Cardiac Rehabilitation

Cardiac rehabilitation under an interprofessional approach has well-established benefits.[9][10] The cardiac rehabilitation team is made up of members including the following [4]:

• Patient
• Patient's family
• Physicians (surgeons, cardiologists, physiatrists, other specialists)
• Pharmacists
• Nurses
• Physical therapists
• Occupational therapists
• Speech and language pathologists
• Behavioral therapists
• Dietitian
• Case managers

Cardiac rehabilitation consists of three phases.

Phase I: Clinical phase

• This phase begins in the inpatient setting soon after a cardiovascular event or completion of an intervention. It begins by assessing the patient's physical ability and motivation to tolerate rehabilitation. Therapists and nurses may start by guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a range of motion and limiting hospital deconditioning. The rehabilitation team may also focus on activities of daily living (ADLs) and educate the patient on avoiding excessive stress. Patients are encouraged to remain relatively rested until completion of treatment of comorbid conditions, or post-operative complications. The rehabilitation team assesses patient needs such as assistive devices, patient and family education, as well as discharge planning. 

Phase II: Outpatient cardiac rehab

• Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts three to six weeks though some may last up to up to twelve weeks. Initially, patients have an assessment with a focus on identifying limitations in physical function, restrictions of participation secondary to comorbidities, and limitations to activities. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice, tailored training program, and a relaxation program. The treatment phase intends to promote independence and lifestyle changes to prepare patients to return to their lives at home. 

Phase III: Post-cardiac rehab

• This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening, and aerobic conditioning. Patients receive encouragement towards maintaining an active lifestyle and continue exercise. Outpatient visits to physician specialists are recommended to monitor cardiovascular health and medications regimens, promote healthy lifestyle changes and intervene when necessary to prevent relapse.[11][12]

There is also a pre-surgery phase, where the patient starts cardiovascular rehabilitation. A small number of studies demonstrate that the post-surgical pathway is better tolerated by patients.

A study in France reviewing the safety of cardiac rehabilitation found the cardiac arrest rate was 1.3 per million patient hours of exercise.[13] Rakhshan et al. studied the potential complications of heart rhythm device malfunction after eight weeks of cardiac rehabilitation, but the study revealed a decrease in physical complications in patients who received cardiac rehabilitation versus a control group.[14] 

Benefits

Overall cardiac rehabilitation increases quality of life and decreases health care costs.[15] Cardiac rehabilitation has many physiologic benefits due to its exercise component. Exercise training has been shown to increase maximal oxygen uptake (VO2max), improve endothelial function, and improve myocardial reserve flow. Additionally, cardiac rehabilitation can reduce smoking, body weight, serum lipids, and blood pressure.[11] Milani et al. found that cardiac rehabilitation decreased depression in heart disease patients who suffered a major coronary event.[16] A Cochrane review noted that cardiac rehabilitation reduced hospital admissions and showed a long-term decrease in all-cause mortality in patients heart failure patients with preserved ejection fraction. However, there was no short-term (less than 12 months) benefit to all-cause mortality.[9]

Goals

As stated above, cardiac rehabilitation goals can be designated into two broad categories [4]:

• Short-term
• Control cardiac symptoms
• Enhance functional capacity
• Limit unfavorable psychological and physiologic effects of cardiac illness
• Boost psychosocial and vocational status
• Long-term
• Alter natural history of coronary artery disease
• Stabilize or reverse progression of atherosclerosis
• Lessen risk of sudden death and reinfarction

Future Research

In a systematic review of 19 random clinical trials, complex e-coaching was found to be an effective method of delivering therapies targeting physical capacity, clinical status, and psychosocial health; however, detailed protocols were not well described. Therefore, determining which aspects of e-coaching have the most benefit and need to be further developed have not been determined. In addition, basic e-coaching was not found to be effective.[17] Studies on the effects of cardiac rehabilitation for congenital heart disease (CHD) patients is lacking. Randomized clinical trials in adult and pediatric populations are needed to establish specific guidelines and the current evidence.[18]

Even though there is an overwhelming body of evidence to support the benefits of cardiac rehabilitation, patient participation is unusually low. Data from Medicare and the CDC reveal 14-35% of heart attack survivors and about 31% coronary bypass grafting surgery patients utilized or enrolled in cardiac rehabilitation or secondary prevention programs.[7] Leon et al. noted that low utilization correlated to a low referral rate, lack of insurance coverage, poor patient motivation, and limited program site accessibility.[19] A 2017 qualitative study on the patients’ perspectives of cardiac rehabilitation revealed psychosocial barriers to attending cardiac rehabilitation were lack of time and fear of exercise. Patients’ perceptions of cardiac rehabilitation (and subsequent participation) were also affected by prior exercise experience, physiotherapist communication, the severity of the cardiovascular disease or event, and the patient's’ future goals after rehabilitation. Therefore, the cardiac rehabilitation team should take these points into consideration when creating rehabilitation programs for patients.[20]