Cardiac rehab - What is cardiac rehabilitation and who needs it?

Cardiac rehab is a comprehensive program that is designed to lower the risk of future heart problems and to improve quality of life for patients with heart disease. Cardiac rehabilitation is particularly important for patients with congestive heart failure since quality of life depends so closely on maximizing heart function.

While heart cells that die from a heart attack cannot be restored, the heart muscle that surrounds that dead area can be conditioned to take over some of the dead area’s function. Also, if the risks that lead to the heart damaged are controlled or reversed, the likelihood that further damage will occur to the heart can be reduced. One of the best ways to improve heart function and prevent subsequent damage is through cardiac rehabilitation or simply cardiac rehab.

Understanding Heart attack

In Western countries, the most common reason that people experience congestive heart failure is from an ischemic cause. This means that the blood vessels that provide blood to the heart—the coronary arteries—become diseased and blood flow to the heart is less than normal. If the coronary arteries are blocked completely, it is called a myocardial infarction or heart attack. If blood flow to the heart is interrupted, the heart muscle rapidly begins to die, a condition that can become permanent. Even if blood flow to the heart is not completely blocked, but is less than needed, the heart muscle will not function properly. These are examples of ischemic heart failure.

Cardiac Rehab program

A cardiac rehab program should have, at a minimum, a medical evaluation, a tailored exercise regimen, education about the disease and is treatment, and patient counseling. Programs include a number of specialized medical professionals working as a patient care team. In order to provide these services, a cardiac rehab team usually consists of a cardiologist, nurse educator, physical therapist, social worker/psychologist and registered dietician. This system not only provides an accurate initial assessment of the patient’s congestive heart failure status, but it also provides a method for tracking progress and failure. Treatment and rehabilitation can be changed or augmented depending on the patient’s current condition.

In the near term, the overarching goal for congestive heart failure patients is to stabilize the patient and optimize heart function. The earliest phase of cardiac rehab begins in the hospital at which time the patient is visited by most of the cardiac rehab team. During this first visit, a number of goals are set and exercises are prescribed. The heart muscle is conditioned (gently) so that it can regain as much function as possible after the insult (like a heart attack). In fact, range of motion exercises begin within the first day or two. Personal care activities are encouraged early in order to establish self-sufficiency.

Why is self-sufficiency so important in the early phase of cardiac rehab?

One consequence of heart disease that is mostly underappreciated by the public is the psychological impact of a heart attack and subsequent congestive heart failure. The rate of depression in these individuals is very high. There are feelings of helplessness and worthlessness that interfere with quality of life every bit as much as limited capacity for exercise or shortness of breath. Moreover, patients with depression after a heart attack are more likely to die or be seriously disabled from the disease. Treating the psychological impact of congestive heart failure is an important part of overall treatment. The diagnosis and treatment of psychological/psychiatric illness is included in the cardiac rehabilitation plan.

The first phase of cardiac rehab includes a good deal of patient education, about the disease, the medications and the necessary lifestyle changes. Patients that know and understand their disease do better with congestive heart failure than those that do not.

The second phase of cardiac rehab begins after discharge from the hospital. In actuality, the second phase is split into two parts. The first part includes a healing process that usually takes place in the home. At this point, patients are helped to regain independence and mobility. The patient is encouraged to do as much for themselves as possible. In addition, gentle exercises are performed to increase physical conditioning and overall heart strength. While in the home, patient educators and dieticians lay the ground work for healthy eating and teach a congestive heart failure diet. Both the patient and family members/support system are educated in this diet.

After the home recovery is complete, the second part is commenced, which is usually about a month long. The patient begins visits to a cardiac rehabilitation center. This involves a more intense exercise plan that is done with heart monitoring. An EKG (ECG) worn during exercise provides physical therapists and physicians with a real time assessment of how the heart is doing during exercise. If the heart is being taxed too much, the exercise intensity can be reduced or stopped temporarily. In this way the patient is pushed to condition the heart, but not so much that it is dangerous. Supervised exercise treatments take place three times a week at a cardiac rehabilitation clinic.

