Cardiac Rehabilitation

Question 1

What were the concerns about early mobilization after cardiac events?

Answer 1

Arrhythmias, ischemia, aneurysm formation

Question 2

Why was it traditional to limit mobility following cardiac events?

Answer 2

To avoid complications and promote healing

Question 3

What are the potential consequences of prolonged bed rest after cardiac events?

Answer 3

Decline in functional capacity, prolonged hospital stay, increased morbidity, and mortality

Question 4

What is the definition of cardiac rehabilitation?

Answer 4

The coordinated sum of activities required to influence favorably the underlying cause of cardiovascular disease and provide optimal physical, mental, and social conditions for patients’ optimal functioning.

Question 5

What are some components of cardiac rehabilitation?

Answer 5

Structured exercise, education, psychological support, social support, lifestyle advice, and risk factor management.

Question 6

Which patient groups can benefit from cardiac rehabilitation?

Answer 6

Post MI (Myocardial Infarction), CABG (Coronary Artery Bypass Graft), PCI (Percutaneous Coronary Intervention), Stable CAD (Coronary Artery Disease), Chronic heart failure, GUCH (Grown-Up Congenital Heart) patients, patients with complex devices, cardiac transplants, and those who have undergone valve/other surgeries.

Question 7

What are the goals of cardiac rehabilitation?

Answer 7

• Reduce the risk of adverse cardiac events such as death, MI, and rehospitalization.

Improve cardiac symptoms.
Curtail the physiological and psychosocial effects of heart disease.
Reintegrate patients into the community with good functional status.

Question 8

What are some benefits of cardiac rehabilitation?

Answer 8

• Reduced mortality.

Reduced adverse cardiac events (e.g., MI).
Reduced rehospitalizations.
Higher smoking cessation rates.
Improved functional status.
Weight reduction.
Lower blood pressure and lipids.
Better diabetic control.

Question 9

What does the evidence show regarding exercise training in cardiac rehabilitation?

Answer 9

Meta-analyses have shown that exercise training in patients following MI can lead to a reduced risk of cardiovascular death, reduced need for hospital readmission, improved functional capacity, and reduced overall and cardiovascular mortality in patients with stable IHD (Ischemic Heart Disease).

Question 10

What are some considerations regarding cause and effect in cardiac rehabilitation?

Answer 10

• Observational data is available, but prospective randomized studies are limited.

Patient self-selection may influence outcomes, with potentially fitter, more motivated, and better-compliant patients participating.
Reporting bias can affect the interpretation of results.
However, cardiac rehabilitation has been associated with better health outcomes.

Question 11

What are the lipid targets in cardiac rehabilitation?

Answer 11

Target total cholesterol <4 mmol/L and LDL <2 mmol/L.

Question 12

How does exercise training impact lipid levels?

Answer 12

Exercise training is associated with reductions in total cholesterol, LDL-cholesterol, and triglyceride levels, as well as an increase in HDL cholesterol. It also improves compliance with medication, including statins.

Question 13

What are the blood pressure targets in cardiac rehabilitation?

Answer 13

The target blood pressure is <140/90 mmHg (ideally <130/85 mmHg).

Question 14

How does long-term exercise training impact hypertension?

Answer 14

Long-term exercise training is associated with a reduction of approximately 10-20 mmHg in systolic blood pressure. It is recommended to combine exercise with lifestyle modifications such as weight loss, reduced salt intake, reduced alcohol intake, and improved compliance with medication, including ACE inhibitors.

Question 15

What are the effects of exercise training on diabetes?

Answer 15

Exercise training is associated with improved glucose tolerance, lower serum insulin levels, increased cellular insulin sensitivity, reduced triglyceride levels, and reduced body fat levels. It also improves compliance with diet and medication, such as Metformin and insulin.

Question 16

What are the six core components of cardiac rehabilitation according to BACPR (British Association for Cardiovascular Prevention and Rehabilitation)?

Answer 16

Health behavior change and education
Lifestyle risk factor management
Physical activity and exercise
Healthy eating and body composition
Tobacco cessation and relapse prevention
Psychosocial health and medical risk management, including long-term strategies, audit, and evaluation.

Question 17

What activities are typically involved in Phase 1 of cardiac rehabilitation?

Answer 17

In-hospital activities include clinical assessment, education, reassurance, addressing risk factors, mobilization in/around the ward, and discharge planning. It usually takes place during the first week after admission.

Question 18

What does Phase 2 of cardiac rehabilitation involve?

Answer 18

Phase 2 occurs immediately post-discharge and typically lasts from week 2 to week 6. It includes a personal exercise program, stress management, reinforcement of health education, and daily exercises in and around the home. Patients have telephone contact with the rehabilitation team and may receive home visits if required.

Question 19

What are the characteristics of Phase 3 in cardiac rehabilitation?

Answer 19

Phase 3 takes place in a community setting such as a local leisure center or gym, starting around week 6 and lasting up to 6 months. It involves an assessment of exercise capacity, an individualized exercise program, multi-modality exercises (steady-state/intervals/circuits), a health education program, and psycho-social support. The exercise program is ideally based on a symptom-limited exercise stress test.

