Coronary Artery Disease: When Plaques AttackPage 10 of 12

8. Cardiac Rehabilitation (Secondary Prevention)

For CAD the techniques of prevention, treatment, and rehabilitation overlap considerably. Cardiac rehabilitation, which is the long-term treatment of patients who have suffered an episode of severe heart ischemia, is a variant of the same medical care that patients receive in all phases of their CAD. In some medical centers the cardiac rehabilitation program that is prescribed for patients recovering from MIs is also offered as preventive therapy for patients at high risk for acute coronary syndromes.

Whereas primary prevention strategies are interventions during an acute phase of CAD, cardiac rehabilitation is referred to as secondary prevention. For CAD a key part of both rehabilitation and prevention programs is the reduction of the patient’s atherosclerotic risk factors. Both programs strongly urge smoking cessation, supervised weight loss, physical exercise, and help in planning nutritionally balanced, low-fat/high-fiber/low-calorie meals. In addition, both programs stress aggressive management of hypertension, diabetes, and dyslipidemia.

Team Care

As with the management of all chronic illnesses, the most effective cardiac rehabilitation programs are organized utilizing a team of physicians, nurses, physical therapists, dieticians, social workers, occupational therapists, and clinical psychologists. Within their own area of expertise, healthcare professionals focus on helping to restore a cardiac patient’s comfort, sense of well-being, and normal daily activities. At the same time, each worker aims to reduce specific risk factors to prevent future episodes of ischemia (Graham et al., 2008).

Individual Medical and Social Profiles

Cardiac rehabilitation programs are individualized. When a rehabilitation team takes over the care of a cardiac patient, they begin by compiling a medical and social history. Besides the standard health history, the team needs to know the details of the patient’s normal daily home, work, and recreational activities. The physical examination information in the profile should include ECG recordings at rest and during exercise. Stress test results are added to the profile and can be used to set exercise guidelines.

Supportive and Protective Medications

After a serious episode of heart ischemia, patients will be taking a number of medications. A typical drug regimen includes a statin (with the goal of lowering LDL cholesterol blood levels to 70 mg/dl), a beta blocker (to ease the work of the left ventricle), and aspirin and clopidogrel (to reduce the risk of clots).

If patients have a poorly functioning left ventricle, they may also be taking an ACE inhibitor or an angiotensin-receptor blocker. When a patient continues to have hypertension on the existing drug and lifestyle regimens, a thiazide diuretic is added (Bashore et al., 2009).

Smoking Cessation

Smoking is dangerous for patients who have had an MI. Health professionals need to tell patients who smoke that stopping will cut in half their risk of dying from another ischemic episode.

Clinicians are encouraged to take five steps—the Five A’s—with their patients who smoke:

  • Ask. Ask the patient if they smoke.
  • Advise. Strongly advise quitting.
  • Assess. Ask the patient whether they are ready to quit.
  • Assist. Help to formulate a workable smoking cessation plan, including medications and regular interactions with a counselor.
  • Arrange. Take steps to put the plan into action: organize the necessary medications, counseling, and follow-up visits.

Healthy Diet

Eating that fulfills psychological or emotional needs is not always heart-healthy eating. Many cardiac patients eat out of habit and in response to psychological or emotional stress. These patients need guidance and support when trying to improve their diet. A cardiac diet should be prescribed, which includes low fat, high fiber and fresh fruits and vegetables.

Dieticians

Ideally, a dietician will be part of the cardiac rehabilitation team. Dieticians can help plan meals that:

  • Meet the rehabilitation goals
  • Patients can afford
  • Patients will prepare and eat
  • Is customized to their culture and needs

Rehabilitation Goals

A major rehabilitation goal is to keep blood levels of LDL cholesterol and triglycerides low and levels of HDL cholesterol high. Diets that help to meet these goals are low in saturated fats (<7% of daily calories), have minimal trans fats, and have about 25 g of dietary fiber daily for women and 38 g for men (Am. Diet. Assoc., 2008).

Other dietary advice includes:

  • Drinking excess alcohol can raise blood pressure, an atherosclerotic risk factor.
  • Salt and certain salt substitutes can contribute to hypertension, especially in those patients with a sensitivity to excess sodium.
  • Excess body weight is an atherosclerotic risk factor, so diets should be calorie-controlled.
  • Saturated fats should be replaced by monounsaturated fats, polyunsaturated fats, and omega-3 fatty acids (found in oily fish).
  • Fruits, vegetables, and grains are recommended.

