Cardiac Rehabilitation in Coronary Artery Disease

CHAPTER 20 JPS Sawhney, Saurabh Bagga, Kushal Madan

INTRODUCTIONIn 1993, World Health Organization (WHO) defined cardiac rehabili tation as “The rehabilitation of cardiac patients is the sum of activities required to influence favorably the underlying cause of the disease, as well as to ensure the patients best possible physical, mental and social conditions so that they may, by their own efforts, preserve, or resume when lost, as normal a place as possible in the life of the community. Rehabilitation cannot be regarded as an isolated form of therapy, but must be integrated with the whole treatment, of which it forms only a facet.”1

According to 2013 European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease, cardiac rehabilitation should be considered in all patients with coronary artery disease (CAD), including those with chronic angina.2 According to 2016 European Guidelines on cardiovascular disease prevention in clinical practice, participation in cardiac rehabilitation program has been given a Class IA recommendation for patients hospitalized for an acute coronary event or revascularization, and for patients with heart failure (HF), to improve patient outcomes.3

EVIDENCE According to a meta-analysis of 46 randomized control trials of secondary prevention programs in patients with CAD, it was concluded that secondary prevention programs improve processes of care, enhance quality of life/functional status, reduce hospitalizations, reduce recurrent myocardial infarctions, and reduce mortality in patients with established CAD.4

One meta-analysis of 63 randomized trials with a total of 21,295 patients showed a 17% reduction of recurrent myocardial infarction at 12 months and a 47% reduction of mortality at 2 years with cardiac rehabilitation.5

CURRENT MODEL OF CARDIAC REHABILITATIONAnother objective of cardiac rehabilitation is to control the modifiable risk factors. This involves not only smoking cessation and the optimization of medication for blood pressure, diabetes and cholesterol control, but also the therapeutic education that emphasizes the importance of the measures of therapeutic life changes. In a variety of populations, incidence of CAD is explained by exposure to risk factors like unhealthy diet, tobacco, lack of physical activity, diabetes, hypertension, stress, etc. There is ample evidence to suggest that beneficial cardioprotective effects of cardiac rehabilitation include improvements in multiple risk factors. The efficacy of exercise-based cardiac rehabilitation in secondary prevention of atherosclerotic cardiovascular disease (ASCVD) is well established. In United States, cardiac rehabilita tion has evolved as a treatment modality (Fig. 1).6

Cardiac Rehabilitation in Patients with Percutaneous Coronary Angioplasty

In a retrospective analysis, cardiac rehabilitation (CR) parti cipation after percutaneous coronary intervention was associated with a significant reduction in mortality rates. The association between CR participation and reduced

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mortality rates was similar for men and women, for older and younger patients, and for patients undergoing elective or nonelective percutaneous coronary intervention.7

In a prospective cardiac rehabilitation registry of 576 patients with de novo long coronary artery lesions treated with drug-eluting stent, 50% of patients who performed comprehensive cardiac rehabilitation programs, showed a significant improvement in the overall risk profile compared with the non-CR group, including current smoking, biochemical profiles, depression, obesity, and exercise capacity. The rate of in-stent late luminal loss in the CR group was 35% less than in the usual care group at the 9-month angiographic follow-up.8

CARDIAC REHABILITATION IN PATIENTS WITH CORONARY BYPASS GRAFT SURGERYCardiac rehabilitation participation is associated with a significant reduction in all-cause mortality after coronary artery bypass grafting (CABG). Participation in any CR phase I (early CR during hospitalization) or phase II (out-

patient CR participation) was associated with a significant reduction in mortality.9 In a community-based analysis, authors concluded that participation in CR was associated with a 10-year relative risk reduction in all-cause mortality of 46% (p < 0.001) and a 10-year absolute risk reduction of 12.7%.10

STRUCTURE OF CARDIAC REHABILITATION

Phase I

This phase refers to the inpatient cardiac rehabili ta-tion program comprising mainly of early mobilization and patient education. Nowadays, these programs are uncommon but remain useful in mobilizing patients after CABG, elderly patients after ST-elevation myocardial infarction (STEMI) or sicker patients with complications. During hospitalization, there is an educa tional class for all appropriate surgical and medical patients. During this session, patients and their family members are taught about the causes, risk factors and management of coronary artery disease. Inpatient rehabili tation

Fig. 1 Cardiac rehabilitation and ASCVD prevention pyramid Source: Sandesara PB, et al. J Am Coll Cardiol. 2015;65(4):389-95.

