Cardiac rehabilitation should be tailored to the patient
What are the benefits of CR?
Which patients should undergo CR?
What are the key components of a CR programme?
Cardiac rehabilitation (CR) is, in effect, a chronic disease management programme with a very strong evidence base. A systematic review covering 48 trials with nearly 9,000 patients, published in 2004, showed that exercise-based CR resulted in a 20% reduction in all cause mortality and a 25% reduction in total cardiac mortality.1
Other benefits of CR have also been clearly demonstrated.2 These include:
• Reduction in symptoms in those with angina
• Increase in exercise capacity and general fitness
• Reduction in blood pressure
• Improvement in lipid profile (mainly by raising HDL)
• Reduction in arrhythmias
• Improved coronary blood flow
• Improvement in psychological measures.
CR has been defined by the WHO as the ‘co-ordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease'.
Cardiac rehabilitation models
CR programmes can be carried out in hospital or the community. The traditional hospital-based programme is divided into four phases.
The other widely used model is a six-week, home-based programme using written and audiotape materials. Patients are supervised by phone, or through home visits, by a specially trained facilitator, usually a nurse or physiotherapist. This method, as described in The Heart Manual,3 has been shown to be better than ‘usual care' and achieve similar outcomes to hospital-based programmes.4,5
More recently, the ‘Care closer to home' initiative outlined in the White Paper Our health, our care, our say6 has seen a shift towards moving cardiac rehabilitation services from the hospital to a community setting. Community-based services are preferred by many patients and have been shown to be feasible and effective.7
The primary care team
It is imperative that CR programmes have strong links with the primary care team.
GPs already have their own effective initiatives to improve lifestyle and reduce risk factors, such as smoking cessation strategies and nurse-run secondary prevention clinics.9 The GP and other members of the primary healthcare team play vital roles in reinforcing healthy lifestyle change, optimising medical risk factor management and ensuring long-term continuation of appropriate cardioprotective medication.
GP referral for Phase IV sessions
GPs can refer CHD patients to an appropriately qualified instructor for Phase IV community-based exercise sessions, using the British Association for Cardiac Rehabilitation's (BACR) protocol for GP referral.
‘Exercise on prescription' at local leisure centres can have social as well as physical benefits for patients undergoing CR. It can encourage them to build exercise into their lives and continue to use these community facilities and stay physically active long after they have recovered.
The patient should be clinically assessed by their GP using the BACR protocol and the decision to refer should be made in accordance with published UK guidelines cited in the protocol.
The BACR exercise referral pathway recommends annual review of the patient by their GP or other designated health professional.
Which patients will benefit?
The following patient groups have been shown to benefit from CR programmes:
• post-revascularisation (either surgical or PCI)
• stable angina1
• heart failure10
• post-valve surgery, cardiac transplantation or ICD insertion.
Patients should be offered cardiac rehabilitation at the time of diagnosis, e.g. in the rapid access chest pain clinic for stable angina patients or in hospital post MI/PCI/CABG (i.e. Phase I). Patients typically enter the Phase III programme 2 weeks post MI (uncomplicated) or 4 weeks for CABG.
The National Service Framework for Coronary Heart Disease recommended, in 2000, that patients should be offered CR after acute MI, coronary artery bypass grafting and percutaneous coronary intervention.11 The target was 85% of these groups to be offered CR by 2002. Once this target had been reached, the NSF recommended that programmes should be widened to include patients with heart failure, angina, and other conditions. The recent NICE guideline on secondary prevention stated that CR should be equally accessible to all patients post-myocardial infarction.12
Despite these recommendations, this life-saving treatment is still only provided to a minority of cardiac patients, around 30% in the UK, although every hospital has access to a programme.13 This is mainly due to two factors: lack of uptake by patients and inadequate provision of services.
