Cardiac rehabilitation is a medically supervised program designed to help heart patients recover quickly and improve their overall physical and mental functioning. Cardiac rehabilitation may follow a heart-related surgery, heart attack or diagnosis of heart disease. These programs can be found at most hospitals or within local communities around the country. Typically, outpatient programs last 8 to 12 weeks.
Every rehabilitation plan is tailored to meet the individual needs of each patient. The programs are designed and overseen by a physician (usually a cardiologist), along with a team of other health care professionals. This may include nurses, dietitians, occupational and physical therapists, psychologists, and health educators. Most programs, therefore, consist of carefully planned and supervised exercise training, nutritional counseling to lower dietary fat and cholesterol levels, stress management, and relaxation training, modification of coronary risk factors, and careful monitoring of cardiac health. Medications may or not be included as part of the rehabilitation program, depending on the results of various tests, including cholesterol and blood pressure tests.
Cardiac rehabilitation can help to reduce the risk of another cardiac event, or the worsening of a heart condition already present. Not only can cardiac rehabilitation improve the patient’s physical health, but it can also be helpful to the patient’s emotional well being if patients are struggling with depression – a common condition among recovering heart patients.
Unfortunately, recent studies indicate that only about 10 to 20 percent of heart patients attend cardiac rehabilitation programs, despite their proven benefit. In particular, women, elderly and minority patients are less likely to take advantage of a cardiac rehabilitation program.
About cardiac rehabilitation
Cardiac rehabilitation is a medically supervised program designed to help heart patients recover quickly and improve their overall physical and mental functioning. The goal of these programs is to significantly reduce the risk of another cardiac event, and to prevent the worsening of a heart condition already present. The programs can also greatly improve a patient’s outlook on life and provide the support needed to make important lifestyle changes. Social support and optimism have long been considered important factors in heart patient survival.
In 2006, the Centers for Medicare and Medicaid Services expanded the list of approved conditions for which a cardiac rehabilitation program is covered. These conditions are also covered by many private insurers. They include:
Recent heart attack, within the previous 12 months
Coronary bypass surgery
Stable angina, or chest pain that occurs at predictable times, such as exercise, and is typically caused by coronary artery disease
Heart valve repair or replacement surgery
High blood pressure (hypertension)
Heart failure (a condition in which the heart cannot pump efficiently enough to meet the body’s demand for oxygen)
Recent balloon angioplasty (a catheter based procedure in which a blocked artery is widened with a balloon, usually followed by the placement of a stent)
Heart transplant surgery
Although heart failure is currently not covered by Medicare or most private insurers, studies have confirmed that cardiac rehabilitation can also benefit these patients. Ongoing research in this area may soon add heart failure to the list of covered conditions. In any event, if a heart failure patient is able to afford cardiac rehabilitation on their own, and they have their physician's approval, there is some proven benefit. In addition, patients with peripheral arterial disease may benefit from cardiac rehabilitation, although it won't likely be covered by insurance and is not covered by Medicare.
Heart patients who begin the program while in the hospital usually start by working on regaining basic skills, such as getting out of bed and going to the bathroom by themselves. Once out of the hospital, heart patients work on getting stronger and learning how to avoid future heart-related problems. A program of cardiac rehabilitation is specifically designed to fit each individual, and the length of the program can vary from weeks to months, depending on that person’s unique needs. Typical programs last between 8 and 12 weeks and meet three times weekly for monitored exercise. This may vary.
At the outset of the outpatient phase of a cardiac rehabilitation program, the health care team will assemble an extensive medical history of the patient and take various measurements, including cholesterol levels, blood pressure testing, diabetes status, body mass index and other indicators of heart health. These measures will be continually monitored throughout the rehabilitation program in an effort to monitor cardiac risk factors. The goal of cardiac rehabilitation is to lower the risk of a cardiac event by favorably altering individual risk factors and thereby increase quality of life for heart patients. Typically, cardiac rehabilitation programs have both short-term and long-term goals.
