Cardiovascular Prevention and Rehabilitation

Cardiovascular Prevention and Rehabilitation

Joep Perk, Peter Mathes, Helmut Gohlke, Catherine Monpère, Irene Hellemans, Hannah McGee, Philippe Sellier, and Hugo Saner, Editors

Cardiovascular Prevention and Rehabilitation

Joep Perk, FESC Public Health Department Kalmar County Oskarshamn Sweden

Peter Mathes, MD, FACC, FESC Department of Cardiology Technical University of Munich Munich Rehabilitation Center München Germany

Helmut Gohlke, FACC, FESC Klinische Kardiologie II Herz-Zentrum Bad Krozingen Germany Irene Hellemans, MD, (Speciality Cardiology), PhD Institute of Health Sciences Department of Earth Sciences Vrije University and Department of Cardiology Vrije University Medical Center Amsterdam The Netherlands Philippe Sellier, MD Hôpital Broussais-HEGP Assistance Publique-Hôpitaux de Paris Paris France

Catherine Monpère, MD Cardiac Rehabilitation Center Bois Gilbert Ballan Miré France Hannah McGee, BA(Mod), PhD, RegPsycholFPsSI Department of Psychology Royal College of Surgeons in Ireland Dublin Ireland Hugo Saner, MD Swiss Cardiovascular Center Bern Cardiovascular Prevention and Rehabilitation University Hospital Inselspital Switzerland

British Library Cataloguing in Publication Data Cardiovascular prevention and rehabilitation 1. Cardiovascular system – Diseases – Patients – Rehabilitation Prevention I. Perk, Joep 616.1′2 ISBN-13: 9781846284625 ISBM-10: 1846284627

2. Cardiovascular system – diseases –

Library of Congress Control Number: 2006926876 ISBN-10: 1-84628-462-7 ISBN-13: 978-1-84628-462-5

e-ISBN-10: 1-84628-502-X e-ISBN-13: 978-1-84628-502-8

Printed on acid-free paper

© Springer-Verlag London Limited 2007 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 9 8 7 6 5 4 3 2 1 Springer Science+Business Media springer.com

Preface

Over the past decades the medical care of the patient with cardiovascular disease (CVD) has shown an impressive development, with marked positive consequences for mortality, morbidity, and the quality of life of coronary patients. This improvement has profoundly changed the arena in which cardiac rehabilitation (CR) has been acting over the past 40 years. The younger patient from the 1970s with uncomplicated myocardial infarction without ventricular dysfunction was joined in the early 1990s by patients with advanced heart failure, and the transition continues: modern cardiac rehabilitation is increasingly faced with a generation of patients who have been diagnosed and adequately treated early with minimal residual cardiovascular damage. The focus of CR is changing from physical rehabilitation to lifestyle counseling. But this development is paradoxical indeed: with more cardiac patients surviving the acute event, the numbers of elderly patients have grown and the total need for comprehensive CR has not been reduced. The elderly were rarely enrolled in the early years of exercise-based training programs. Therefore, this large population presents a new challenge, especially as CR has proved to be particularly beneficial for patients with congestive heart failure. Other factors play a role in the changing arena for CVD prevention and rehabilitation: the worldwide pandemic of obesity is expected to again raise the numbers of young cardiac patients and the disease is now extending into other parts of the globe. Thus CVD will remain the main cause of premature death in the first half of this century. Preventive public health measures are required. The relative weight of different risk factors appears to be altering, with disturbances in the psychosocial sphere becoming more important. With new diagnostic methods atherosclerosis can be detected well before an acute event, which creates a greater demand for preventive cardiology, as has been appreciated in the 2003 European Guidelines on Cardiovascular Prevention. Prevention and rehabilitation are gradually becoming a united and intertwined multidisciplinary service. Furthermore, the theoretical basis for prevention and rehabilitation has been strengthened over past years and the medical, social and economic benefits have now been well established, contributing to their incorporation in standard cardiac care in many countries. In the context of this scenario, the aim of the textbook is to give guidance in prevention, lifestyle counseling and rehabilitation for cardiologists, other physicians, and many different categories of health professionals in CR teams. For this purpose we have gathered over 60 experts from all parts of the globe, many of them members of the recently

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founded network, the European Association for Cardiovascular Prevention and Rehabilitation, a registered branch of the European Society of Cardiology. Commencing with an introduction on the rationale for prevention and rehabilitation and its application worldwide, the book continues with two sections on the cornerstone of CR: exercise testing and training. Thereafter the other key elements of a multidisciplinary service are described: nutrition, smoking cessation, behavioral and social support and the caring aspects of CR. Special attention has been given to adapted programs for newer groups with specific demands, such as the elderly, patients with implantable devices, and patients after cardiac transplantation. In the final section, a concise overview of CVD pharmacology is given and the organizational aspects of CR, including quality assurance and economic evaluation, are addressed. We do hope that the textbook will be of value to CR teams around the world and thereby contribute to a high quality, comprehensive service for the cardiovascular patient of the 21st century. Joep Perk Peter Mathes Helmut Gohlke Catherine Monpère Irene Hellemans Hannah McGee Philippe Sellier Hugo Saner

Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Section I: Introduction Edited by Peter Mathes 1. From Exercise Training to Comprehensive Cardiac Rehabilitation . . . . . . . . Peter Mathes

3

2. The Evidence Base for Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . Rod S. Taylor and Kate Jolly

9

3. Indications for Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peter Mathes

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4. Prevention Guidelines: Management of the Coronary Patient . . . . . . . . . . . . Guy de Backer

26

5. Cardiac Rehabilitation: Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L. Vanhees, M. Martens, S. Beloka, A. Stevens, A. Avram, and Dan Gaita

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6. Cardiac Rehabilitation: United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nanette K. Wenger

34

7. Cardiac Rehabilitation: Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Terence Kavanagh

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8. Cardiac Rehabilitation: Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michael V. Jelinek and Stephen J. Bunker

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9. Cardiac Rehabilitation: South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wayne E. Derman

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10. Cardiac Rehabilitation: China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David R. Thompson and Cheuk-Man Yu

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11. New Concepts for Early Diagnosis of Coronary Artery Disease . . . . . . . . . . Sigmund Silber and Peter Mathes

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Section II: Exercise Testing in Heart Disease Edited by Helmut Gohlke 12. The Molecular Base of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rainer Hambrecht

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13. Exercise and Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jonathan Myers

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14. Exercise Testing in Coronary Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . Stamatis Adamopoulos, Katerina Fountoulaki, and John T. Parissis

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15. Cardiopulmonary Exercise Testing in Chronic Heart Failure . . . . . . . . . . . . Alain Cohen-Solal, Florence Beauvais, and Jean Yves Tabet

