Cardiopulmonary rehabilitation

Cardiac rehabilitation (CR) is a branch of rehabilitation medicine/Physical Therapy dealing with optimizing physical function in patients with cardiac disease or recent cardiac surgeries. CR services can be provided during hospitalization for the event^[1] or in an outpatient setting.^[2] While the "glue" of cardiac rehabilitation is exercise, programs are evolving to become comprehensive prevention centers where all aspects of preventive cardiology care are delivered. This includes nutritional therapies, weight loss programs, management of lipid abnormalities with diet and medication, blood pressure control, diabetes management, and stress management. CR exercise and prevention programs are supported by the American Heart Association and the American College of Cardiology.

Procedure

Patients typically enter cardiac rehabilitation in the weeks following an acute coronary event such as a myocardial infarction (heart attack), coronary artery bypass surgery, with a diagnosis of heart failure,^[3] replacement of a heart valve, percutaneous coronary intervention (such as coronary stent placement), placement of a pacemaker, or placement of an implantable cardioverter defibrillator.^[2] A 2017 Cochrane review showed similar short-term benefits from home- and centre.based rehabilitation, though there was not sufficient data to know whether this is sustainable over time.^[4]

Inpatient program

Patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms and legs. Heart rate is monitored and continues being monitored as the patient begins to walk.^[1]

Outpatient program

Most patients wishing to participate in outpatient CR are able to begin within 4–6 weeks after surgery. In order to participate in an outpatient program, the patient must first obtain a physician's referral.^[5] Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipid measures, blood pressure, body weight, and smoking status. An exercise stress test is usually performed both to determine if exercise is safe and to allow for the development of a custom exercise program. During exercise, the patient's heart rate and blood pressure are monitored to check the intensity of activity.^[2]

Short and long-term risk factors and goals are established, and patients are closely monitored by a "case-manager" who may be a cardiac-trained Registered Nurse, Physiotherapist, respiratory therapist, or an exercise physiologist. A dietitian helps create a healthy eating plan, and a counselor may help to alleviate stress or, for smokers, may give counseling on how to quit.^[2]

The duration of the program varies from patient to patient and can range from six months to several years.^[2] Even after CR is finished, there are long-term maintenance programs that should not be minimized, as benefits are maintained only with long-term adherence.

Underuse

Participation in cardiac rehabilitation is associated with a 25% decrease in overall mortality over three years.^{[citation needed]}

Cardiac rehabilitation services are significantly underused in the United States, with only 19–29% of patients with eligible cardiac diagnoses participating. Underuse is related to many factors, including lack of available programs nearby and low referral rates by physicians, who often focus more attention on better reimbursed cardiac-intervention procedures than on long-term lifestyle treatments.^{[citation needed]} With a contemporary focus on the cost-effectiveness of medical interventions, CR programs are well-positioned to assume a more prominent role in the long-term care of patients with coronary heart disease.^[6]

Benefits

The use of cardiac rehabilitation is well established in the scientific community. A Cochrane Review of 147 studies demonstrated that for myocardial infarction and heart failure patients, exercise-based cardiac rehabilitation improves quality of life and reduces readmission rates. However, there was no benefit in mortality.^[7][8] There appears to be no difference in outcomes between inpatient and outpatient programs. Rehabilitation programs that only have an educational or psychological component have not been shown to be effective. Another Cochrane Review of six randomised controlled trials in adults with atrial fibrillation found that exercise-based rehabilitation may improve physical exercise capacity, but there was no effect on health-related quality of life. Due to the limited number of trials, the authors could not estimate the impact on mortality or serious adverse events.^[9]

Notes

References

• Ades PA. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. New England Journal of Medicine. 2001 Sep 20;345(12):892-902.
• Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007 Oct 9;116(15):1653-62.
• Ayala C et al. Receipt of cardiac rehabilitation services among heart attack survivors—19 states and the District of Columbia. Morbid Mortality Weekly. 2003; 52:1072-1075

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