Question 20

What is the focus of Phase 4 in cardiac rehabilitation?

Answer 20

Phase 4 is the lifelong maintenance phase of cardiac rehabilitation. It involves unsupervised exercise and encourages at least 2.5 hours of moderate-intensity aerobic exercise per week, spread across at least 5 days. The exercise should consist of bouts of at least 10 minutes and should be performed at a moderate intensity (around 60-70% of maximum heart rate). This phase can be conducted in various settings, such as a local gym.

Question 21

What is the recommended Borg Level for perceived exertion during activity in cardiac rehabilitation?

Answer 21

Aim for Borg Level 4-6 activity.

Question 22

What are some benefits of patient education in cardiac rehabilitation?

Answer 22

Patient education helps patients cope with their illness, improve their health-related quality of life, and improve compliance with lifestyle interventions, medication, investigations, and non-drug treatments.

Question 23

What are the targets for weight optimization in cardiac rehabilitation?

Answer 23

Assess diet, target BMI of 18.5-25 kg/m2, target waist measurement of <94 cm for men and <80 cm for women. This involves reducing calorie intake, saturated fat, and salt, and following a reduced-calorie diet. Exercise is also important.

Question 24

How can smoking cessation be achieved in cardiac rehabilitation?

Answer 24

Smoking cessation strategies include quitting smoking altogether, participating in the NHS smoking cessation program, considering hypnosis, and using drugs such as nicotine replacement therapy.

Question 25

What are some key nutritional recommendations for cardiac rehabilitation?

Answer 25

Key nutritional recommendations include reducing saturated fats to <7% of total calories, increasing mono-/polyunsaturated fats to about 25% of total calories, consuming complex carbohydrates (about 60% of total calories), ensuring adequate protein intake (about 15% of total calories), increasing fiber intake (about 20-30 g/day), moderating food intake, predominantly choosing plant-based foods, and consuming 2,000-2,500 calories per day.

Question 26

What aspects of psycho-social management should be addressed in cardiac rehabilitation?

Answer 26

Psycho-social management involves screening for psychological distress such as anger, depression, and anxiety. It also involves addressing social issues such as social isolation, occupational issues (e.g., HGV drivers, physical jobs, “reasonable adjustments”), marital/partner issues, and sexual dysfunction.

Question 27

What is the current uptake of cardiac rehabilitation programs in the UK?

Answer 27

Currently, approximately 50% of UK patients join a rehabilitation program. The uptake is higher for CABG (Coronary Artery Bypass Graft) patients at around 70%, while for MIs (Myocardial Infarctions) and PCIs (Percutaneous Coronary Interventions), it is around 30%. The uptake is very low for heart failure patients.

Question 28

What is the NHS plan for cardiac rehabilitation uptake?

Answer 28

The NHS plan aims for an 85% uptake of cardiac rehabilitation programs.

Question 29

What are some barriers to recruitment in cardiac rehabilitation programs?

Answer 29

Barriers to recruitment include patient factors such as co-morbidities, being perceived as “too ill,” apathy, and lack of home support. Service organization factors such as geography/transport, group sessions, exercise modalities, return to work considerations, and other commitments also contribute to barriers in recruitment.

Question 30

What options are available to improve recruitment and completion of cardiac rehabilitation programs?

Answer 30

Options include alternative delivery modes in line with patients’ needs and preferences. These can include home-based delivery, which is currently at 8% but has shown comparable outcomes to group sessions, as well as self-managed programs. Online delivery is another option, currently at 0.2%, but over 40% of patients would prefer multi-modality programs.

Question 31

What are the six standards set by BACPR (British Association for Cardiac Prevention and Rehabilitation)?

Answer 31

The six standards are:

Delivery of the six core components by a multidisciplinary team.
Prompt identification and recruitment of eligible patients.
Early assessment of individual patient needs.
Early provision of a structured cardiovascular prevention and rehabilitation program.
Upon completion of the program, a final assessment of individual needs.
Data submission to the national audit program.

Question 32

What is the purpose of clinical audit in cardiac rehabilitation?

Answer 32

Clinical audit is a powerful tool used to address variation in clinical standards, inequalities in health provision, and ensure adherence to guidelines from national and international bodies such as NICE (National Institute for Health and Care Excellence). It involves reviewing the service against key performance indicators (KPIs), developing and implementing action plans based on the results, and conducting re-audits.

Question 33

What are some key performance indicators (KPIs) for cardiac rehabilitation programs?

Answer 33

Some KPIs include having a team that includes at least three different staff types, ensuring the program includes all priority groups, having a Phase 3 program that lasts at least eight weeks, starting Phase 3 within 33 days for ischemic heart disease (IHD) patients and within 46 days for CABG (Coronary Artery Bypass Graft) patients, conducting an initial assessment in the hospital, and conducting a final assessment at the end of Phase 3.