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16. Exercise Testing in Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . Christa Gohlke-Bärwolf

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Section III: Exercise Training in Heart Disease Edited by Helmut Gohlke 17. Exercise Training in Coronary Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . Helmut Gohlke 18. Exercise Training in Diabetes Mellitus: An Efficient but Underused Therapeutic Option in the Prevention and Treatment of Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Josef Niebauer

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19. Exercise Training in Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stephen Gielen, Josef Niebauer, and Rainer Hambrecht

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20. Exercise Training in Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . Christa Gohlke-Bärwolf

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21. The Role of Sports in Preventive Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . Hans H. Bjørnstad, Tor H. Bjørnstad, and Yngvar Ommundsen

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22. Advising Patients with Cardiac Disease and after Cardiac Interventions about Sports Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hans H. Bjørnstad, Asle Hirth, Saied Nadirpour, and Britt Undheim

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Section IV: Nutrition Edited by Catherine Monpère 23. Secondary Prevention of Coronary Heart Disease: Impact of Nutrition on the Risk of Fatal Complications and Importance of the Concept of Omega-3 Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michel de Lorgeril and Patricia Salen 24. Nutrition Counseling for Diabetic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . Bénédicte Vergès-Patois and Bruno Vergès 25. Nutritional Counseling for Overweight Patients and Patients with Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . André J. Scheen and Nicolas Paquot

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26. Nutritional Counseling: Practical Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . Catherine Monpère

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Section V: Tobacco Addiction Edited by Irene Hellemans 27. The Burden of Smoking on Cardiovascular Disease . . . . . . . . . . . . . . . . . . . Ulrich Keil

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28. The Role of Tobacco Dependence and Addiction . . . . . . . . . . . . . . . . . . . . . . Trudi P.G. Tromp-Beelen

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29. Treatment of Tobacco Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trudi P.G. Tromp-Beelen and Irene Hellemans

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Section VI: Psychological and Behavioral Support Edited by Hannah McGee 30. Psychosocial Aspects in Prevention and Rehabilitation . . . . . . . . . . . . . . . . . Annika Rosengren

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31. Health-Related Quality of Life in Cardiac Patients . . . . . . . . . . . . . . . . . . . . . Hannah McGee

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32. Depression Following Myocardial Infarction: Prevalence, Clinical Consequences, and Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deirdre A. Lane and Douglas Carroll

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33. Educating Cardiac Patients and Relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gunilla Burell

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34. Stress Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul Bennett

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35. Adherence to Health Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David Hevey

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Section VII: Social and Caring Support Edited by Philippe Sellier 36. Prevention Programs: The Role of the Nurse . . . . . . . . . . . . . . . . . . . . . . . . . Alison Cahill

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37. Heart Failure Rehabilitation: The Role of the Nurse . . . . . . . . . . . . . . . . . . . Anna Strömberg

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38. Returning to Work after Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . Joep Perk

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39. Return to Work after Coronary Interventions . . . . . . . . . . . . . . . . . . . . . . . . Philippe Sellier

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40. Sexual Counseling of the Cardiac Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tiny Jaarsma and Elaine E. Steinke

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41. Cognitive Behavioral Rehabilitation for Angina . . . . . . . . . . . . . . . . . . . . . . . Robert J. Lewin

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42. National Heart Foundations, European Heart Network . . . . . . . . . . . . . . . . . Susanne Løgstrup, Ulla-Riitta Penttilä, Silvia Aepli, and Therese Junker

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43. Long-Term Maintenance Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Miguel F. Mendes

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44. New Models of Care and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jill F. Pattenden and Robert J. Lewin

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Section VIII: Adapted Programs for Special Groups Edited by Hugo Saner 45. Cardiac Rehabilitation in Congenital Heart Disease . . . . . . . . . . . . . . . . . . . Birna Bjarnason-Wehrens, Sigrid Dordel, Narayanswami Sreeram, and K. Brockmeier

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46. Gender Issues in Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Karin Schenck-Gustafsson and Agneta Andersson

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47. Rehabilitation in Elderly Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hugo Saner

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48. Cardiac Rehabilitation in Chronic Heart Failure . . . . . . . . . . . . . . . . . . . . . . Ugo Corrà

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49. Rehabilitation after Cardiac Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . Carsten B. Cordes

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50. Rehabilitation in Patients with Implantable Devices . . . . . . . . . . . . . . . . . . . L. Vanhees, S. Beloka, M. Martens, and A. Stevens

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51. Rehabilitation in Peripheral Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . Jean-Paul Schmid

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52. Cardiac Rehabilitation and Wellness in the Corporate Setting . . . . . . . . . . . L. Dorian Dugmore

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Section IX: Pharmacotherapy, Organization, Evaluation Edited by Joep Perk 53. Pharmacotherapy in Prevention and Rehabilitation . . . . . . . . . . . . . . . . . . . Dan Atar and Serena Tonstad

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54. Rehabilitation Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pantaleo Giannuzzi

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55. Developing Cardiac Rehabilitation Services: From Policy Development to Staff Training Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . John H. Horgan 56. Safety Aspects of Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bo Hedbäck

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57. Communication: Automatic Referral to Phase II Cardiac Rehabilitation . . . P.J. Senden 58. Future Developments in Preventive Cardiology: The EUROACTION Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David A. Wood

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59. Outcome Measurement and Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Joep Perk

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60. Economic Evaluation of Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . N.B. Oldridge

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contributors

Stamatis Adamopoulos, MD, PhD Onassis Cardiac Surgery Centre and Attikon University Hospital Athens, Greece

S. Beloka, MSc Cardiovascular Rehabilitation Unit Department of Rehabilitation Sciences K.U. Leuven Leuven, Belgium

Silvia Aepli Swiss Heart Foundation Switzerland

Paul Bennett, PhD Health and Social Care Research Center University of Cardiff Cardiff, UK

Agneta Andersson, MD Department of Cardiology Karolinska University Hospital Solna Stockholm, Sweden

Birna Bjarnason-Wehrens Institute for Cardiology and Sports Medicine German Sport University Cologne Cologne, Germany

Dan Atar, MD, FESC, FACC FAHA Department of Cardiology Aker University Hospital Oslo, Norway

Hans H. Bjørnstad, MD PHD Department of Heart Disease Haukeland University Hospital Bergen, Norway

A. Avram, MD Cardiac Rehabilitation Clinic University of Medicine and Pharmacy “Victor Babes” Timisoara Timisoara, Romania

Tor H. Bjørnstad, MD Institute of Circulation and Imaging St. Olav University Hospital Trondheim, Norway

