Multidisciplinary approach to cardiac rehabilitation

1. CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES
JAMIA MILLIA ISLAMIA
TOPIC – Multidisciplinary approach to cardiac rehabilitation
Presented by- Purnima Kushwaha
MPT -3rd semester (cardiopulmonary)
Roll no. 18MPC003

2. • Cardiac rehabilitation (CR) is defined by the World Health Organization
(WHO) as "The sum of activity and interventions required to ensure the
best possible physical, mental, and social conditions so that patients with
chronic or post-acute cardiovascular disease may, by their own efforts,
preserve or resume their proper place in society and lead an active
life".(WHO)
• CR is a comprehensive model of care including established core
components, (Grace, 2016) including structured exercise, patient
education, psychosocial counselling, risk factor reduction and behaviour
modification, with a goal of optimizing patient's quality of life while
helping to reduce the risk of future heart problems.(Mampuya & Warner,
2012).

3. • CR is delivered by a multi-disciplinary team, often headed by a physician
such as a cardiologist. Nurses support patients in reducing medical risk
factors such as high blood pressure, high cholesterol and diabetes. A
dietitian helps create a healthy eating plan, and a social worker or
psychologist may help to alleviate stress or, for smokers, may give
counseling on how to quit.(American Heart Association) Support for
return-to-work can also be provided. CR programs are very patient-
centered.
• 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,
(Long et al .,2019) replacement of a heart valve, percutaneous coronary
intervention (such as coronary stent placement), placement of
a pacemaker, or placement of an implantable cardioverter
defibrillator.(American Heart Association)

4. REHABILITATION ASSESSMENT
Assessment for rehabilitation should address the following
needs (DoH, 2000):
● Physical needs – including increased physical activity, smoking
cessation, diet, alcohol consumption, medication, and further
clinical management;
● Educational needs;
● Psychological needs;
● Social, cultural, and vocational needs;
● Family and carer needs.

5. The rehabilitation of cardiac patients involves four stages of medical treatment and
care:
● Phase one – immediate acute physical, psychological, and social care following
the cardiac event or diagnosis and before discharge from hospital;
● Phase two – expands on the initial needs identified in phase one during the early
period postdischarge, extending advice to family members and carers;
● Phase three – builds on phase two by introducing further assessment and
allocation where appropriate to cardiac rehabilitation groups. These involve
structured exercise and relaxation, and psychoeducational, health promotion,
and vocational advice. At this point patients may be referred for specialist input,
if required;
● Phase four – focuses on the long-term maintenance of a healthy lifestyle within
the community. This involves encouraging the patient to undertake the required
activity to maintain good cardiac health, such as increased physical exercise,
losing weight, improving diet, and managing stress. This phase may be carried
out in conjunction with local community sports centres, where appropriate.
However, it should be noted that the onus to change during this stage lies with
the patient and her or his individual choice. Again patients may be referred to
specialist services if they require specific help to meet their individual targets.

6. What occurs during cardiac
rehabilitation?
• The aims of rehabilitation are to limit the physiologic and psychologic
effects of cardiac illness, reduce the risk of sudden death or reinfarction,
control cardiac symptoms, stabilize or reverse the atherosclerotic process
and enhance the psychosocial and, when appropriate, the vocational
status of patients with heart disease.(Cardiac Rehabilitation Guideline
Panel, 1995)
• These aims are achieved by a multidisciplinary team that offers patients a
comprehensive educational program and exercise prescriptions as well as
additional services tailored to patient needs, including weight-loss
strategies, lipid management, smoking cessation techniques, measures to
decrease stress and improve psychosocial well-being and vocational
counselling.

7. Patient education
• Education and counselling are integral components of cardiac
rehabilitation programs. With the trend toward early discharge, patients
and their families need further explanations about how best to live with
heart disease and how to develop lifestyle-change strategies.
• To implement such changes, information about the various risk factors and
practical techniques to alter behaviours are provided. Such education can
occur in formal sessions with group support or informally, on a one-to-one
basis.
• The educational needs of each patient and family are unique and depend
on a number of factors, including age, sex, level of education and the
readiness for change for each risk factor.

