Modernising Cardiac Rehab Flashcards
Define cardiac rehab, and identify its main components.
‘Cardiac rehabilitation is a structured set of services that enables people with
coronary heart disease (CHD) to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society.’
◦ Exercise
◦ Education
◦ Emotional
Identify the stages of cardiac rehab according to the traditional approach.
TRADITIONAL/CURRENT Phase 1 – hospital stay Phase 2 – recovery at home -Titrate medication, review, emotional, physical and practical support provided by cardiac nurses Phase 3 – exercise component -Overlap with phase 2 work -Circuit class -Ongoing support Phase 4 – gym based
Identify the stages of cardiac rehab according to the new approach.
◦ Stage 0: Identify and refer patient
◦ Stage 1: Manage referral and recruit to rehab programme
◦ Stage 2: Assess patient for cardiac rehab
◦ Stage 3: Develop patient care plan
◦ Stage 4: Deliver comprehensive cardiac rehab programme
◦ Stage 5: Conduct final assessment
◦ Stage 6: Discharge and transition to long-term management
What components are present in both the traditional, and new steps of cardiac rehab ?
- 3 components remain:
◦ Exercise, education and psychological support
What are the main differences between the traditional and new steps of cardiac rehab ?
Phases: ‘do’ things to patients
Stages: individualise patient care (frees up space in hospital classes for frailer patients)
Define the Heart Manual.
Home based supported self management programme for individuals recovering from acute Myocardial Infarction
Describe the evidence for the Heart Manual.
- Reduced anxiety and depression
- Fewer visits to GP and fewer hospital re-admissions up to 6 months after the MI
- Reduced total cholesterol and improved smoking cessation
What is the role of the facilitator in the Heart Manual ?
Monitoring of clinical symptoms Clarifying misconceptions Provide ongoing education Provide psychological assessment & support Promote the return to normal activity Facilitate lifestyle changes
Identify the main parts of the Heart Manual.
Part 1: Your Heart Attack: the Facts. Recovering in Hospital
Part 2: The Weekly Programme
Part 3: Facts and Advice to Help your Recovery
This includes explanations, home based exercices, advice on goal setting, relaxation programme, quizzes against miconceptions, short questionnaires to determine adjustment.
What are the most common cardiac misconceptions?
Once the damage is done you can’t turn the clock back!
If you’ve had a heart attack you’ll die prematurely of heart disease
Any shock or excitement could kill me
There is a dead part in my heart that could burst if
it was put under too much pressure
Rest restores the heart
You were lucky this time…you will be ok if you take it easy = It was a warning – a big one is on the way
Now I’ve had the revascularisation/stent/ICD etc I’m fixed
Using an example of a misconception, explain the result of misconceptions.
Misconception: Stress at work caused my MI and nearly killed me.
Result is the following vicious circle.
1) Feel safe at home
Avoid work
Poor attendance
Avoid responsibility
2) Phobic avoidance
Avoid physical exertion
Consider early retirement
3) Anxious at work
Palpitations Sweaty
Feel weak
Define health anxiety. How does it happen ? What should we encourage patients to do to overcome this ?
Misconceptions of normal bodily function.
- Paying attention to things makes us notice them more (e.g. heart attack, attention to breathing, pulse rate but we should try to switch their attention to something else)
Does stress cause heart disease ?
- Increased risk if depressed, socially isolated (or poor quality social support)
- Increased risk after catastrophic event (eg terrorist attack)
- NOT increased risk for chronic life stress, workplace stress, hard work…(unless it’s making you depressed!)
Identify implications of cardiac misconceptions.
Higher level of emotional distress and invalidism
Slower recovery
Reduced rate of return to work
Increased hospitalisations
Poor attendance at cardiac rehab
Angina patients: more likely to be anxious,
depressed and/or physically limited
Angina misconceptions = sig predictor of patients physical limitations at one year follow up
What is a doctor’s role in challenging cardiac misconceptions/beliefs ?
Patient not aware of their misconception -need to“pick up” casual comments
Direct challenge not always the best way
Re-framing their beliefs (“The heart is a worn out battery, but you re-charge it with activity, not rest”)
Socratic questioning (use questions to lead someone to a different conclusion about their beliefs)
Base discussion on the patients own values and experiences (use of self-discipline at work)
Watch out for flippant comments ( “ Take it easy!”)
What are the NICE guidelines concerning cardiac rehab ?
Prior to leaving hospital, people admitted to hospital suffering from coronary heart disease (and in general, chronic heart failure) should be invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life.
What percentage of patients do we aim to invite to cardiac rehab sessions ?
Goal: 85% offered cardiac rehab
What are the benefits of cardiac rehabilitation ?
- Reduces mortality and hospital admissions
- Improves quality of life and exercise tolerance
Identify the priorities for improvement of heart disease in Scotland. What are these priorities underpinned by ? Where does cardiac rehab fit ?
- Prevention of Cardiovascular Disease
- Mental Health for Heart Disease
- Secondary and Tertiary Care Cardiology
- Heart Disease Management and Rehabilitation (E.G. CARDIAC REHAB)
- Heart Failure
- Arrhythmias
Underpinned by patient information and engagement, and heart disease data.
Describe the Scottish government vision for Cardiac Rehab in 2020.
- Patient assessment at forefront
- Individualised programme of care meeting needs of patients (includes referring and sigoposting to appropriate services depending on individual need)
Identify some barriers to cardiac rehab (explaining why uptake of CR is so low).
- Significant waiting times
- Geographic variability
- Inequalities (women, elderly, severe CHD, minority ethnic groups under-represented)
Explain whether or not cardiac rehab is safe, giving reasons why or why not.
YES
- Patients have stable cardiovascular symptoms before undertake cardiac rehab
- Unstable angina, uncontrolled arrhythmia, severe heart failure = higher risk and assessed by an experienced clinician before engaging in exercise component.
Describe the timeline of facilitation as part of the heart manual.
1) Patient, partner and carer introduced to heart manual programme in hospital (preferably) or soon after discharge
2) One hour with the patient, then phone or visit at week 1 and every couple of week (semi-structured interview)
What questions may we ask before starting the Heart Manual programme ?
How will the patient benefit ? What are the patient's needs ? What are the health perceptions of the patient ? What are the risk factors ? Are they motived to make changes ? What is their psychological state ?
What medical outcomes is psychological distress an indicator for ?
Hospitalisation costs
Mortality rates
What proportion of CHD patients have anxiety or depression ?
25-30%
True or False: Physically fit but disabled = psychological issues ?
True
What are potential sources of conflicting information, which may lead to misconception?
Patient Support Group Family GP Insurance Friends