Guy de Backer, MD, PhD Department of Public Health Ghent University Ghent, Belgium Florence Beauvais Service de Cardiologie Hôpital Beaujon Clichy, France

K. Brockmeier Pediatric Cardiology University Hospital University of Cologne Cologne, Germany Stephen J. Bunker St.Vincent’s Hospital Melbourne and National Heart Foundation of Australia Australia

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Gunilla Burell Behavioral Medicine and Health Promotion Department of Public Health and Caring Sciences Uppsala University Sweden Alison Cahill Cardiac Rehabilitation Beaumont Hospital Dublin, Ireland Douglas Carroll, PhD School of Sport and Exercise Psychology University of Birmingham Edgbaston Birmingham, UK

Contributors

Katerina Fountoulaki, MD Onassis Cardiac Surgery Center and Attikon University Hospital Athens, Greece Dan Gaita, MD, PhD Cardiac Rehabilitation Clinic University of Medicine and Pharmacy “Victor Babes” Timisoara Timisoara, Romania Pantaleo Giannuzzi, MD Salvatore Maugeri Foundation Institute for Clinical Care and Research (IRCCS) Scientific Institute of Veruno (NO), Veruno, Italy

Alain Cohen-Solal Service de Cardiologie Hôpital Beaujon Clichy, France

Stephen Gielen, MD Department of Internal Medicine/Cardiology University of Leipzig Leipzig Saxony, Germany

Carsten B. Cordes, MD Cardiac Rehabilitation Centre Gollwitzer-Meier-Klinik Bad Oeynhausen, Germany

Helmut Gohlke, FACC, FESC Klinische Kardiologie II Herz-Zentrum Bad Krozingen Germany

Ugo Corrà, MD Divisione di Cardiologia, Fondazione “Salvatore Maugeri” (NO), Italy

Christa Gohlke-Bärwolf Herz-Zentrum Bad Krozingen Germany

Wayne E. Derman, MBchB, PhD, FACSM MRC/UCT Research Unit for Exercise Science and Sports Medicine University of Cape Town Sport Science Institute of South Africa Cape Town, South Africa Sigrid Dordel Institute for School Sports and School Development German Sport University Cologne Cologne, Germany L. Dorian Dugmore, PhD Wellness International Hazel Grove Stockport Nr Manchester, Cheshire, UK

Rainer Hambrecht, MD Department of Internal Medicine/Cardiology University of Leipzig Leipzig Saxony, Germany Bo Hedbäck, MD, PhD Department of Cardiology University Hospital Linköping, Sweden Irene Hellemans, MD, (Speciality Cardiology), PhD Institute of Health Sciences Department of Earth Sciences Vrije University and Department of Cardiology Vrije University Medical Center Amsterdam, The Netherlands

Contributors

David Hevey, BA, MA, PhD Department of Psychology Trinity College Dublin Dublin, Ireland Asle Hirth, MD Department of Heart Disease Haukeland University Hospital Bergen, Norway John H. Horgan Cardiac Rehabilition Programme Beaumont Hospital Dublin, Ireland Tiny Jaarsma, PhD, RN Department of Cardiology University Hospital Groningen Groningen, Netherlands Michael V. Jelinek, MBBS, MD, FRACP, FACC, FCSANZ Department of Cardiology St.Vincent’s Hospital Melbourne and National Heart Foundation of Australia Australia Kate Jolly, MBChB, MSc Department of Public Health and Epidemiology University of Birmingham Edgbaston, Birmingham, UK Therese Junker Swiss Heart Foundation Switzerland Terence Kavanagh, MD, FRCPC Faculty of Medicine, Graduate Program in Exercise Science University of Toronto Ontario, Canada Ulrich Keil, FESC Institute of Epidemiology Institute of Social Medicine University of Munster Munster, Germany

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Deirdre A. Lane, BSc, PhD University Department of Medicine Sandwell and West Birmingham Hospitals NHS Trust Birmingham, UK Robert J. Lewin Department of Health Sciences University of York York, UK Susanne Løgstrup European Heart Network Brussels, Belgium Michel de Lorgeril, MD School of Medicine University of Grenoble Domaine de la Merci La Tronche, France M. Martens, MSc Cardiovascular Rehabilitation Unit Department of Rehabilitation Sciences K.U. Leuven Leuven, Belgium Peter Mathes, MD, FACC, FESC Department of Cardiology Technical University of Munich Munich Rehabilitation Center München, Germany Hannah McGee, BA(Mod.), PhD, RegPsycholFPsSI Department of Psychology Royal College of Surgeons in Ireland Dublin, Ireland Miguel F. Mendes, MD Instituto Do Coraçao Hospital Santa Cruz Carnaxide, Linda-a-Velha, Portugal Catherine Monpère, MD Cardiac Rehabilitation Center Bois Gibert Ballan Miré, France

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Contributors

Jonathan Myers, PhD Department of Cardiology VA Palo Alto Health Care System Palo Alto, CA, USA

Joep Perk, MD, FESC Public Health Department Kalmar County Oskarshamn, Sweden

Saied Nadirpour, MD Department of Medicine Haugesund Hospital Haugesund, Norway

Annika Rosengren Department of Medicine Sahlgrenska University Hospital/Ostra Goteborg, Sweden

Josef Niebauer, MD, PhD Department of Internal Medicine/Cardiology University of Leipzig Leipzig Saxony, Germany

Patricia Salen, BSc School of Medicine University of Grenoble Domaine de la Merci La Tronche, France

N.B. Oldridge, PhD College of Health Sciences University of Wisconsin-Milwaukee Milwaukee, WI, USA Yngvar Ommundsen, PhD Department of Coaching and Psychology Norwegian School of Sports Sciences Oslo, Norway Nicolas Paquot, MD, PhD Head Associate Division of Diabetes Nutrition and Metabolic Disorders Department of Medicine University of Liège Academic Hospital Sart Tilman Liège, Belgium

Hugo Saner, MD Swiss Cardiovascular Center Bern Cardiovascular Prevention and Rehabilitation University Hospital Inselspital Switzerland André J. Scheen Division of Diabetes Nutrition and Metabolic Disorders Department of Medicine CHU Sart Tilman Liège, Belgium Karin Schenck-Gustafsson, MD, PhD, FESC Department of Cardiology Karolinska University Hospital Solna Stockholm, Sweden

John T. Parissis, MD Onassis Cardiac Surgery Center and Attikon University Hospital Athens, Greece

Jean-Paul Schmid, MD Department of Cardiovascular Prevention and Rehabilitation Swiss Cardiovascular Centre Bern, Switzerland

Jill F. Pattenden, BA, PGCE, MSc Department of Health Sciences University of York Heslington York, UK

