Managing Heart Disease with Cardiac Rehabilitation
January 31, 2017
Leanne Loranger, PT
Heart disease is a bucket term that can refer to several problems including heart attack, ischemic heart disease, angina, and heart failure. Heart disease is the single most common cause of death around the world; however, in recent decades the mortality rate from heart disease has decreased.1
As many as 1.6 million Canadians report having heart disease.2
Heart disease is the second leading cause of death in Canada, with 48,000 deaths attributed to heart disease in 2012.
The occurrence of heart disease is significantly influenced by lifestyle-related risk factors such as smoking, lack of exercise, diet, being overweight or obese, and stress.2
Other conditions such as high blood pressure, high cholesterol and diabetes are also risk factors for heart disease.2
Four out of five Canadians aged 20 or older have at least one risk factor for heart disease or stroke.3
Obesity and diabetes, two major risk factors for heart disease, are on the rise.3
Over the past few decades, treatments such as medication and surgery (including angiogram, angioplasty, and coronary artery bypass grafts) have become more successful when managing the acute signs and symptoms of heart disease.4
Enter cardiac rehabilitation
While the resulting decrease in mortality rate is clearly good news, this also means that an increasing number of people live with heart disease and need assistance and support to manage their condition and optimize their quality of life in the long term.1, 4 This trend has led to the need for cardiac rehabilitation.
More than just an exercise program, cardiac rehabilitation should be delivered by a team of health professionals and should include the following components:5
Exercise training including both aerobic and strength training
Dietary education and interventions
Psychosocial treatments to address depression, anxiety, isolation, and distress
Management of co-morbidities (diabetes, cholesterol, blood pressure)
Research into the effectiveness of cardiac rehabilitation has demonstrated the following benefits:
Decreased mortality from heart disease1
Some estimates are a 20-25% reduction, which is a similar impact to major cardiac medications and surgery6
Reduced risk of hospital readmission1
Improved quality of life1
Improved management of risk factors associated with heart disease (such as high blood pressure, obesity, and lack of physical activity)7
Although in the early days of research into heart disease there tended to be a focus on males who had experienced a heart attack, in recent years there has been increased attention paid to females, older patients, and those who have undergone surgical treatment for the management of their heart disease. Along the way, researchers have demonstrated that cardiac rehabilitation is effective for women as well as men, for older populations, and for people diagnosed with a range of heart conditions including angina, heart attack, heart failure, and those seen following bypass surgery or angioplasty.7,8
Participation is the key
Given that cardiac rehabilitation has been demonstrated to be as effective at decreasing mortality rates as medications and surgery (and without the side effects of either), one would expect that every person with heart disease would attend cardiac rehabilitation following diagnosis or an admission to hospital, but that is not the case. In the United States, it is estimated that less than 20% of potential Medicare-funded patients attend cardiac rehabilitation programs. In other words, only 20% of people for whom program costs are not a barrier attend these programs.7 In Canada, the attendance rate is not much better, with an estimated 34% of potential cardiac rehabilitation patients attending programs.9
Yet, attending is the key to success! Research has shown that the mortality rate changes seen with cardiac rehabilitation vary based on the number of sessions people attend, with those who attend more rehabilitation sessions having a lower mortality rate and lower rates of second heart attack in the four years after starting the program. Similar dose-response relationships have been found for people attending cardiac rehabilitation with angina of following bypass surgery.7
Some of the factors found to affect the likelihood of attendance at cardiac rehabilitation include:6
Physician endorsement and referral to the program
Patients were more likely to attend if their physician had a positive attitude towards cardiac rehabilitation.
Ease of access to the program
Longer distances and lack of transportation to the program made people less likely to attend.
High self-efficacy (belief that one can manage their condition) were associated with participation.
High social support, socioeconomic status and education levels also were predictive of participation.
Family obligations and resumption of previous roles (or return-to-work) were found to negatively impact attendance.
Gender was also found to impact participation in cardiac rehabilitation, with women being less likely to attend than men. It is unclear, however, if this was due to gender itself, or due to differences in physician referral rates, the presence or absence of social supports, and family obligations.6
To improve patient participation in cardiac rehabilitation and ensure people gain the benefits of these programs, it is imperative that health-care professionals and family members alike strongly endorse and support participation.6 It is also essential that barriers to attendance be addressed.6
One such barrier, the distance to the program, can be addressed through home-based delivery of cardiac rehabilitation programs.4 Home-based programs have been shown to result in improved program adherence and garner similar outcomes for certain low-risk patient populations.4 Given that in Canada it has been estimated that 70% of programs are hospital-based, and over 75% are located in urban settings,9 the concept of home-based programming to reach rural and remote populations is being met with positive reaction. Research has also suggested that in addition to being well received by patients, programs delivered using internet or telehealth-based technology have demonstrated improvements in risk factors and exercise outcomes.9
Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2016; Issue 1. Art. No.: CD001800. DOI: 10.1002/14651858.CD001800.pub3.
Government of Canada. Heart disease-heart health. Available at: http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/heart-disease-eng.php Accessed January 18, 2017.
Public Health Agency of Canada. 2009: Tracking heart disease and stroke in Canada: Available at: http://www.phac-aspc.gc.ca/publicat/2009/cvd-avc/pdf/cvd-avs-2009-eng.pdf Accessed January 18, 2017.
Dalal HM, Zawada A, Jolly K, Moxham T, Taylor RS. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis. BMJ 2010; 340:b5631.
Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, Franklin B, Sanderson B, Southard D. Core components of cardiac rehabilitation/secondary prevention programs: 2007 Update: A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115:2675-2682.
Jackson L, Leclerc J, Erskine Y, Linden W. Getting the most out of cardiac rehabilitation: A review of referral and adherence predictors. Heart 2005; 91:10-14.
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63-70.
Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation 2011: 123: 2344-2352.
Grace SL, Bennett S, Ardern CI, Clark A. Cardiac rehabilitation series: Canada. Progress in Cardiovascular Diseases 2014; 56(5): 530-535.