Abbreviations: MI, myocardial infarction; CHF, congestive heart failure; PAD, peripheral arterial disease

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programs also assist the patients and family in coping with the psychological stress that accompanies such coronary event. Phase I service is usually included in the package charges for the acute event.

Phase II

It is a supervised exercise-based outpatient program in the postdischarge period. Patients exercise for 3–4 times/week for a total of 36 sessions over 3–4 months. Many patients who do not attend supervised exercise training program should be advised about home-based unsupervised exercises. Nowadays home-based telephonically monitored electrocardiography (ECG)-based exercise programs have been researched with standard supervised programs and found to be favorable in research settings. Medicare in the United States routinely covers for a total of 36 exercise sessions for patients who have suffered acute MI or have undergone CABG or percutaneous transluminal coronary angioplasty (PTCA).

Phase III

It is a nonsupervised, non-ECG monitored lifetime maintenance program in which physical fitness and additional risk-factor reduction are emphasized, at least 6 months after the cardiovascular event. During this phase exercise prescription becomes closer to that recommended for the healthy adult. It is generally used to maintain the results achieved during the earlier phases of rehabilitation.

INPATIENT CARDIAC REHABILITATION

The main purpose is to counter the deconditioning effects of bed rest and to prepare the patient for a return to normal activities. It includes sitting at the edge of the bed, standing, walking within the room followed by walking in the corridors. It also includes breathing exercises, active assisted followed by active range of motion (ROM) exercises. During hospital stay before the discharge patients and their spouses should be counseled to cope with the psychological and emotional stress that accompanies a coronary event. As soon as the patient is clinically stabilized, he is mobilized. During mobilization, the goal should be keep the heart rate within 20 beats above resting heart rate. Patients who exhibit a 10–20 mm Hg drop in orthostatic systolic blood pressure (BP) may need further evaluation prior to ambulate the patient.

Patient Education

According to American Heart Association/American College of Cardiology (AHA/ACC) guideline, recommendation patients should be educated about appropriate cholesterol manage ment, BP, smoking cessation, and lifestyle manage ment (Class I, Level of Evidence: C). Patients who have undergone percutaneous coronary intervention (PCI) or CABG derive benefit from risk factor modification and should receive counseling that revascularization does not obviate the need for lifestyle changes (Class I, Level of Evidence: C).13

While the specific queries and concerns of some patients require individual attention, most education and counseling is delivered in a group setting. Group sessions allow patients to listen to questions which are asked by others and which they themselves may have been too inhibited to raise. Further, group programs involve less staff time and are, therefore, more cost-effective than individual counseling.

OUTPATIENT CARDIAC REHABILITATIONOutpatient cardiac rehabilitation programs have gradually become an important part of the rehabilitation process. A well planned cardiac rehabilitation program includes all aspects of risk factor modification through lifestyle, supervised exercise and medications. The purpose is to progressively improve the patient’s functional capacity and lower the cardiovascular risk factors.

Exercise Training Exercise prescription should be individualized according to the patient’s functional capacity. The main principles of each exercise prescription are the frequency, intensity, duration, mode and progression of the exercise. Appropriate warm up and cool down before and after conditioning phase respectively are important components of a training session for cardiac patients. For risk stratification and to obtain a desired training intensity, exercise stress testing may be of value in patients entering a formal cardiac rehabilitation program. Treadmill exercise testing before cardiac rehabili tation provides information about peak exercise capacity and heart rate, helping to stratify patients for the level of supervision during training.11

Diet ModificationAccording to 2016, European Guidelines on cardiovascular disease prevention in clinical practice a healthy diet is recommended as a cornerstone of cardiovascular disease (CVD) prevention in all individuals (Class IB).3

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Table 1 Healthy diet characteristics

•   Saturated fatty acids to account for <10% of total energy intake, through replacement by polyunsaturated fatty acids

•   Transunsaturated  fatty  acids  as  little  as  possible,  preferably  no intake from processed food, and <1% of total energy intake from natural origin

•  <5 g of salt per day•  30–45 g of fiber per day, preferably from wholegrain products•  >200 g of fruit per day (2–3 servings)•  >200 g of vegetables per day (2–3 servings)•  Fish 1–2 times per week, one of which to be oily fish•  30 g unsalted nuts per day•   Consumption  of  alcoholic  beverages  should  be  limited  to  2 

glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women

•   Sugar-sweetened soft drinks and alcoholic beverages consump-tion must be discouraged