Philippe Sellier, MD Hôspital Broussais-HEGP Assistance Publique-Hôpitaux de Paris Paris, France

Ulla-Riitta Penttilä Finnish Heart Association Helsinki, Finland

P.J. Senden Department of Cardiology Ziekenhuis Eemland (Hospital) Amersfoort, The Netherlands

Contributors

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Sigmund Silber, MD, FACC, FESC Department of Cardiology Cardiology Practice and Hospital Munich, Germany

Trudi P.G. Tromp-Beelen Jellinek Medical Center Amsterdam, The Netherlands

Narayanswami Sreeram Pediatric Electrophysiology University Hospital University of Cologne Cologne, Germany

Britt Undheim MD Department of Heart Disease Haukeland University Hospital Bergen, Norway

Elaine E. Steinke, BSN, MN, PhD School of Nursing Wichita State University Wichita, KS, USA

L. Vanhees, PhD, FESC Cardiovascular Rehabilitation Unit Department of Rehabilitation Sciences K.U. Leuven Leuven, Belgium

A. Stevens, MSc Cardiovascular Rehabilitation Unit Department of Rehabilitation Sciences K.U. Leuven Leuven, Belgium

Bruno Vergès Endocrinology-Diabetology Department University Hospital Dijon France

Anna Strömberg, RN, PhD, NFESC Department of Cardiology Linköping University Hospital Linköping, Sweden Jean Yves Tabet Service de Cardiologie Hôpital Beaujon Clichy, France Rod S. Taylor, MSc, PhD Department of Public Health and Epidemiology University of Birmingham Edgbaston, Birmingham, UK David R. Thompson, BSc, MA, PhD, MBA, RN, FRCN, FESC The Nethersole School of Nursing The Chinese University of Hong Kong Shatin, New Territories Hong Kong SAR People’s Republic of China Serena Tonstad, MD, PhD Department of Preventive Cardiology Ullevål University Hospital Oslo, Norway

Bénédicte Vergès-Patois Cardiac Rehabilitation Unit University Hospital Dijon France Nanette K. Wenger, MD Department of Cardiology Emory University School of Medicine Grady Memorial Hospital Emory Heart and Vascular Center Atlanta, GA, USA David A. Wood Cardiovascular Medicine National Heart and Lung Institute Imperial College London, UK Cheuk-Man Yu, MD, FRACP, FRCP, FHKAM Division of Cardiology Department of Medicine and Therapeutics The Chinese University of Hong Kong Shatin, New Territories Hong Kong SAR People’s Republic of China

Section I Introduction

The concept of exercise as a fundamental part of a healthy lifestyle has its origin in ancient Greece. Lost for many hundred years, it re-emerged in the British Isles, rapidly spreading into Western societies. As a therapeutic modality, the preventive aspect was discovered early. As a treatment concept for heart patients, it was a controversial issue for many years, now even being accepted in heart failure, a condition regarded as a strict contraindication only a few years ago. Cardiac rehabilitation programs improve outcome, recent meta-analyses have revealed. A reduction in cardiac events, increase in functional status, and an improvement of the quality of life are the sustained beneficial effects. Initially reserved for the patient with an uncomplicated myocardial infarction, these programs are now extended to all cardiac patients with a condition that endangers their functional capacity. Although the interventions vary considerably in the different parts of the world, rehabilitation programs improve the process of care, coronary risk factor profiles, functional status, and the quality of life. Particularly in aging societies, but also beginning in the developing world, such programs are a means of preserving an independent lifestyle for the elderly, thus preventing an overuse of nursing services, which the majority of countries are unable to provide. Risk factor profiles give us a good guideline for the management of the coronary patient. In the field of prevention, they are helpful in targeting the high-risk individual. Since the majority of patients fall into the average category of risk, it will be mandatory to identify those at risk in this

large group more clearly. Newer diagnostic concepts such as the coronary calcium score or the intima–media thickness of the carotid artery as determined by ultrasound are promising steps in this direction.

Main Messages Chapter 1: From Exercise Training to Comprehensive Cardiac Rehabilitation Following the initial description of the gradual healing of a myocardial infarction, utmost care was taken to avoid any exercise for the patient. Much to the surprise of the medical profession, it turned out that a sizeable portion of the patients who had survived this treatment reached their previous functional level. Gradually, a more active approach was adopted, including a formal exercise prescription as a therapeutic aspect. Later, educational counseling and psychosocial support were added. The current is best defined by the WHO definition: “The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as possible in the society.”

Chapter 2: The Evidence Base for Cardiac Rehabilitation Cardiac rehabilitation programs improve outcomes for patients with coronary disease.

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Meta-analyses confirm that rehabilitation programs not only reduce the risk of recurrent myocardial infarction and death, but also improve risk factor profiles, use of therapies, functional status, and quality of life. Benefits did not differ among the types of programs, those that incorporated education and counseling about coronary risk factors with or without a supervised exercise program, and those that consisted of a structured exercise program only. Rehabilitation and secondary prevention programs improve processes of care, coronary risk factor profiles, functional status, and quality of life.

Chapter 3: Indications for Cardiac Rehabilitation Cardiovascular diseases constitute the leading cause of morbidity and premature mortality in Western societies, while they are increasing in numbers in developing countries. Whereas rehabilitation and secondary prevention were once seen as valuable only to patients with an uncomplicated myocardial infarction, they are now regarded as a treatment option for all patients with heart disease. Improvement in functional status, reduction in morbidity, improvement of the quality of life, and maintenance of an independent lifestyle are valuable aims in the treatment of any form of heart disease.

Chapter 4: Prevention Guidelines: Management of the Coronary Patient The effective prevention of myocardial infarction and death from coronary disease requires accurate identification of persons at risk. Risk factor stratification has recently been redefined to allow a more precise identification for the different areas in Europe.

Chapters 5 to 10: Practice Worldwide Different programs and approaches have been developed in the different areas of the world,

Introduction

all aiming at a similar outcome, utilizing a variety of methods. The Anglo-Saxon countries have largely preferred a primarily ambulatory approach, favoring long-term exercise-based rehabilitation programs, to which educational, psychological, and social components are being added in a stepwise fashion. Countries with a long-standing spa tradition such as Germany, Austria, and some eastern and southern European countries including Italy have adopted an inpatient residential center approach, with a rather short duration, consisting of an intense, gradually increasing exercise program, where educational, psychological, and social components are begun during the very first days of the program. Formidable differences in availability, distance, funding, and acceptance have led to an increasing diversity of rehabilitation services worldwide. Chapter 5: Cardiac Rehabilitation: Europe Chapter 6: Cardiac Rehabilitation: United States Chapter 7: Cardiac Rehabilitation: Canada Chapter 8: Cardiac Rehabilitation: Australia Chapter 9: Cardiac Rehabilitation: South Africa Chapter 10: Cardiac Rehabilitation: China

Chapter 11: New Concepts for Early Diagnosis of Coronary Artery Disease In the effort to identify the person at risk of myocardial infarction and death, an ideal and valuable additional tool should be a proven independent risk factor, providing additional information without inherent risk and with wide availability. A sizeable number of studies have shown that a high calcium score is a predictor of cardiac events, independent of the traditional risk factors, thus providing additional information. The two approaches – conventional risk estimation and calcium scoring – should enable the physician to better delineate the individual risk in the “intermediate-risk category,” which is of such an importance because of the sheer number of people in this category.

