoke. Medication adherence and socioeconomic factors could have also played a part in their attendance record.
Because only 18 percent of the patients studied attended all 36 sessions, the study authors suggest that doctors promote greater use of cardiac rehabilitation and try to understand the barriers to attendance.
For more information, see:
UK HealthCare cardiac resources - UK Gill Heart Institute
For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874.