There should be a detailed assessment of the dietary habits of the patient. Patients should be advised to eat more fruits, vegetables, nuts, fish, low fat dairy and products based on plant oils. Patients must be educated about the right choice of cooking media and healthy methods of cooking food. Healthy eating should be extended to the whole family.12 According to the ESC guidelines, characteristics of healthy diet are given in Table 1.3

Sexual Counseling

In the initial few weeks to months of recovery, many post- MI patients report a fear of resuming sex and partners share the same worries and fear. As per the AHA and ESC council on Cardiovascular Nursing and Allied Professions, sexual activity is reasonable ≥1 week after uncomplicated MI, when the patient is without cardiac symptoms during mild to moderate physical activity (Class IIa; Level of Evidence C).14 Sexual counseling content includes a review of medications and potential effects on sexual function. It can be beneficial to encourage patients to report any side effects of medications related to sexual activity.

Tobacco Cessation

Recommendations for smoking interventions strategies are given in Table 2. Complete tobacco cessation (smoking as well as chewing tobacco) and no exposure to passive smoking should be the goal. According to 2016 ESC guidelines on CVD prevention in clinical practice there is Class IA recommendation for identification of smokers and provide repeated advice on stopping with offers to help, by the use of follow-up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination.3

The US Public Health Service 2008 Clinical Practice Guideline Update15 has strongly recommended the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco. The recom-menda tions are given as 5As which are: Ask: Ask about tobacco use. Advise: Advice to quit. Assess: Assess willingness to make a quit attempt Assist: Assist in quit attempt. Arrange: Arrange for follow-up.

A meta-analysis of twelve studies containing data on 5878 MI patients showed a significant decrease in mortality associated with smoking cessation. Relative risk reductions across studies ranged from 15% to 61%. The number needed to quit smoking to save 1 life is 13 assuming a mortality rate of 20% in continuing smokers.16

In a randomized, The Survival and Ventricular Enlargement (SAVE) trial of post-MI patients with LV dysfunction, it was shown that smoking cessation is associated with a 40% lower hazard of all-cause mortality and a 30% lower hazard of death or recurrent MI or death or HF hospitalization.17

Psychosocial Assessment in Cardiac Rehabilitation

It is important to address the psychological issues of patients. All the individuals taking part in cardiac rehabilitation should undergo a valid assessment of anxiety, depression, quality of life and other relevant psychological factors using an appro priate assessment tool.

Yoga and Cardiac Rehabilitation

Yoga practice leads to similar outcomes as cardiac rehabili tation (improved physical fitness, stress reduction and lifestyle change). Several studies have shown that yoga and/or meditation can control risk factors for

Table 2 Recommendations for smoking intervention strategies3

Recommendations Class Level

It is recommended to identify smokers and provide repeated advice on stopping with offers to help, by the use of follow-up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination

I A

It is recommended to stop all smoking of tobacco or herbal products, as this is strongly and independently causal of CVD

I B

It is recommended to avoid passive smoking I B

Abbreviation: CVD, cardiovascular disease

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cardiovascular disease like hypertension, type II diabetes and insulin resistance, obesity, lipid profile, psychosocial stress and smoking. Yoga, therefore, could provide a useful framework to develop an economical cardiac rehabilitation program.

BARRIERS AND CHALLENGES TO CARDIAC REHABILITATION Cardiac rehabilitation has been a therapeutic option since 1950s, but still it has not received the attention it deserves. There is ample evidence available in the literature to support the fact that most of the risk factors for cardiovascular disease can be modified with heart-healthy diet and physical exercise training but in the real world, treatment strategies concentrate solely on pharmaceutical interventions, neglecting the beneficial effects of cardiac rehabilitation. Many potential barriers to participation in cardiac rehabili tation have been proposed including lack of physician recommendation, lack of insurance and lower education. Predictors of participation include revascularization, left ventricular dysfunction, and regular physical activity before MI. Psychosocial barriers have also been identified including depression, social deprivation and lower socioeconomic status, dependent spouse at home, lack of transportation, lack of motivation, reduced self-efficacy, and perception that rehabilitation is inconvenient or unnecessary.

CONCLUSIONCardiac rehabilitation reduces mortality, morbidity and improves quality of life and functional capacity and hence is necessary in modern era. However, it is poorly utilized. Low referral and low attendance rates are the major challenges of cardiac rehabilitation. Considering the benefits of cardiac rehabilitation and increasing burden of cardiovascular diseases in developing countries, there is an urgent need to create centers which can offer formal and monitored cardiac rehabilitation program to all the eligible patients. In future cardiac rehabilitation will be the integral part of treatment of coronary heart disease.

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