1 From Exercise Training to Comprehensive Cardiac Rehabilitation Peter Mathes

The WHO definition of cardiac rehabilitation from 19681 refers to a “process by which a person is restored to an optimal physical, medical, psychological, social, emotional, sexual, vocational and economic status.” Over the ensuing years this statement of intent has remained remarkably similar. The World Health Organization’s current definition addresses the cardiovascular status of the patient before, during, and after the event: The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as possible in the society. Rehabilitation cannot be regarded as an isolated form of therapy but must be integrated within the entire treatment.2

Current cardiac rehabilitation programs strive to involve the patient’s family in the whole process, thereby deploying health promotion intervention in a wider section of the community. Objectives of cardiac rehabilitation include: • a significant improvement in the patient’s functional capacity • psychological adaptations to the chronic disease process • a foundation for long-term behavior and lifestyle changes to favorably influence the longterm prognosis • maintenance of an independent lifestyle for as long as possible. This was not always the case. Initially, the emphasis was put on physical training as the

mainstay of cardiac rehabilitation, primarily with the intent of improving symptoms and physical capacity. Physical conditioning in reference to heart disease is actually far from new. Fully 200 years ago Heberden observed the beneficial effects in a patient he advised to saw wood for 30 minutes daily over a 6-month period. Although that was long before the first mention of acute myocardial infarction in the medical literature, no doubt some of Heberden’s patients had sustained an infarct as the condition is understood today. The first person to introduce exercise systematically into the therapy of cardiovascular disease was M. Oertel in 1875.3 He successfully treated a patient with overweight and shortness of breath with an increasing number of steps in a hilly terrain, the “Terrain-Kur,” which became popular in the ensuing years. Later he used an arm ergometer for this purpose. As early as 1875, Stokes recommended physical activity for the treatment of angina pectoris. This counsel was all but forgotten following Herrick’s original clinical description of acute myocardial infarction in 1912: the worry that physical exertion heightens the risk of ventricular aneurysm or rupture, or aggravates myocardial ischemia, kept patients virtually immobilized in bed for 6 or 8 weeks. On discharge, anything as strenuous as stair-climbing was forbidden for at least a year. A few patients returned to work many months after hospital discharge; for most, all chance of a normal life was past. Credit is due to Samuel Levine for questioning the wisdom of enforced bedrest and inactivity for

3

4

a prolonged period following the onset of infarction; his “armchair” method, recommended largely on an empiric basis to avoid thromboembolic or respiratory complications, has since been well supported and extended on both a clinical and research basis. When Leonard Goldwater and colleagues assessed their experience at the first cardiac work classification clinic in the US in the 1940s, it came as a surprise to many that fully 50–70% of patients could return to work, although not necessarily to the same job as before. The first inpatient progressive physical activity program for patients with acute myocardial infarction was described by Newman et al. in 1952.4 Physical activity began during the second week of hospitalization and gradually increased until discharge at 6 weeks. During the 1950s, a concept of utilization of residual functional capacity and an occupational classification by energy expenditure was popular.5 Later in the decade, detailed physical activity programs for inpatients were formalized. This was promoted by Wilhelm Raab and P.D. White in the US, Beckmann and Knipping in Germany, and Gottheiner in Israel.6 Beckmann started the first systematic inpatient training program for the prevention of cardiovascular disease. In the 1960s, with the proliferation of coronary care units involving continuous electrocardiographic (ECG) monitoring, progressively earlier mobilization after acute myocardial infarction was practiced. It was realized that the belief that there would be measurable physical invalidism after a coronary event was largely unfounded. Many patients with healed myocardial infarctions were found to have exercise capacities that were equal to those of presumably healthy, sedentary middle-aged men. Rehabilitation was dominated by exercise training and included some vocational readjustment. It was recognized that such measures resulted in an earlier return to normal activities as a result of improvements in both physical and psychological capabilities.7 Early mobilization helped reduce the fear of disability, although a restrictive attitude still hampered patient progress.8 During the 1970s, the multidimensional aspects of cardiac rehabilitation were acknowledged, and the team approach became popular.9 Established methods were developed, which resulted in a

P. Mathes

proliferation of hospital-based inpatient and outpatient programs.8 Guidelines for cardiac exercise programs were established by the American College of Sports Medicine10 and the American Heart Association.11 During the 1970s, public awareness of the individual’s potential role in his or her own health destiny grew. Rehabilitation and secondary prevention gained widespread support as an integral component of comprehensive coronary care.

Developments in Rehabilitation Care Enormous changes in the rehabilitative approach to the care of patients with cardiovascular disease have occurred since the WHO Expert Committee on the Rehabilitation of Patients with Cardiovascular Disease was organized by WHO in 1963. At that time, rehabilitation was concerned predominantly with individuals recovering from acute, essentially uncomplicated, myocardial infarction; the rehabilitative interventions recommended for such patients were considered to encompass “the sum of activities required to ensure them the best possible physical, mental and social conditions so that they may, by their own efforts, resume and maintain as normal a place as possible in the community.” Now, however, rehabilitation is considered to be an essential part of the care that should be available to all cardiac patients. Its goals are to improve functional capacity, alleviate or lessen activity-related symptoms, reduce unwarranted invalidism, and enable the cardiac patient to return to a useful and personally satisfying role in society. Cardiovascular disease is the number one medical problem in the Western world. It is becoming an increasing problem in developing countries; rheumatic heart disease, hypertension, and cardiomyopathy are already prevalent, and coronary heart disease is assuming growing significance. Despite differences in patterns of cardiac disease between and within developing countries, current concepts of cardiac rehabilitative care can be applied even in societies with minimal medical personnel and equipment resources. Guidelines are essential for their application. Rehabilitative care should be incorporated into the existing healthcare system, and should