8. Exercise
• Today, exercise remains a cornerstone of cardiac rehabilitation programs.
To devise a realistic exercise program, rehabilitation staff conduct a
detailed assessment that includes documentation of pre-event and post-
event exercise habits and the patient’s aerobic capacity, as determined by
exercise testing.
• Patients with heart disease are naturally concerned about the appropriate
intensity of exercise as well as “safe” vocational and avocational activities.
Most patients are not satisfied with vague recommendations to “listen to
your body” or “just try out any activity”; they appreciate specific
guidelines.
• It is, of course, impossible to give an exact intensity of exercise that will be
appropriate in all conditions, since the disease process is dynamic, the
status of the coronary arteries varies with circadian rhythms and the
workload for tasks is affected by various environmental factors.(Dafoe W
,1992)

9. • Patients with uncomplicated disease can be encouraged to reach a heart
rate 70% to 85% of their peak heart rate achieved during exercise testing
or, in the presence of ischemia, a heart rate below the ischemic
threshold.(American College of Sports Medicine, 1995).
• For patients who are deconditioned, or those with limiting medical
conditions, exercise training intensities in the range of 50% to 70% of the
maximal heart rate are suggested. (Cardiac Rehabilitation Guideline Panel,
1995; American College of Sports Medicine, 1995).
• This more moderate training level has been shown to induce a training
response and improve functional capacity and is likely to improve long-
term adherence.
• The success of using exercise as a therapeutic modality requires a
thorough knowledge of the effects of exercise on various medical
conditions (e.g., diabetes mellitus or obesity).
• The exercise therapist requires considerable skill to prescribe and adjust
the exercise prescription according to the individual psychological and
medical needs of each patient.

10. Lipid management
• It is well recognized that optimal management of lipid levels can mitigate
symptoms as well as favourably slow the progression of heart disease.
Traditionally, cardiac rehabilitation programs have involved education
about the role of diet and cholesterol, dietary changes to reduce the
intake of saturated fats, exercise and weight loss, to induce a more
favourable lipid profile.
• According to recent guidelines,(National Cholesterol Education Program,
1993). target lipid levels for patients with known cardiac disease include a
low-density lipoprotein (LDL) cholesterol level of less than 2.5 mmol/L, an
HDL cholesterol level of more than 1.0 mmol/L and a triglyceride level of
less than 1.8 mmol/L.
• Lipid levels may drop temporarily after myocardial infarction or bypass
grafting. Thus, an assessment of the patient’s fasting lipid levels should be
performed 8 weeks after the cardiac event as a component of a
comprehensive risk-factor evaluation.

11. • If the lipid levels are higher than those noted above, then both lifestyle
modification (low-fat diet and exercise) and treatment with lipid-lowering
drugs are indicated.(Working Group on Hypercholesterolemia and Other
Dyslipidemias,1995). Which lipid-lowering drugs to use are also noted in
these recent guidelines.(National Cholesterol Education Program, 1993).
• Educating patients about lipid-lowering diets can be difficult because of
the differences between dietary and serum cholesterol as well as between
saturated and unsaturated fats, and the difficulty in learning how to
determine the percentage of fat in the diet.
• Dietary changes require patients to understand food labels, prepare new
and different foods and convince family members to embark on new
dietary directions.
• Most rehabilitation programs have a dietitian as a member of the
multidisciplinary team; he or she can provide group or individual
educational sessions in order to help patients achieve a more favourable
lipid profile or lose weight.

12. Smoking cessation
• Smoking cessation after a myocardial infarction reduces the expected risk
of death by 40% to 60%,(Wilhelmsen L , 1988) as well as lowering the risk
of vein graft failure(Hermanson , Gersh & Frye ,1988). and decreasing the
incidence of angina. (Deanfield , Wright & Krikler ,1984)
• A combined educational and behavioural intervention program can result
in smoking cessation among 17% to 26% of patients who smoke.(DeBusk
et al., 1994; Taylor et al., 1990) Most traditional cardiac rehabilitation
programs offer education and other interventions (e.g., stress
management) that may help with smoking cessation and relapse
prevention.
• It has been our experience that patients who are still smoking upon entry
to rehabilitation programs are often the strongly addicted, recalcitrant
smokers. By the time they reach rehabilitation, they have been
admonished to stop smoking by a phalanx of health care workers, family
members and coworkers.

13. • It is still worth while to have a thorough discussion with such patients, as
they may not know the impact of smoking cessation on other factors such
as low HDL cholesterol levels, dyspnea levels and frequency of anginal
episodes. Such patients often need to achieve success in another area of
risk-factor modification, such as weight loss, before embarking on smoking
cessation.
• Adjunctive aids such as nicotine gum or the patch are usually necessary.
Patients who use the nicotine patch should remove it before exercise to
avoid an increased absorption of nicotine through the vasodilated skin
overlying exercising muscle.

14. Blood pressure control
• Cardiac rehabilitation programs can provide frequent measurements of
blood pressure and promote appropriate lifestyle changes that may lessen
resting and exercise blood pressure levels.
• Such lifestyle changes, consistent with the National High Blood Pressure
Education Programs report issued in 1993, include weight reduction,
increased physical activity, reduced dietary sodium levels and moderate
alcohol consumption.
• The exercise program may need to be modified so that aerobic exercise
and resistance training are in the lower intensity range.(American College
of Sports Medicine,1995) If drug treatment is required, then further
information should be provided concerning the purpose of recommended
drugs, their potential side effects and strategies to improve adherence.

