Introduction to Cardiac Rehab

Question 1

Cardiac rehabilitation benefits? (Bethel et al., 2009)

Answer 1

ØIncreased physical fitness ØReduced angina ØEnhanced coronary blood flow
ØReduced arrhythmias ØImproved lipid profiles ØLowered blood pressure
ØImproved fibrinolysis ØPsychological benefit (improved quality of life with increase in confidence, wellbeing and happiness and with decreases in anxiety and depression) ØReturn to work ØImproved survival

Question 2

Overcoming barriers to cardiac rehabilitation

Answer 2

physicians reluctance to refer some patients - women, ethnic minorities or lower socioeconomic classes
Lack of resources, capacity and funding
Adherence affected by;
Psychological wellbeing
Geographical location
Access to transport
Dislike of group based rehab sessions

Question 3

How to increase uptake?

Answer 3

Clinicians endorse cardiac rehab by inviting patients still in hospital after a recent diagnosis of coronary heart disease or HF to participate and for nurse-led prevention clinics to be linked with primary care and cardiac rehabilitation services
Novel ways of providing cardiac rehabilitation are emerging using the internet and mobile phones
Offering patients a choice of centre-based, home, or online programmes likely to improve uptake across all groups.

Question 4

Cochrane Systematic review and meta-analysis

Answer 4

ØA total of 63 studies with 14,486 participants with median follow-up of 12 months were included.
ØCR led to a reduction in cardiovascular mortality (relative risk: 0.74; 95% confidence interval: 0.64 to 0.86) and the risk of hospital admissions(relative risk: 0.82; 95% confidence interval: 0.70 to 0.96). No significant effect on total mortality, myocardial infarction, or revascularization. The majority of studies showed higher levels of HRQoLin 1 or more domainsfollowing exercise-based CR compared with control subjects

Question 5

Sandercock et al. 2013

Results

Answer 5

Four centres were included – total N = 950 patients. All centres used the ISWT. Some also used the Bruce test, 6MWT, or cycle ergometer test
• Compared with a recent meta-analysis of international studies, which reported a mean increase of 1.55 METs, the overall increase reported here (0.52 METs) is very conservative.
• Findings suggest that the outpatient cardiac rehabilitation programmes sampled in this study commonly prescribed a dose of exercise insufficient to provide meaningful benefits to patients. The volume of exercise prescribed is equivalent to approximately one third that which a patient in North America typically receives

Question 6

Sandercock et al. 2013

Discussion

Answer 6

• When increases in patient fitness are quantified, the response of the UK cardiac rehabilitation patients receiving between 6 and 16 supervised exercise sessions is much lower than that reported in our systematic review of international trials in which a median of 36 sessions was prescribed.
• The authors suggest that cardiac rehabilitation patients in the UK are not receiving the full potential benefit available from supervised outpatient cardiac rehabilitation. (As an example, if international trials of a drug demonstrated its efficacy at a daily dose of 600 mg, it seems unlikely that doctors would routinely prescribe 200 mg to UK patients.)
• Whether this is through ignorance of exercise prescription, or due to spatial, temporal and financial restrictions in service provision, such under-prescription of exercise seems to be common practice in UK cardiac rehabilitation.

Question 7

Taylor and Tsakiries et al. 2016 results and conclusion

Answer 7

• Results: Baseline sCRF was a strong predictor of all- cause mortality; compared to the lowest sCRF group (<5 METs for women and <6 METs for men), mortality risk was 41% lower in those with moderate sCRF and 60% lower in those with higher sCRF levels (≥7 METs women and ≥8 METs for men).
• Improvement in sCRF at 14 weeks was not associated with a significant mortality risk reduction for the whole cohort but in those with the lowest sCRFat baseline, each 1-MET improvement was associated with a 27% age-adjusted reduction in mortality risk.
•CR appears to be safe for most CVD subgroups
•CR has the potential to reduce CV mortality and hospitalisation and improve HRQoL
ØAn adequate dose of exercise is required for effects to be optimal (just like any other prescribed treatment)