1. From Exercise Training to Comprehensive Cardiac Rehabilitation

conform to cultural traditions and social norms. Guidance is also needed on maintenance of cardiovascular health, particularly for societies undergoing social transition, with consequent changes in culture, foods, lifestyle, and economics. Demographic factors have had a radical influence on the range of cardiac patients considered eligible for exercise therapy during rehabilitation. Among patients with coronary heart disease, it is not only those who have recovered from uncomplicated myocardial infarctions, but also patients with complications of the acute episode, those with angina pectoris of varying severity, and those who have undergone coronary artery bypass surgery and coronary angioplasty who are now considered candidates for rehabilitative care. The spectrum of coronary disease is extensive. At one end are the patients treated by acute myocardial reperfusion with coronary thrombolysis and/or early coronary angioplasty or coronary bypass surgery, who exhibit a lesser severity of disease, minimal residual symptoms, little functional impairment, and a characteristically excellent prognosis. At the other end are patients who, having survived several acute infarctions and surgical procedures, often have severe end-stage coronary heart disease characterized by varying combinations of myocardial ischemia, ventricular dysfunction, and ventricular arrhythmias. For all these patients, one of the most significant advances has been the emergence of a variety of test procedures designed to identify both the risk of early recurrent coronary events and the long-term prognosis. These assessments are typically exercise-based, and are designed to distinguish patients who can perform reasonable levels of activity without adverse consequences (low-risk patients) from those with a very limited exercise capacity in whom there is early onset of myocardial ischemia, ventricular dysfunction, or serious arrhythmias. An intermediate-risk group can also be identified. This delineation can serve as a basis for recommending not only medical and surgical therapies but also exercise (including the need for and intensity and duration of professional supervision of exercise).It can also serve as a guide to the resumption of work and other pre-illness activities.12–14 At the extremes of the coronary risk profile, computation of morbidity and mortality is

5

unlikely to be a sensitive measure of the outcome of rehabilitative or other interventions. For very low-risk coronary patients, the morbidity and mortality are so low, at least in the short term, that any intervention is unlikely to affect the outcome. On the other hand, the outlook in end-stage coronary disease is so uniformly poor that other measures are required to ascertain the benefits of any intervention. Prominent among these are likely to be quality of life measures, which are related to an individual patient’s perception of improvements in physical, social, and emotional status, and the value he or she places on such improvements.15,16 Other categories of patients now considered candidates for rehabilitation include those who have undergone cardiac valvular surgery, those (both adults and children) who have undergone surgical correction or amelioration of congenital heart disease, those with cardiomyopathy and ventricular dysfunction of other etiology, those with implanted cardiac pacemakers and cardioverter-defibrillators, and individuals who are recovering form cardiac or cardiopulmonary transplantation.12,17 These categories include large numbers of elderly cardiac patients. In both developed and developing countries, the numbers of “frail elderly” – the oldest members of society – are increasing more rapidly than any other population group. For many elderly patients with cardiovascular disease, return to remunerative work is often not an appropriate outcome measure of rehabilitation: rather, the attainment and maintenance of an independent lifestyle is an outcome that is valued both personally and, given the high cost of institutional care, by society. Thus, small improvements in capacity for physical work may exert a major and favorable impact on the quality of life of elderly cardiac patients.14,18

Current Concepts In addition to the more favorable functional status and prognosis in a variety of cardiovascular illnesses, which reflect improved medical and surgical therapies, changes in a number of aspects of rehabilitative care per se have substantially influenced its application.

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First, there is evidence that patients classified by stratification procedures as being at low risk can safely exercise without medical supervision and safely and promptly return to pre-illness activities, including remunerative work. Further, it is now accepted that exercise training of lower intensity can produce improvements in functional capacity comparable to those produced by higher-intensity exercise. The lower-intensity exercise is characterized by greater safety, which is particularly important if exercise sessions are unsupervised; it causes less discomfort and is more enjoyable, and thus makes adherence to the recommended exercise regime more likely. Among patients who can safely perform modest levels of dynamic exercise, the relative safety and substantial value of lowintensity isometric or resistive (strength training) exercise have also been identified.26 That patients receiving all types of antianginal drugs can benefit from exercise training has been extensively documented. Cardiac enlargement and compensated heart failure are no longer considered contraindications to physical activity, and rehabilitation has improved functional status. Another important observation is the lack of correlation between the extent of ventricular dysfunction and physical work capacity.19–21 Greater attention is now being devoted to the educational and counseling components of rehabilitative care, with new techniques being applied in these areas as well. Prominent among these is the behavioral approach to reducing coronary risk; this comprises not only transmission of information, but also practical training in the skills needed for adoption of a healthy lifestyle, and provision of opportunity to practice and reinforce these skills. To achieve successful lifestyle changes, patients must actively participate in the management of their disease. Evidence that favorable modification of coronary risk factors can not only limit progression of the disease but even induce regression of the underlying atherosclerosis has encouraged efforts of this area. This is particularly true for individuals with accelerated atherosclerosis, manifest as myocardial infarction or a requirement for myocardial revascularization procedures. The importance of the family – and often the workplace – in encouraging and reinforcing efforts to reduce coronary risk is increasingly acknowledged. It is thus essential that

P. Mathes

healthcare professionals at all levels are trained to be effective teachers to their patients.15,22 Perception of health status is recognized as having an influence on clinical outcomes; for example, the perceived ability to exercise correlates better with resumption of work than do objective measurements of exercise capacity during formal testing. There is also substantial correlation between perception of health status and return to usual family and community activities, and recreational and occupational pursuits. Importantly, this perception can be favorably altered by education and counseling.23,24 Psychological problems, predominantly anxiety and depression, are recognized as greater obstacles to the resumption of pre-illness activities by coronary patients than physical incapacity. Return to work is increasingly viewed as an outcome measure that is economically, physically, and socially relevant to a wide variety of coronary patients, but one that may relate poorly to restoration of functional capacity. Total restoration of functional status, occupational as well as physical, remains a challenge to be met.

