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Mending Broken Hearts with Cardiac Rehab

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The odds are great that you or someone you care about will have a heart attack and survive it. But until I had a heart attack I was totally unaware that after surviving one there is a critically important option that far too few survivors take advantage of. It is called cardiac rehab, a medically supervised and monitored program of exercise with counseling, dietary and other features.

After a seven-day hospital stay where I received angioplasty, three stents and a pacemaker, my cardiologist informed me about the cardiac rehab program at the hospital. It sounded terrific and I did not hesitate entering the program. I had to wait awhile while I recuperated and then I had to pass a stress test to qualify for the program. But as soon I could, I entered the award-winning program at Suburban Hospital in Bethesda, Maryland.

An individualized, tailored program based on my medical condition was designed and over time the program evolves to restore physical strength and endurance through use of a variety of exercise machines. Rehab programs also provide referring physicians with valuable surveillance information on how well their patients are doing, information that may cause new decisions on medical treatment or drug intervention.

As I learned more about cardiac rehab I was shocked to learn that about two thirds of patients in the United States who survive a heart attack do not undergo outpatient cardiac rehabilitation, even though such programs have been proven to reduce the risk of illness and death, and to also improve psychological recovery, according to findings reported by the Centers for Disease Control and Prevention in Atlanta.

"Programs and policies directed at increasing the number of patients who are referred to and participate in cardiac rehabilitation need to be strengthened," CDC researchers reported in a recent issue of the Morbidity and Mortality Weekly Report. "Future research should focus on identifying barriers to cardiac rehabilitation participation and interventions to improve referral and receipt of outpatient rehabilitation services," they added.

To estimate the use of outpatient cardiac rehabilitation services among heart attack survivors, the CDC investigators analyzed data from a 2005 survey where 129,416 individuals responded to questions relating to heart attack and the use of cardiac rehabilitation. Amazingly, just 34.7 percent of heart attack survivors participated in outpatient cardiac rehab, which usually includes a number of interventions to address modifiable cardiac risk factors, as well as psychosocial counseling. The District of Columbia had the lowest usage rate at 22.6 percent, while Nebraska had the highest rate at 59.1 percent.

Note that cardiac rehab is covered by Medicare and I suspect many other forms of health insurance, because its benefits are so certain.

In the CDC study, patients who were more likely to participate in rehabilitation included men, those older than 49 years, Hispanics, married patients, college educated individuals, those with annual incomes of $15,000 or higher, and patients who lived in the middle of a metropolitan area. Employment status and health insurance coverage had no statistically significant effect on whether patients attended rehab.

In 2004, the Mayo Clinic reported: "Cardiac rehabilitation raises your chances of surviving at least three years after a heart attack by more than 50 percent." The Mayo study found that about half of the 1,821 eligible patients in one Minnesota county participated in a rehab program.

And nearly half (48 percent) of the deaths within three years of hospital discharge were attributable to not participating in cardiac rehabilitation. "On average, for patients who participated in cardiac rehab, it was almost as if the heart attack never had happened. They had the same three-year survival as what would be expected from area residents of the same age and sex who had not suffered heart attacks," said Veronique Roger, M.D., the Mayo Clinic cardiologist who led the study. "Increased participation in cardiac rehabilitation could lead to improved survival among a large proportion of heart attack patients." Another finding was that women were less likely to participate in cardiac rehab.

In 2007, research from Brandeis University revealed fewer than one-in-five (18.7 percent) patients get cardiac rehab services after a heart attack or coronary bypass surgery. But, bypass patients are much more likely (31.0 percent) than heart attack patients (13.9 percent) to receive rehabilitation.

The study evaluated Medicare claims data from 267,427 men and women age 65 and older who survived at least 30 days after being released from a hospital following a heart attack or coronary bypass surgery in 1997. Despite Medicare coverage of cardiac rehabilitation services, women participated less than men, older patients less than younger ones, and non-whites much less than whites. There were big geographic differences in use, ranging from 53.5 percent of patients in Nebraska to 6.6 percent in Idaho.

In 2005, the American Heart Association said that physicians should aggressively encourage patients to enter cardiac rehab programs. "Cardiac rehabilitation programs remain underused in this country, with only 10 to 20 percent of the 2 million eligible patients a year who experienced heart attack or underwent cardiac revascularization procedures participating," said Arthur Leon, M.D., chairman of the writing group and Henry L. Taylor professor in exercise science and health enhancement at the University of Minnesota in Minneapolis.

"In addition to a low physician referral rate, factors contributing to the under use of the services include poor patient motivation and inadequate third-party reimbursement. We need to motivate physicians to be more progressive in educating and referring patients to cardiac rehabilitation programs and motivate insurance companies to cover them." It was noted that research had found average cardiac death was 26 percent lower in rehabilitation patients who were exercise-trained compared with those who received "usual care." There were also 21 percent fewer nonfatal heart attacks, 13 percent fewer bypass surgeries and 19 percent fewer angioplasties in the exercise-trained people.

Leon said the specific benefits of the exercise training component are improved functional capacity for the patient, improved blood vessel function, improvement in cardiovascular risk factors, improved coronary blood flow, improved electrical stability of the heart muscle (thus reducing the risk of a fatal heart rhythm disturbance), reduced risk of blood clots and reduced cardiac work and oxygen requirements.

In 2006, a Johns Hopkins University article reported: "A recent analysis examined the findings from 63 studies of cardiac rehabilitation programs that involved more than 21,000 survivors of a heart attack. The results showed that participation in a cardiac rehab program reduced the likelihood of having a second heart attack within the next year by 17 percent; 2 years after the heart attack total mortality decreased by nearly 50 percent."

In 2007, it was reported that research at the Ochsner Medical Center, New Orleans, Louisiana found that the prevalence of depression decreased a significant 63 percent, from 17 percent to 6 percent, following rehabilitation. And depressed patients who completed cardiac rehabilitation had a nearly 4-fold decrease in mortality compared with depressed patients who did not complete cardiac rehabilitation (30 percent versus 8 percent). They looked at 522 patients with coronary artery disease who were an average of 64 years old and these were compared with a control group of 179 coronary artery disease patients who did not complete rehabilitation.

Clearly, there is no question about the benefits of cardiac rehab. Physicians, relatives and friends should strongly encourage heart attack survivors and those receiving treatment for coronary disease to enter a cardiac rehab program. It is as important as taking prescribed medicines and following a recommended diet.

My own experience, including listening to comments from other longer term participants, is that participating in a formal cardiac rehab program – typically three days a week for twelve weeks, with the option to stay in a maintenance program – helps people stay committed to regular physical exercise. And this surely is important if losing weight is a goal.

It should be noted that research at the University of Toronto reported in 2005 found that the optimal time for a rehab program is nine months. But the problem in the US is that Medicare and other forms of insurance just cover three months.

I want to emphasize the benefits of having professionals carefully and routinely monitor blood pressure and heart function at a time when one is inevitably fearful about regaining physical strength and endurance after a heart attack. One feels safe exercising because of all the careful, close supervision. Confidence, confidence, confidence is a prime benefit of a participating in a cardiac rehab program.

If mending broken hearts is a priority, then clearly more must be done to get more heart attack survivors and heart disease patients into cardiac rehab programs. This is really heartwise.

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About Joel S. Hirschhorn

Formerly full professor Univ. of Wisconsin, Madison, and senior official Congressional Office of Technology Assessment and National Governors Association. Author of four nonfiction books and hundreds of articles.