15. Optimization of weight
• Obesity, commonly defined as a body mass index over 27, is relatively
common in adults(Ostbye et al., 1995) and is well known to be associated
with hypertension, non-insulin-dependent diabetes mellitus and coronary
artery disease.
• A multifactorial intervention program is usually required to induce
significant weight loss.(Cardiac Rehabilitation Guideline Panel, 1995).
Dietary recommendations involve lower dietary fat, moderate intake of
concentrated sugars and portion control.
• Patients who can do this in combination with their exercise program are
usually successful in losing weight. Often, however, obese patients have a
long history of inactivity and dislike formal exercise programs. Thus, the
rehabilitation staff members need to encourage the gradual resumption of
activities and look for creative alternatives to traditional exercise classes
that are attractive to obese patients.
• The exercise intensity should be in the low to moderate-intensity range in
order to produce an energy expenditure of 1256 kJ (300 kcal) or more per
session and involve minimal risk of orthopedic problems.(American
College of Sports Medicine, 1995).

16. • Food consumption has a number of determinants, including cultural
influences, eating patterns and coping strategies. Since weight loss is one
of the more difficult goals to accomplish, patients may prefer to seek extra
help from a commercial weight-loss program. Fenfluramine has been used
as an appetite suppressant but its safety and long-term efficacy in patients
with heart disease have not been determined.(Mathus-Vliegen et al.,
1992)

17. Management of diabetes mellitus
• Patients with diabetes mellitus are at 2 to 5 times greater risk of coronary
artery disease than those who are normoglycemic,(Multiple Risk Factor
Intervention Trial Research Group, 1982). and those with heart disease
should be given a high priority for cardiac rehabilitation programs.
• The complications of diabetes mellitus — neuropathy, retinopathy and
nephropathy — all affect the exercise prescription. The altered dietary and
exercise habits in cardiac rehabilitation influence glycemic control.
• Blood glucose levels should be monitored before and after exercise
sessions at the outset of the program and, if levels are stable, as indicated
thereafter.
• Close communication is required between the treating physician and the
rehabilitation program to optimize medical management.(American
College of Sports Medicine, 1995). Graded exercise testing is
recommended if any exercise more strenuous than walking is undertaken.
This recommendation is especially important for patients with diabetes
mellitus because of their higher incidence of silent ischemia.

18. Maximizing psychosocial well-being
• Depression and social isolation after a myocardial infarction are significant risk
factors for subsequent death.(Cardiac Rehabilitation Guideline Panel,
1995;(Frasure-Smith , Lesperance & Talajic ,1995). Rehabilitation programs help
health care professionals to identify patients who are significantly depressed and
to initiate appropriate treatment that acts in synergy with other components of
the rehabilitation program, such as exercise.( North TC, McCullagh & Tran ,1990).
Friendship and altruism often develop among participants in cardiac rehabilitation
programs; these qualities help to foster a new social-support network.
• The popular perception that the “Type A” personality is associated with a risk of
further cardiac events holds true only for those with the so-called “toxic type A”
elements: anger and hostility.(Barefoot , Dahstrom & Williams ,1983; Shekelle ,
Gale & Ostfeld ,1983 ; Helmers et al.,1993) Intervention to alter these elements is
difficult; routine stress-management programs may need to be supplemented with
individual counselling or group therapy specifically designed for hostility
reduction.(Gidron & Davidson ,1996)
• Since the family, as individual members and as a unit, is affected by a
cardiovascular event, rehabilitation programs include the spouse and interested
family members in various educational sessions.

19. • It is a common perception among patients with heart disease that stress is
a major contributory factor to their disease. The provision of stress-
management programs helps participants acquire skills that may lessen
the need for maladaptive supports, whether these be nicotine, alcohol,
overwork or food.
• The stress of a cardiac event usually aggravates any pre-existing stressors,
be they marital, financial or family-related. Coping with these stressors
may require individual, couple or family counselling by the patient’s
physician, an appropriate therapist to whom he or she is referred or one of
the trained cardiac rehabilitation professionals.
• For most patients, return to work is an important objective. The economic
realities of the patient’s life and the life of his or her family usually depend
on gainful employment. The cardiac rehabilitation program can help ease
the transition of work return by providing objective assessments of
functional capabilities, improving the patient’s fitness capacity (from both
an aerobic and strength perspective) and imparting needed skills for
better functioning in the work environment, such as stress management.

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