Practice Worldwide Different programs and approaches have been developed in different areas of the world, all aiming at a similar outcome, utilizing a variety of different ways. The Anglo-Saxon countries have largely preferred a primarily ambulatory approach, favoring long-term exercise-based rehabilitation programs, to which educational, psychological, and social components are being added in a stepwise fashion (R. Mulcahy16). Countries with a long-standing spa tradition such as Germany, Austria, some eastern European countries and some of the southern European countries including Italy have adopted an inpatient, residential rehabilitation center approach, with a rather short duration (up to 4 weeks), consisting of intense, gradually increasing exercise programs, where educational, psychological and social components are begun during the very first days of the program. In Germany, the initial, primarily exercise oriented-rehabilitation programs were begun

1. From Exercise Training to Comprehensive Cardiac Rehabilitation

by Oertel,3 followed by Peter Beckmann.6 Patients were put together in groups of similar physical fitness, and the goal to be achieved was to make a proper mountain climbing tour at the end of this rehabilitation period. Koenig and Halhuber added psychological counseling and social support as essential components.16 In the days of a booming economy with the ever-present need for a large workforce, such rehabilitation centers proliferated within Germany and neighboring countries. Now that the economy is lagging, the number of centers is declining, being replaced in a less comprehensive way by ambulatory programs.16,25 Rehabilitative interventions are increasingly undertaken in children and young adults with a variety of cardiovascular disorders. The growing quantity of information about appropriate interventions in these age groups warrants wider dissemination. Medical and surgical treatments have significantly improved life expectancy in children with cardiovascular disease; subsequent comprehensive rehabilitation will thus have long-term economic and social benefits.25 Surgical treatment is available for over 95% of congenital cardiac lesions, yet postoperative results after successful surgery show that these children fail to achieve the same functional capacity as their healthy peers. Children with cardiac disease require significantly different physical activities from adults, and the educational and counseling requirements for both the children and their families are also different. Comprehensive cardiac rehabilitation for children is cost-effective and prudent, benefiting individual patients and the society in which they live. Moreover, a large percentage of cardiac patients in developing countries are children and adolescents. Specific attention should therefore be directed to disseminating rehabilitative guidelines and promulgating the implementation of appropriate programs for this section of the population.

References 1. Rehabilitation of patients with cardiovascular disease. Report of WHO Expert Committee. Geneva: WHO, 1964. WHO Technical Report Series No 270.

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2. Rehabilitation after cardiovascular disease with special emphasis on developing countries. Geneva: WHO, 1993. WHO Technical Report Series No 831. 3. Oertel M. Allgemeine Therapie der Kreislaufstörungen. In: Ziemssen J. Handbuch der allgemeinen Therapie. Leipzig: Vogel; 1891. 4. Newman LB, Andrews MF, Koblish MO, et al. Physical medicine and rehabilitation in acute myocardial infarction. Arch Intern Med 1952;89: 552–561. 5. Chapman CB, Fraser RS. Studies of the effect of exercise on cardiovascular function. III. Cardiovascular response to exercise in patients with healed myocardial infarction. Circulation 1954;9: 347–351. 6. Hellerstein HF, Ford AB. Rehabilitation of the cardiac patient. JAMA 1957;164:225–231. 7. Naughton J, Balke B, Poarch A. Modified work capacities studies in individuals with and without coronary artery disease. J Sports Med Phys Fitness 1964;4:208–212. 8. Hellerstein HK. Cardiac rehabilitation: a retrospective view. In: Pollock ML, ed. Heart Disease and Rehabilitation. Boston: Houghton Mifflin Professional; 1987:509–520. 9. Hayes JR. Evaluating the efficacy of cardiac rehabilitation. Psychiatr Ann 1978;8(Oct):100–110. 10. American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. Philadelphia: Lea & Febiger; 1975:1– 48. 11. American Heart Association. The Exercise Standards Book. Dallas: American Heart Association; 1979. 12. Foxworth GD. Rehabilitation for hospitalized adults after open-heart procedures: the team approach. Heart Lung 1978;7:834–839. 13. Gau GT. Cardiac rehabilitation. I. A cardiologist’s view: Psychiatr Ann 1978;8(Oct):31–43. 14. Squires RW, Lavie CJ, Brandt TR, et al. Cardiac rehabilitation in patients with severe ischemic left ventricular dysfunction. Circulation 1979;60:1519– 1536. 15. Wenger NK. Patient and family education and counseling: a requisite component of cardiac rehabilitation. In: Mathes P, Halhuber MJ, eds. Controversies in Cardiac Rehabilitation. New York: Springer-Verlag; 1982:108–114. 16. Mathes P, Halhuber MJ. Controversies in Cardiac Rehabilitation. New York: Springer-Verlag; 1982. 17. Rod JL, Squires RW, Pollock ML, et al. Symptomlimited graded exercise testing soon after myocardial revascularization surgery. J Cardiac Rehabil 1982;2:199–205.

8 18. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction: hemodynamic and metabolic effects. Circulation 1988;78:506–515. 19. Théroux P, Waters DD, Halphen C, et al. Prognostic value of exercise testing soon after myocardial infarction. N Engl J Med 1979;301:341–334. 20. Smith JW, Dennis CA, Gassmann A, et al. Exercise testing three weeks after myocardial infarction. Chest 1979;75:12–16. 21. Starling MR, Crawford MH, Kennedy GT, et al. Exercise testing early after myocardial infarction: predictive value for subsequent unstable angina and death. Am J Cardiol 1980;46:909– 914. 22. Cassem NH, Hackett TP. Psychological rehabilitation of myocardial infarction patients in the acute phase. Heart Lung 1973;2:382–388.

P. Mathes 23. Hackett TP, Cassem NH. The psychologic reactions of patients in the pre- and post-hospital phases of myocardial infarction. Postgrad Med 1975;57:43– 46. 24. Friedman M, Thoresen CE, Gill JJ, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results on the recurrrent coronary prevention project. Am Heart J 1986;112:653– 665. 25. Oldridge NB, Guyatt GH, Fischer ME, et al. Cardiac rehabilitation after myocardial infarction: combined experience of randomized clinical trials. JAMA 1988;260:945–950. 26. Hollmann W, Rost R, Dufaux B, Liesen H. Prävention und Rehabilitation von HerzKreislaufkrankheiten durch körperliches Training. Stuttgart: Hippokrates; 1983.

2 The Evidence Base for Cardiac Rehabilitation Rod S. Taylor and Kate Jolly

Introduction • How effective is cardiac rehabilitation? • Are particular interventions in cardiac rehabilitation more effective than others? • Does cardiac rehabilitation offer benefits over and above other secondary prevention measures, such as drug therapy? • Are there groups of patients in which cardiac rehabilitation is more (or less) effective? • Is home-based cardiac rehabilitation as effective a method of delivering cardiac rehabilitation as supervised center- or hospital-based programs? • Does cardiac rehabilitation provide good value for money? These are the principal questions raised by healthcare administrators, hospital managers, and regional and national healthcare policy makers involved in the commissioning of cardiac rehabilitation (CR) services. This chapter examines the evidence for CR in order to address each of these questions. The question of value for money (or “cost-effectiveness”) will be dealt with in Chapter 60, Economic Evaluation of Cardiac Rehabilitation. Before we examine the evidence for CR, we need to determine what constitutes “good” evidence and, specifically, consider the concept of the “hierarchy of evidence.”