This phase of cardiac rehab also includes an intensive education program. During this time the congestive heart failure patient is taught about stress management, proper eating habits, and weight loss regimens. If the patient smokes, an intensive smoking cessation program is begun. This part of the cardiac rehab process may last between three to six months.

The final phase of cardiac rehabilitation is the maintenance phase. Exercise continues three times a week in this phase, but heart monitoring is not required. In fact, the maintenance phase of cardiac rehab usually takes place in the home or at a gym. At this point the patient should have a good grasp of the exercise regimen and the heart should be rehabilitated to the point that exercise is safe. In fact this phase is rarely supervised by medical staff. It exists mainly to facilitate healthy habits over the long term. Patients transition to exercise that they find enjoyable.

Cardiac rehabilitation is not for everyone.

Patients that have significant chest pain at rest or with mild exertion are not candidates. Also, if the heart has frequent of uncontrolled rhythm abnormalities it may not be safe for the patient to participate in cardiac rehab. If congestive heart failure is uncompensated or if heart function is very low, patients may not be able to handle the stress of cardiac rehabilitation unless the heart function can be optimized.

The long term goals of cardiac rehabilitation are about minimizing the risk of subsequent damage of the heart.

Since most cases of congestive heart failure are due to an ischemic event (like a heart attack), long term cardiac rehab often focuses on changing a person’s lifestyle to eliminate or reduce risk factors and behavior. The exercise treatments usually foster a commitment to heart conditioning but weight loss is also emphasized if overweight or obesity is a problem. If dyslipidemia is a problem, patients will be educated about cholesterol and cholesterol treatment will be optimized, including diet. If the patient has other contributory diseases, such as diabetes, this will be incorporated in diet, exercise, and education plans.

The atherosclerosis that contributed or caused the inciting heart attack is the focus of cardiac rehab over the long term. While many people have stent placed, angioplasty, or coronary artery bypass surgery (CABG) after a heart attack, halting further progression of coronary disease and stroke is now critical since recurrence rates for these are so high.

If done effectively, cardiac rehabilitation can have a number of life-saving and life-improving benefits.

Cardiac rehab exercise training improves the coronary arteries ability to respond to stress, either the stress of exercise or of a disease within the artery. Exercise conditioning not only strengthens the heart muscle and the pump works more efficiently, but the blood vessels supplying the heart are healthier, too. This can reduce the risk of another heart damaging incident.

Patients that are better able to tolerate exercise under cardiac rehab conditions are also better able to do tasks of everyday living, too. The chest pain that occurs with exertion (angina) tends to improve as the heart is in better shape. Improved exercise tolerance helps people participate in work and in their social lives—this can have profound implications for long term psychological and emotional health as well as quality of life.

Cardiac rehabilitation cost

While it may sound like cardiac rehabilitation is expensive since it involves the participation of a team of medical professionals, in actuality the cost-benefit of such an approach is actually more cost-effective than the alternative. The approach is comparable in price to cholesterol lowering drugs and less expensive than coronary artery bypass graft surgery when considered in terms of health benefit gained for the patient. In cost-benefit studies, doctors have demonstrated that a comprehensive cardiac rehabilitation program can reduce hospital admissions for congestive heart failure, reduce the length of stay required if admission is necessary, and increase the proportion of people that can successfully return to work. In other words, while cardiac rehabilitation is expensive, it is no more expensive than other medical interventions used to treat congestive heart failure and is as effective or more effective for the cost. These positive cost-benefit analyses have prompted many health insurance companies to reimburse patients for the cost of cardiac rehabilitation.

ABOUT THE AUTHOR: Michael T. Spako is an M.D. who specializes in medical writing. I am pleased to have him as the principal writer for this congestive heart failure site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.

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