Dietary Counseling Programs

A dietary counseling program begins with the dietician seeing each patient individually. The dietician takes a dietary history and measures the patient’s height, weight, and waist circumference. Patients are then given diaries in which to record all their food and drink intake for five days.

Patients mail or email their diaries to the dietician, and at the next visit the dietician suggests specific ways that the patient can improve what and how they eat. Regular followup visits continue. At each visit, the patient’s height, weight, and waist circumference are measured, the patient’s progress is charted, and specific dietary recommendations are suggested. This dietary rehabilitation program should continue until the patient has found a stable, healthy eating routine.

Weight Management

Excess weight is a heart stressor and an atherosclerotic risk factor, so weight reduction is an important component of cardiac rehabilitation for overweight patients. Heart-healthy weight goals are:

  • BMI <25 kg/m2 and
  • Waist circumference <102 cm (40 in) in men and <90 cm (35 in) in women

To lose weight, a person must eat fewer calories. People should maintain a nutritional balance while they reduce their caloric intake, and crash diets should be discouraged. By itself, exercise rarely leads to a significant weight loss, but exercise can be an important weight loss aid.

For weight reduction and weight maintenance, regular one-on-one sessions with a dietician are usually the most successful tools. Experienced dieticians can help patients to devise a healthy reduced-calorie eating plan that the patient can stick with for the long term.

Exercise

Well-planned exercise training can restore many patients to a normal or near-normal lifestyle and weight. Modifications should be made for those with retinopathy or neuropathy, and for those on beta blockers.

Ineligible Patients

Some cardiac patients will not yet be sufficiently stable, mobile, or resilient to begin the exercise component of cardiac rehabilitation. Ineligible patients include those with:

  • Worrisome ischemic symptoms (eg, unstable angina, significant resting ST-segment displacements, BP drop >20 mm Hg during episodes of angina)
  • Heart rhythm or conduction problems (eg, uncontrolled tachycardia, atrial arrhythmias, ventricular arrhythmias, third-degree heart block)
  • Severe aortic stenosis
  • Uncompensated heart failure
  • Recent thrombi (eg, from thrombophlebitis)
  • Uncontrolled high blood pressure (systolic >200 mm Hg or diastolic >110 mm Hg)
  • Uncontrolled diabetes
  • Recent heart infections or inflammation (endocarditis, myocarditis, or pericarditis)
  • Acute systemic illness or fever
  • Acute metabolic problems
  • Physical problems that prohibit exercise

Medically supervised exercise can be started for most other cardiac patients, including those who are stable following an MI, a coronary reperfusion procedure, or a heart transplant.

Structured Exercise Rehabilitation

To many people, cardiac rehabilitation is synonymous with post heart attack exercise programs. The exercise component of cardiac rehabilitation reconditions a patient’s musculoskeletal and cardiovascular systems as well as strengthening the heart.

Reconditioning begins in the hospital. Supervised programs then continue for many months. The final goal is for the patient to develop an independent exercise plan that will last for years and become a part of his lifestyle.

Phase I: In the Hospital

Exercise rehabilitation can begin as soon as patients are medically stable. Breathing exercises and leg exercises get patients to use their muscles, and these exercises help to re-establish the patient’s confidence that it will be safe to become active again. As the patient heals, assisted walking and light physical therapy can be added. By day four, patients are usually able to walk for 5 to 10 minutes in the corridors 3 to 4 times/day.

Phase II: After Discharge

Following discharge from the coronary care unit, a reconditioning program is begun. This usually includes having the patient walk indoors on a level floor at a speed that does not raise the patient’s pulse >20 beats/minute above its resting rate. Patients should be reassured that they may fatigue easily, which is normal after a cardiac event.

Over 4 to 6 weeks, patients who are recovering well should be encouraged to increase gradually the total distance they walk until they are walking a total of 1 to 3 miles/day. Patients are asked to keep a diary of their daily exercise and the occurrences of any problems, and the physical therapist checks the diary regularly.