The Evidence Hierarchy – the Randomized Controlled Trial and the Systematic Review It is well accepted that the gold standard study design for establishing the effect of a therapy (or collection of therapies as in the case of cardiac rehabilitation) is the randomized controlled trial (RCT).1 For example, let’s say we want to know the effectiveness of a 12-week outpatient cardiac rehabilitation program for patients with New York Heart Association (NYHA) class II and III heart failure (HF). According to this design, patients would be randomly assigned (usually by means of a computer-generated random number sequence) to receive usual medical care (e.g. drug therapy, advice etc.) or outpatient CR plus usual medical care. Patients would undergo an assessment battery (e.g. exercise test, questionnaires of psychological well-being, number of hospitalizations for HF in last 3 months) prior to randomization and, then again, at various follow-up points thereafter. The strength of the RCT (assuming that the study size is large enough) is that the process of randomization ensures that the characteristics of the two groups (e.g. age, sex, severity of disease) are identical. Thus it can be assumed that any difference in the outcome at follow-up is due to CR rather

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than selection bias, that is, a difference in the patient characteristics of the two groups. Such is this bias, that it is well documented that nonrandomized studies tend to overestimate the effect of therapies by some 20% to 30% compared to RCTs.2 Nevertheless, one RCT is rarely enough evidence on its own. A single study may well not be large enough to have the statistical power to detect the effect of the treatment being tested, particularly if that effect is fairly small – as most modern day therapies are. A single study may not be representative of the range of real world practice. For example, returning to the example RCT, it may be that your practice includes patients with NYHA class IV heart failure. It may be that your CR practice only includes exercise training while the RCT is based on exercise training plus stress management training and education. By looking for all RCTs that have investigated the question of the impact of CR on patients with HF, it is more likely that this overall body of evidence will reflect the range of real world practice than will one RCT alone. The systematic review is a methodology that comprehensively gathers studies (RCTs or other design) together in as unbiased a manner as possible to address a particular healthcare question.3 Many systematic reviews include a “meta-analysis,” that is, a statistical technique that allows the results of several studies to be combined into a single numerical estimate. Meta-analyses provide greater statistical power than a single RCT alone. One of the best sources of good quality systematic reviews and meta-analyses over the last decade has become the Cochrane Library.4 The Cochrane Library is the output of the Cochrane Collaboration, an international movement with the bold mission of “Preparing, maintaining and disseminating systematic reviews of the effects of (whole of) health care.” At the time of writing this chapter, three Cochrane systematic reviews were published that directly examine the effectiveness of CR.5–10 The remainder of this chapter discusses the findings of these three systematic reviews in the context of the questions posed above.

R.S. Taylor and K. Jolly

How Effective Is CR? Although the question “how effective is my therapy?” appears a simple one, for CR a careful framing of the question is required in order to provide a meaningful answer. In contrast to taking a drug, CR is a “complex intervention” – one “made up of various interconnecting parts.”11 CR is complex in a number ways. First, it is a multifaceted intervention that can consist of exercise training, psychological therapy (e.g. stress management), education, and other interventions (e.g. occupational counseling) and is usually delivered by a multidisciplinary team. It can be delivered in a variety of different settings (hospital, community center, or patient’s own home) and at different points in the disease continuum (phase I to IV programs). Finally, CR is often targeted at/to a population of patients that include a variety of cardiac diagnoses, usually post acute myocardial infarction, post coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) and, increasingly, heart failure. Each of three Cochrane systematic reviews has been scoped to address specific aspects of the question of the effectiveness of cardiac rehabilitation.

1. Effectiveness of Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease (CHD) – Taylor et al.6 This Cochrane review examines the question of the effectiveness of exercise-based CR (exercise training alone or exercise training combined with other therapies, such as education or psychological interventions) compared to usual care in patients with CHD (post myocardial infarction, angina pectoris, or following CABG and PTCA). The latest version of this review was published in 2004 by Taylor and colleagues and updates the original Cochrane review on this subject performed in 2000 by Jolliffe et al. and previous systematic reviews in 1988 by Oldridge et al. and 1989 by O’Connor et al. The 2004 review identified a total of 48 RCTs in 8940 CHD patients. A total of 19 RCTs assessed exercise training only, 30 RCTs combined exercise with other interventions

2. The Evidence Base for Cardiac Rehabilitation

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Pooled Odds Ratio All cause mortality [33]

0.80 (0.68 to 0.94)

Cardiac mortality [16]

0.74 (0.61 to 0.90)

Non fatal MI [19]

0.79 (0.57 to 1.09)

Need for CABG [19]

0.87 (0.65 to 1.16)

Need for PTCA [11]

0.81 (0.64 to 1.34)

0.50

1.00

Favours rehabilitation

2.00

Favours control

FIGURE 2-1. Summary of impact of exercise-based CR on clinical events in patients with CHD.6 [ ], number of trials.

(“comprehensive CR”) and one RCT assessed both exercise only and comprehensive CR. The review reported three groups of outcomes – clinical endpoints (mortality and morbidity), risk factor levels, and health-related quality of life. The metaanalysis of clinical endpoints is shown in Figure 2-1. Compared to usual care, exercise-based CR significantly reduced total mortality by 20% and cardiac mortality by 26%, although there was no significant reduction in nonfatal MI events or the need for recurrent CABG or PTCA. Exercise-based

cardiac rehabilitation was associated with improvements in a number of primary risk factors including lipid profile and smoking behavior (Table 2-1). A total of nine RCTs assessed patient health-related quality of life (HRQoL) using a validated outcome measure. Given the range of HRQoL instruments used, the authors were not able to pool results across studies. However, all RCTs reported an improvement in HRQoL (total or domain score) with exercise-based CR. Nevertheless, and perhaps

TABLE 2-1. Summary of impact of exercise-based6 and psychology-based CR7 on primary risk factors Exercise-based CR Outcome Total cholesterol (mmol/L) HDL cholesterol (mmol/L) LDL cholesterol (mmol/L) Triglycerides (mmol/L) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Smoking

Psychology-based CR

Mean difference+ −0.34 (−0.56 to −0.11)* −0.27 (−0.55 to 0)* 0.03 (−0.06 to 0.11) 0.05 (−0.10 to 0.08) −0.32 (−0.55 to −0.10)* −0.16 (−0.69 to 0.37) −0.28 (−0.49 to −0.06)* Not reported −0.5 (−6.5 to 5.5) 0.05 (0.01 to 0.08)* −0.6 (4.5 to 2.8) −1.9 (−4.8 to −1.1)* Relative risk++ 0.77 (0.62 to 0.94)* 0.81 (0.53 to 1.25)

*Statistically significant at P ≤ 0.05. + Mean difference