Those patients less likely to take up CR include women, the elderly and ethnic minorities.14 Furthermore, patients who are depressed, socially isolated and those who smoke are also less likely to attend.15
Inadequate funding (only around 50% of programmes have a dedicated budget) means that programmes vary in their quality and staffing levels and many are underresourced limiting their capacity.16 This has led to the practice of only taking patients following MI or cardiac surgery excluding patients with angina even though they would benefit as much.17 It does not help that the CR service is often separate from the acute cardiology service and rarely has direct physician support.16
In an ideal world, patients should be offered a choice as to which type of programme they are referred to e.g. hospital-based, community-based or a home programme such as that provided by The Heart Manual. However, lack of funding usually means that only one option is available.
A recent study showed that when the choice of either a hospital or a home-based programme was offered, the NSF standard for patients being offered CR post-MI was achieved.17 Where both hospital and community-based programmes are available, the community programme typically is for those patients who are perceived at lower risk (e.g. angina patients) with often a heavy focus on exercise and little in the way of secondary prevention and risk factor management.
There has been concern in the past over exercise in those patients who are perceived to be at high risk e.g. those with LV dysfunction or prior to revascularisation in the community. Indeed the SIGN guidelines, published in 2002, stated that such patients should undertake exercise in a hospital-based programme.18
However, as more and more CR programmes move to the community such a limitation will not be practical and indeed will result in exclusion of many eligible patients from CR programmes.
More recently, the BACR has published a position statement along with Resuscitation UK on this topic which has left it open to local CR providers to decide where such patients should have their CR programme but with a minimum standard that the CR team must have intermediate life support training and that a plan is in place for a prompt response via a 999 emergency protocol.
Improving service provision
To try to fill the gap in the provision of CR services in the UK, there is a newly developed National Audit of Cardiac Rehabilitation (NACR), part of the Central Cardiac Audit Dataset, funded by the British Heart Foundation (BHF), which reports annually. The aim of this audit is to show what services are achieving locally and nationally and where services are not reaching acceptable standards.
Furthermore in 2007, the BACR published its Standards and Core Components for Cardiac Rehabilitation clearly setting out the minimum standard for CR programmes.19 The core components reflect that cardiac rehabilitation services are moving away from the traditional model with its focus on exercise, psychological support and education to a more comprehensive approach which includes optimising secondary prevention measures.
The optimal model of cardiac rehabilitation is one that provides these core components but also takes into account the fact that the needs and beliefs of individual patients vary considerably. Programmes are thus becoming increasingly patient-centred and moving towards a menu-based approach where the patients choose the components most relevant to them. For instance, a patient may choose not to participate in a supervised exercise programme but to take part in a home–based programme such as regular walking or cycling.
There has also been a move away from didactic lecture-style education to strategies to change behaviour such as motivational interviewing. This dynamic non-confrontational counselling approach whereby patients are encouraged to mobilise their own resources to change20 has been shown to be effective in improving outcomes in secondary prevention particularly with regard to smoking cessation.21 Goal setting with realistic targets being negotiated between the CR practitioner and the patient is also a key component in successful behaviour change.
CR is an effective evidence-based, life-saving treatment for individuals with heart disease. There is currently inadequate provision of services in the UK, particularly for certain groups, but genuine efforts to reduce this inequality are underway. Secondary prevention is now firmly a part of cardiac rehabilitation with a focus on a comprehensive approach. Use of behavioural strategies such as motivational interviewing is becoming increasingly important as it is recognised that changing behaviour in the longer term is key. The optimal CR programme is one that is accessible, inclusive and offers a menu-based approach in conjunction with meeting the minimum standards laid down by the BACR. It is vital we work towards providing such a model to all patients with heart disease.Cardiac rehabilitation Author
Dr Susan Connolly
MB BCh BAO MRCPI PhD
Consultant cardiologist, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London
The Heart Manual
General practice pack available
British Association for Cardiac Rehabilitation
BACR website can be accessed via www.bcs.com