Phase III: Supervised Exercise Program

When they have been medically cleared by their physician, patients can begin a 6- to 12-month program of regular exercise. Often, the physician will perform a symptom-limited stress test to establish the patient’s initial exercise capacity for the exercise program.

One commonly followed rehabilitation plan offers supervised exercise programs in 8-week sessions of 2 to 5 classes per week. The intensity of exercise is increased slowly over the sessions.

The main cardiac rehabilitation exercises are aerobic (walking on treadmills, stationary bicycling) and the intensity of exercise is limited by the patient’s heart rate or feeling of fatigue (perceived exertion). Exercising to 60% to 75% of their maximum heart rate is a typical goal for cardiac patients. A rough calculation of maximum heart rate is 220 minus the patient’s age. Those on beta blockers may not be able to reach the maximum heart rate.

Each session begins with 5 to 15 minutes of gentle exercise to decrease peripheral vascular resistance. Patients then undertake 5 to 30 minutes of aerobic exercise. On their physician’s advice, some patients should have ECG monitoring during the exercises. Classes end with a 10-minute cool down period.

Phase IV: Continued Independent Exercising

The effects of exercise programs will fade unless patients continue to exercise regularly. Some patients have the self-discipline to stick to a lifelong independent exercise regimen. Many patients are more successful when they enroll in structured exercise programs, which can be found at community or health centers in most cities. After the formal cardiac rehabilitation program ends and the patient is exercising under self-direction, physicians should check on the patient’s lifestyle at each medical visit and encourage remaining active and continuing a healthy diet plan.

Resuming Normal Daily Activities

The goal of cardiac rehabilitation is to enable patients to resume a normal life. Patients can be fearful after a heart attack, and they will need specific advice as to how much daily exercise they should attempt and when to return to sexual activities, although they may hesitate to ask. Physicians should introduce the subject and offer a simple guide: one common rule is that people can resume sexual activities when they can walk up and down two flights of stairs without any cardiac symptoms.

Patients should wait to resume driving a car for 4 weeks after an MI and 6 weeks after heart surgery. As they ease into driving independence, patients should begin by driving with a companion and avoid long trips or heavy traffic (Davis, 2008).

Psychological and Emotional Help

Patients who worry about suffering another serious cardiac ischemic event can feel overwhelmed, and they often need help making realistic decisions about their lifestyles. Many patients become overly timid, anxious, or depressed. Some patients deny the seriousness of their heart disease. Other patients become angry.

Few patients are able to manage these emotions without help. Physicians should be proactive by probing for clues that their patient might be suffering emotional or psychological distress. Because unapparent emotional and psychological problems can become disabling, all patients should be offered the opportunity to talk with a mental health professional (Antman et al., 2008).

So what happened to Mr. Hansen?

After stabilization from his angina and double stent placement, he took cardiac rehabilitation seriously to prevent an acute coronary episode and full myocardial infarction. The angiogram showed he had no permanent myocardial tissue damage and was very lucky.

He began to lose weight with the help of his wife, who wanted to lose her pregnancy weight. He joined a gym and lost 40 pounds. His blood pressure lowered to normal levels, his cholesterol levels decreased, and his HDL was 60 mg/dL. He ultimately ran a sprint triathlon!

Mr. Hansen continued to follow up with his cardiologist annually for lab tests to measure liver function and general health. He was fully adherent to medication management of statins, antihypertensives and antiplatelets. He developed a chronic cough from an ACE inhibitor and his medications were readjusted to reduce the side effect. He learned meditation and stress management strategies.

Every several years Mr. Hansen repeat a treadmill stress test and he has an angiogram every five years, which has resulted in no manifestations of progressive CAD. He and his wife went on to have another baby and both learned that the price for good health must be paid in healthy living choices day by day.

Test Your Knowledge

After an MI, patients can usually resume sexual activity:

  1. When a coronary arteriogram has documented they now have an unobstructed arterial tree.
  2. After a few sessions of counseling for patients and their partners.
  3. When they can walk up and down two flights of stairs without cardiac symptoms.
  4. In 4 to 8 days for men and 6 to 10 days for women.

Online Resource

Cardiac Rehab [3:58]

https://www.youtube.com/watch?v=fXRdrF0DKsQ

Answer: C