1. Cardiac Rehabilitation

2. Objectives To gain an understanding of: Aims and benefits of cardiac rehabilitation Cardiac rehabilitation pathway Assessment Risk stratification Exercise session Monitoring Safety Transfer to Phase IV

3. Principle of Cardiac Rehabilitation Enable the patient to regain full physical, psychological and social status Promote secondary prevention to optimise long term prognosis Comprehensive cardiac rehabilitation

4. Patient groups Acute cardiac event Awaiting or post revascularisation Stable angina Stable heart failure Post valve surgery Post heart transplantation Post ICD insertion

5. Benefits of Cardiac Rehabilitation ↓ angina ↓ blood pressure ↓ anxiety and depression ↓ hospital admissions ↑ lipid profile ↑ functional capacity ↑ compliance with lifestyle modification ↑ confidence ↑ return to work ↑ return to leisure activities ↓ mortality by 31% (Taylor et al,2004)

6. Cardiac Rehabilitation Team Multi-professional Overall coordinator Interdisciplinary working Multi tasking / skill extension Rehabilitation services should be available from people trained in: Cardiology Exercise Lifestyle intervention Psychological treatments SIGN 2002

7. Phases of CR Phase IIn-patient stay Phase IIPost discharge at home (2 – 6 weeks) Phase IIIOut-patient care Hospital or community Delivered by health care services (6 -12 weeks) Phase IVLong term maintenance Delivered by leisure services

8. Pre Phase 1 Pre operative sessions for patients/spouse. Invited along to local CR site. Provide with information regarding surgery, hospital stay, and planned follow up. Very well received and demonstrating positive outcomes.

9. Phase I Education about cardiac event / condition Risk factor modification Symptom management Counselling & support Early mobilisation Referral to and contact details for Phases II and III

10. Under care of GP assessment of cardiac risk assessment of physical, psychological and social needs for cardiac rehabilitation provision of lifestyle advice and psychological interventions Community nurse involvement Often a neglected phase – patients can feel isolated Phase II

11. Delivered by: Home visit Telephone contact Telephone help line Heart manual

12. Problems at this stage Symptoms Medication titration Conflicting advice Inequity of cover throughout Grampian

13. Phase III Timeframe 2 – 6 weeks post event Venuehospital / community Duration8 weeks twice week

14. Assessment at Phase III Current clinical / cardiac status Investigations / results Risk stratification Medication Psychological status Functional capacity assessment Calculation of THR Physical limitations Personal goals Habitual activity

15. Functional capacity tests Sub maximal Bruce / Modified Bruce Protocol Shuttle Walk test 6 minute walk test Cycle ergometer Chester step test

16. Risk Stratification Risk Stratification: The process of determining the level of risk of a patient having a further cardiac event whilst exercising Criteria used: cardiac history current cardiac status

17. Risk Stratification Criteria Risks associated with exercise: Extensive myocardial damage Poor LV pumping capacity Residual ischaemia Ventricular arrhythmias Criteria checklist and AACVPR Stratification to risk stratify

18. Risk stratification determines Exercise prescription Exercise intensity Level of monitoring & supervision

19. Contraindications to Phase III exercise component unresolved unstable angina resting BP 200 / 110mmhg significant unexplained drop in blood pressure during exercise resting tachycardia > 100 bpm uncontrolled atrial or ventricular arrhythmias unstable heart failure unstable / uncontrolled diabetes fever (febrile illness)

20. Screening and Induction Checklist prior to each session: Changes in symptoms/ medication Heart rate and BP measurements Home activity Problems / concerns Induction should include an explanation of: the aims of the programme the exercises and equipment to be used and any exercise adaptations pulse monitoring/safe target heart rate ranges the use of ratings of perceived exertion (RPE) reporting abnormal symptoms

21. Conditioning Component FITT principle Both circuit or gym designs used Monitoring Progression Safety

22. Home programme To support the phase III exercise sessions Walking Activities similar to those performed under supervision Home exercise record

23. Education Component Heart disease, investigations and procedures Risk factors for CHD Effects and benefits of exercise Healthy eating Medication Relaxation / stress management

24. Psychological Component Screening: Quality of life tools Anxiety and depression Intervention: Motivational Interviewing Cognitive Behavioural Therapy Counselling Relaxation / Stress management

25. Health Beliefs Health beliefs are central to a person’s management of their CHD. They are formed from a variety of sources and influence perception of their illness and how to cope with it.

26. What are Health Beliefs? When people have a diagnosis, illness or injury they generate beliefs in these 5 areas to help them to understand and respond to their health event: Identity Cause Consequence Time line Cure / control Leventhal el al., (1997)

27. Identity Diagnostic label Symptoms Type of people who have the same condition Typical beliefs may include: ‘I only had a heart attack.’ ‘It’s only men that get heart problems.’ ‘I’m like my Dad, he had problems with his heart and veins.’

28. Cause The patients perception as to why they have CHD may include: Family history Stress Smoking Bad luck Accurate identification of risk factors are crucial Research shows misconceptions about causes of CHD.

29. Consequences This is the patient’s perception of the longer term impact and implications of their CHD on their lifestyle, family and friends. Beliefs may include: ‘ My heart is weak and damaged, I’ll never be the same again.’ ‘If I manage my risk factors, I can reduce the chances that I have if I have another heart attack.’

30. Timeline The length of time patients expect their illness to last will have an effect on their other health beliefs and how much that may do to modify their lifestyle positively. Beliefs that may be held could include: ‘ I have only had a heart attack, once I have finished my rehabilitation I will be fine.’ ‘CHD is for life, I must change my lifestyle to manage my condition.’

31. Cure / Control Patients who believe that their condition is manageable/controllable are more likely to make a better physical and recovery: ‘If I give up smoking and take up exercise I can reduce my chances of problems in the future.’ Patients who wrongly perceive that their condition is cured or uncontrollable may not address their risk factors: ‘I have had a bypass operation and now I am cured.’ It runs in the family, it was bound to happen, that’s life!’

32. Implications for Long Term Beliefs are strongly held Consider patient’s beliefs & experiences Can promote a good recovery and facilitate effective management of patient’s recovery. Can also hinder recovery and prevent an individual adjusting and managing condition.

33. Transfer to Phase IV Ensure medically and psychologically stable Criteria required for transfer from Phase III to IV Ensure individual can: exercise independently and safely self-monitor effectively recognise warning signs and symptoms identify goals for lifestyle change & risk factor reduction identify psychological goals demonstrate knowledge of their cardiac condition demonstrate compliance to home-based activities Fast track protocols

34. Long term management plan Risk factor monitoring & management Local exercise opportunities / resources Details of medical follow up Long-term exercise advice Support services for behaviour change maintenance Local support group information Phase III CR team contact details

35. Summary Principle and benefits Phases MDT Team Exercise component of Phase III Psychological component Discharge and Transfer to phase IV Risk Stratification