The role of Rehabilitation for Cardiovascular Disease
Cardiovascular disease (CVD) is the most prevalent disease in Australia, affecting more than 4 million Australians. CVD is responsible for 26% of all deaths; approximately $5 billion dollars is spent annually in provision of health care to patients with CVD in Australia.
The majority of disease burden is attributable to coronary artery disease (CAD), with the most common manifestation being acute coronary syndrome associated with flow-limiting plaque or lesion due to arteriosclerosis, or other local or diffuse inflammatory processes leading to arterial narrowing.
Other common manifestations of heart disease include non-obstructive CAD and heart failure (HF). Heart failure, a complex clinical syndrome, is effectively an inability of the heart pump to effectively distribute sufficient blood to meet the body’s demand.
Research has been well established with acute interventional procedures, and addressing key CVD risk factors of hypertension, smoking, obesity, physical inactivity, hyperlipidaemia, and diabetes mellitus. Lifestyle modification and pharmacological interventions are keys to controlling these risk factors and limiting disease progression.
Cardiac Rehabilitation (CR) is a relatively new intervention in regard to management of CVD. Prior to the 1950s, common practice was to prescribe mandatory bed rest after an acute cardiac event. Since 1997, with the inaugural International Congress on Cardiac Rehabilitation, guidelines for early mobilisation and exercise prescription were established.
CR is now firmly part of post cardiac event or procedure protocol. It is defined by the WHO as “the sum of activities required to favourably influence both the subjacent cause of the disease and the physical, mental and social conditions of the patient, allowing patients to preserve or reassume their role in the community as soon as possible”
The comprehensive nature of the program utilises a multidisciplinary team (MDT), including physicians (cardiac and rehabilitation), nursing, physiotherapists, occupational therapists, exercise physiologists, psychologists, pharmacists, and dietitians.
Core components of CR include-
- Medical - evaluation and baseline patient assessment
- Exercise - training, physical activity upgrade
- Secondary prevention- nutritional and weight management
- Psychosocial support
- Education – diet, weight management, medications, exercise and lifestyle modification
The program is classically divided into 4 phases-
- Phase I – inpatient stage
- Phase II- early outpatient (supervised and monitored)
- Phase III – late outpatient supervised CR with increasing intensity
- Phase IV – maintenance/home based exercises
Phase I CR is essential to ensuring safe discharge home of a patient post event/procedure, both from a clinical and functional point of view. Involvement of the MDT targets baseline observations, mobility, and activities of daily living.
Phase II to IV (outpatient) CR commences as early as one to two weeks after event. Mt Wilga Private Hospital runs a Phase II program as a Day rehabilitation program twice a week for eight sessions, in conjunction with prescribed home exercises for each patient.
The end goals of CR are individualised to each patient, but essentially for him/her to -
- Continue physical activity and exercise to maintain improved coronary perfusion and function
- Preserve all behavioural changes and risk factor modifications
Outcome measures used for CR at Mt Wilga Private Hospital include -
- 6 minute walk test (6MWT)
- Timed up and go (TUG)
- Patient Specific Functional Scale (PSFS)
- EQ-5D5L Quality of Life questionnaire
The evidence for CR is recognised and proven across a variety of studies -
- Cigarette smoking- Participation in a CR program has been shown to be strongest predictor of continued smoking cessation at 6 months
- Diabetes- Participation in CR has been associated with a clinically significant reduction in Haemoglobin A1c levels
- Hypertension- Participation in CR has shown to be associated with significant reductions in systolic and diastolic blood pressures (aiming for <140/90 in moderate CVD risk patients, <120mm Hg in high CVD risk patients)
- Psychological Wellbeing- significant improvements in quality of life (e.g. using the EQ-5D-5L, HRQoL)
- Hospital readmissions- CR was associated with 25% reduction in all readmission rates 1 year post-acute coronary event
The challenge is to ensure adequate uptake of cardiac rehabilitation post cardiac event or procedure across both public and private sectors of health. Current interventions are being studied to increase cardiac rehabilitation enrolment, adherence, and completion.
For further information about Dr Chan’s cardiac rehab program, contact;
Tel: 02 98475000
Fax: 02 9847 5286
E: chansimon@ramsayhealth.com.au
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Download the kickstart your heart brochure
References
1. Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler A-D, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease.
Cochrane Database of Systematic Reviews2021, Issue 11. Art. No.: CD001800.
2. Anderson L, Taylor RS. Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews.
Cochrane Database of Systematic Reviews2014, Issue 12. Art. No.: CD011273.
3. Terzic CM, Medina-Inojosa JR. Cardiac Rehabilitation. In: Cifu, D, lead editor. Braddom's Physical Medicine and Rehabilitation. 6th Ed. Elsevier Press p. 767-784
4. Martin BJ, Arena R, Haykowsky M, Hauer T, Austford LD, Knudtson M, Aggarwal S, Stone JA. Cardiovascular fitness and Mortality after contemporary cardiac rehabilitation. Mayo Clin Proc. 2013: 88(5): 455-463
5. Dunlay SM, Quinn RP, Thomas RJ, Killian J, Roger VL. Participation in Cardiac Rehabilitation, Readmissions, and Death after Acute Myocardial Infarction. Am J Med. 2014: 127: 538-546.
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