Cardiac rehabilitation is an essential tool in reducing disability and prolonging the life of patients following a heart attack or coronary bypass operation. But according to a report in Circulation, fewer than one in five patients receive the potentially life-saving services.

Researchers evaluated Medicare claims data on 267,427 men and women 65 and older who survived at least 30 days after hospital discharge following a heart attack or coronary bypass surgery in 1997. In the year following hospital discharge, only 18.7% of the patients had at least one session of cardiac rehabilitation. Patients recovering from bypass surgery (31%) were far more likely to receive rehabilitation than patients who had suffered a heart attack (13.9%).

Issues such as race and socioeconomic status also were factors, the study found. Overall, the use of cardiac rehab was twice as great among white patients compared to nonwhite patients, and lower-income elders, who were eligible for Medicaid as well as Medicare, were far less likely to receive rehabilitation than those not on Medicaid.
Although many physicians recommend cardiac rehab for patients recovering from coronary bypass surgery, others differ in how much they value cardiac rehab programs for patients with myocardial infarction as compared to medications and lifestyle changes.

Taking Heart
Coronary artery bypass graft, or CABG, is one of the most common cardiac procedures performed in the U.S. According to the American Heart Association, 325,000 men and 145,000 women received the procedure in 2005, the most recent year for which data are available.

A variety of issues can influence whether patients receive continuing rehabilitation after their MI or CABG, including ease of availability and family support. A decline in medical status, patient refusal, and conflict in services rendered also may contribute to a lack of intervention, says Susan Foster, PT, inpatient operations manager at The Mayo Clinic of Florida, in Jacksonville.

But according to Richard Stein, MD, a national spokesperson for the American Heart Association and director of the Urban Community Cardiology Program at New York University School of Medicine, physician referral is one of the most important factors.

“When [researchers] looked at predictors of people joining cardiac rehab programs, the single most powerful predictor was the physician saying to them, ‘This is a good program for you. It will help you get better and stay well,’” Stein says. “So what we need is a direct statement from the physician to the patient that cardiac rehabilitation is part of the patient’s treatment program, not an optional component. When physicians make those statements, patients tend to follow through.”

Unfortunately, Stein notes, doctors often are lax in making this necessary recommendation.

“We have not been very successful in getting doctors to refer rehab to patients because they tend to think of it as a fitness program for debilitated patients,” he explains. “Cardiovascular surgeons understand the value of rehab programs for patients who have had open heart surgery, but [less so] for patients who have had an angioplasty and spend only one or two nights in the hospital. Physicians look at these patients and say, ‘He isn’t debilitated, so he doesn’t need exercise.’ And that’s not true.”

Heart Healthy
PTs can play an integral role in cardiac rehabilitation throughout the continuum of care. “We definitely are involved in the ICU; that’s where all of our postop bypass patients start off day one,” notes Tami Chin, PT, MS, director of physical medicine and rehabilitation at the California Pacific Medical Center in San Francisco. “We get them out of bed and begin mobility training the day after surgery.”

Postop rehab typically involves learning how to safely go from supine to sitting and from sitting to standing. There are also sternal precautions that include a 10-pound weight limit and not reaching for items over the head and behind the back. “Abiding by these precautions allows the patient’s breastbone to heal and decreases the pain they experience during the healing process,” Foster says.

Rehab also includes pain management, stress management, energy conservation, and monitoring of vital signs, as well as a progressive ambulation program that encourages the patient to walk a measured route several times each day to build strength and stamina.

“We want them to work in a zone of comfort; we don’t want them to exercise to the point of fatigue,” Chin says. “The emphasis is placed on shorter, more frequent activities. When they’re able, we’ll encourage patients to walk around the nursing unit. We know the distance and we’ll time that while checking their vital signs. Then we’ll build on how long and how far they’re walking. That’s how we build up their endurance.”

Once patients are released from the hospital, they are encouraged to continue rehabilitation in an outpatient program that may involve PTs, exercise physiologists, or nurses, depending on the institution.

“[At the Mayo Clinic], nurses and exercise physiologists in the outpatient setting instruct patients in stress management, endurance progression, and resistive exercise progression,” says Deborah Blackshear, PT, a staff therapist at The Mayo Clinic of Florida. “They usually find that the BORG scale for intensity of exercise is better understood than heart rate monitoring.”

Education is an important component of inpatient cardiac rehab. Once an outpatient rehab program ends, patients and their caregivers must be able to monitor the patients’ vital signs and continue their endurance and strengthening exercises.

The skilled intervention that PTs bring to these patients has great value, Stein observes. Their strengths include assessing and reassuring patients, designing programs that alleviate pain and injury during recovery, and encouraging patients to continue exercising, he says. PTs are effective at motivating patients recovering from cardiac diagnoses to pursue wellness long after they’ve finished their institutional rehabilitation.

“Giving patients the education and skill set they are going to need through life to [continue a lifetime exercise regimen] on their own is an important issue,” Stein notes.