In some cases, medications may be recommended as part of the program. The most common medications include:
Aspirin or other antiplatelet agents.
Beta blockers, to protect the heart and/or aid in the control of blood pressure.
Cholesterol-reducing medications, such as statin medications.
ACE inhibitors and/or angiotensin receptor blockers (ARBs), which are used to lower the blood pressure. ARBs are a newer class of pressure-lowering drugs, typically prescribed for individuals who have diabetes and/or those who cannot take ACE inhibitors.
Rehabilitation should not be administered to patients with severe or unstable symptoms, such as uncontrolled heart failure, unstable angina, the acute phase of the heart attack, severe, persistent heart arrhythmias and shock. In these conditions, patients may be considered for rehabilitation after control, stabilization or reversal of the condition has taken place, and in some cases by providing a definite treatment such as bypass surgery or coronary angioplasty.
Education and/or counseling programs within cardiac rehabilitation tend to focus on topics such as:
Depression and other feelings often experienced by people with heart problems or following surgery
Getting back to work
New physical limitations (e.g., weight restrictions – the maximum amount of weight that a physician decides a patient can lift)
Stress management techniques that help people relax instead of getting overly tense, frustrated or angry
Identification of coronary risk factors and advice on how to reduce them
The heart-damaging effects of smoking and strategies for quitting
The importance of a heart-healthy diet and dietary strategies for reducing fat and cholesterol levels
Weight loss
Social support for making necessary lifestyle changes (e.g., quitting smoking)
One of the most important parts of any cardiac rehabilitation program is exercise. Recent research has shown that heart attack patients who participated in a cardiac rehabilitation program that included exercise were 50 percent more likely to survive the next three years after their heart attack. Furthermore, those who exercise have significantly lower readmission rates to the hospital in comparison with those patients who do not exercise. Because exercise is such a critical part of cardiac rehabilitation, this topic is discussed in detail below.
Exercise and cardiac rehabilitation
A person who has just had a heart attack, or who has just been diagnosed with a heart condition, may be feeling a little more vulnerable or a little more fragile. When the physician then recommends exercise, it can be tremendously threatening or frightening to people who are still struggling to accept what has happened. For this reason, many heart patients either drop out of cardiac rehabilitation programs or do not take advantage of them at all. Research has shown that women and the elderly are especially likely to drop out of their rehabilitation program.
It is important for heart patients and their family members to understand that a cardiac rehabilitation program is always very carefully supervised by a healthcare professional. Emergencies are rare, and the professionals are trained to handle them. These professionals take the greatest care in asking people to do only what they are capable of doing, and they do not release anyone from the outpatient program until they have judged that the patient is ready. Furthermore, the patient is not alone while participating in the program. Other participants are present to encourage and support each other.
Each heart patient will have an exercise program designed especially for him or her, by either one healthcare professional or a team of them. In order to design the program, the following steps are usually taken:
The patient is given a complete evaluation of his or her physical functioning, including an exercise stress test. The patient is also tested to evaluate strength, endurance, flexibility and other aspects of physical functioning. These are painless, noninvasive tests. For example, a patient may be asked to gently turn his or her head to the right as far as it will comfortably go.
Exercises are then begun gradually, to help the patient rebuild muscle and increase overall physical functioning and confidence. The patient may be asked to come in once a day, a few times a week or once a week. The goal is to improve physical functioning by the end of the program compared to what the patient was able to do at the beginning of the program. A heart monitor is often used during this time to make certain that the heart is doing well. In addition, blood pressure is consistently monitored. Because most cardiac rehabilitation programs take place in or near a hospital setting, medical equipment and expertise are readily available if there is any sign of a problem.
Progress is carefully monitored and recorded, and new exercise equipment may be used (e.g., lifting weights) as the patient feels more in control. However, it is unlikely that strenuous exercise will be included in a cardiac rehabilitation program. Studies have shown that mild to moderate exercise yields the most benefit, as opposed to the vigorous exercise that is typically used to increase aerobic fitness in healthy people.
When the patient appears to have regained a significant level of physical functioning, he or she is released from the program and need not return. However, the patient is clearly told that exercise must continue even after the program ends in order to maintain and build upon the physical and emotional gains that have been made.
After completing cardiac rehabilitation
People tend to be much more enthusiastic about a program while they are still in it rather than after it is over. For example, people often get very excited during motivational seminars and then never use the strategies that were discussed. Similarly, people often finish a cardiac rehabilitation program (with all the one-on-one attention, the support from fellow participants and the cheering from the healthcare professionals) but have trouble continuing to exercise and follow the dietary prescription on their own.
The American Heart Association offers some good tips to people who are having trouble exercising on their own. People are encouraged to:
Avoid the temptation to completely give up on exercising just because they missed a day.
Either join an exercise group, or start a walking group in their own neighborhood.
Find ways of being more active during the day, such as parking a little further away from the store and getting a good walk across the parking lot.
Make exercise a routine that is done on the same days at the same times.
Try different types of exercise: swimming, biking, walking, water aerobics and so forth.
Pace themselves, without pushing to the point of chest pain or severe shortness of breath.
Benefits of cardiac rehabilitation
Research has shown the following benefits from cardiac rehabilitation:
Better chance of avoiding disability and returning to work
Decreased risk of a recurrence of the heart problem
Decreased risk of death due to heart disease
Decreased risk of future heart attack
Fewer episodes of reduced blood flow to the heart (cardiac ischemia)
Improved physical functioning and strength
Less of a need for heart-related medications
Lower blood pressure
Lower levels of both “bad” low-density lipoprotein (LDL) cholesterol and fats in the blood (triglycerides)
Relief from depression, fear and anxiety
Slowed development, or even reversal, of hardening of the arteries (atherosclerosis)
Weight loss, as many individuals with coronary artery disease are overweight
Patients participating in rehabilitation programs tend to have improved outcomes in managing their condition. Patients are more apt to stick with their drug regimens, and hospital re-admissions tend to be reduced.
Furthermore, programs that involve individual and/or family counseling can help to address the common issues that arise as a result of heart disease. These issues range from sexual concerns to increased tension within the family. Strong ties to both family and friends enhance overall quality-of-life factors. This is particularly important for heart patients, because this support has been linked to better survival rates.
Finding a cardiac rehabilitation program
Heart patients are encouraged to speak with their physician if the topic of cardiac rehabilitation has not already come up. If the physician is supportive of the treatment but unsure of the closest program to where the patient lives, information can be obtained from a local hospital.
Although health insurance and Medicare generally cover cardiac rehabilitation for many heart conditions, it may be helpful to know in advance what out-of-pocket expenses will be expected before beginning a program. It may also be helpful to check out the facility in advance to meet the staff and the other participants, and to see if one feels comfortable there.
Research has clearly shown cardiac rehabilitation to be of significant benefit to heart patients. People are encouraged to speak with their physicians about taking advantage of this widely available option.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to cardiac rehabilitation:
Can you recommend a specific cardiac rehabilitation program?
What sort of cardiac rehabilitation will I need? What will it involve?
How long will I need to receive cardiac rehabilitation?
Can I expect my heart to completely return to its previous capacity?
Will I need to adjust my lifestyle in any way as a part of my rehabilitation?
How often do I need to engage in cardiac rehabilitation?
Will you be prescribing me any medicactions as part of my rehabilitation? Which ones?
What benefits can I expect from a successful cardiac rehabilitation?
Will I need to continue with any of my rehabilitation routines even after the rehabilitation is over? Are there resources available to help me do this?
Will a pregnancy interfere with my cardiac rehabilitation in any way?
