1. Outcomes from a Multi-disciplinary Cardiac Rehabilitation Programme: Are Angioplasty Patients Addressing Lifestyle Changes? Eve Scarle, Mark Giles, Maggie Gallacher, Julian Bath, Julia Harrison, Alison Anderson Gloucestershire Cardiac Rehabilitation Service Gloucestershire Hospitals NHS Foundation Trust

2. Background Death rates from CHD have fallen by 44% in those under 65 years old (1) Death rates from CHD have fallen by 44% in those under 65 years old (1) 2.6 million people in the UK living with CHD (1) 2.6 million people in the UK living with CHD (1) Growth of RACPC and interventional cardiology Growth of RACPC and interventional cardiology 6,000 PTCA in 1982 increased to 54,000 in 2003 (1) 6,000 PTCA in 1982 increased to 54,000 in 2003 (1) NSF for CHD (2000) (2) NSF for CHD (2000) (2) “Once Trusts have an effective system recruiting people who have survived an MI or undergone surgery to a high quality cardiac rehabilitation, they should then extend their rehabilitation services to people admitted to hospital with other manifestations of CHD”. (Chapter 7:4)

3. PTCACABGMI InterventionNormally planned Sudden an unexpected/ can be life-threatening Length of stay 1-2 daysAt least 5 days RecoveryImmediate relief of symptoms Post-operative pain and discomfort Gradual ambulation InterventionLocal anaestheticOpen-heart surgeryPossible intervention History of MINoPossibly Driving1 week off4-6 weeks off4 weeks off Work1-2 weeks6-12 weeks Activity Restrictions Little restriction on activity Physical restrictions e.g. lifting Time for education Little time for in- hospital education Seen by CR team

4. Rationale Limited studies on first time PTCA patients with no history of MI Limited studies on first time PTCA patients with no history of MI May feel cured by the procedure or less sick than other CHD patients-  motivation to change May feel cured by the procedure or less sick than other CHD patients-  motivation to change Evidence suggests 30-40% of individuals experience recurrent angina or a cardiac event by 2 years (4) (5) Evidence suggests 30-40% of individuals experience recurrent angina or a cardiac event by 2 years (4) (5) Less compliance to behaviour changes when compared to CABG patients (3) Less compliance to behaviour changes when compared to CABG patients (3) Low levels of CR participation (0-10%) (6) and twice as likely to drop out (7) Low levels of CR participation (0-10%) (6) and twice as likely to drop out (7)

5. Method- Comparative Study Initial sample- baseline data n=1387 CR programme Accepted and attended n=590 CABG n=285MI n=936PTCA n=166 Completed initial questionnaire and attended 7 weeks rehab Measures- IPQ, SF-12, HADS, Self-efficacy, Risk factor profile Follow-up of patients at 6 months post cardiac event completed second questionnaire Dropped out of CR Programme 13%

6. Cardiac Rehab Programme Seven sessions for two hours Seven sessions for two hours Multi-disciplinary Multi-disciplinary –nurse, physiotherapist, psychologist, dietitian Exercise and education component Exercise and education component Based around cognitive behavioural model Based around cognitive behavioural model Two follow-ups at six months and one year post cardiac event Two follow-ups at six months and one year post cardiac event

7. Results Attendance Attendance Quality of Life (SF-12)- physical and mental Quality of Life (SF-12)- physical and mental Anxiety and Depression (HADS) Anxiety and Depression (HADS) Illness Perceptions (IPQ) Illness Perceptions (IPQ) Risk behaviours Risk behaviours Self-efficacy Self-efficacy

8. Results SF-12 SF-12 –Mental health improved in all 3 groups –Physical health better for PTCA at baseline –Improvements in physical health in MI and CABG group HADS HADS –Reductions in anxiety and depression scores –Greater improvement in those who had clinically meaningful scores

9. Results Illness Perception (IPQ) Illness Perception (IPQ) –Increased timeline scores Patients who accepted their condition to be long-term (timeline) had better diet and exercise self-efficacy scores (8). Perceiving CHD as chronic may be instrumental in engaging individuals in making long-term changes. –MI thought consequences of illness were more serious –Following rehab PTCA patients had increased consequences scores CR may facilitate a raising of awareness of the consequences of CHD and enhance motivation to make behavioural changes

10. Results Self-efficacy Self-efficacy –No group differences Increased SE for stress reduction and dietary changes High SE scores for stopping smoking and increasing fitness Risk Factor Modification Risk Factor Modification –No group differences 80.4% abstinence from smoking at 6 months Significant increases in fruit and vegetable and oily consumption, and frequency of exercise No significant improvements in BMI

11. Study Limitations Lack of control group Lack of control group –No assessment on individuals who refuse CR –Threats to internal validity Data collection difficult with lengthy questionnaire Data collection difficult with lengthy questionnaire –Need all answers for each measure at each time point Data only available up to six months post event Data only available up to six months post event

12. Conclusion No significant differences between three groups in success at CR No significant differences between three groups in success at CR CR a worthwhile venture for PTCA patients CR a worthwhile venture for PTCA patients PTCA motivated to attend CR and make favourable lifestyle changes PTCA motivated to attend CR and make favourable lifestyle changes Evidence suggests only 5-10% of PTCA patients are offered the chance to attend CR (6) Evidence suggests only 5-10% of PTCA patients are offered the chance to attend CR (6)

13. Future Directions Long-term follow-up period beyond one year Long-term follow-up period beyond one year Investigate individuals that refuse CR Investigate individuals that refuse CR Investigate patient activity levels outside CR Investigate patient activity levels outside CR Explore alternative tools for CR Explore alternative tools for CR –Home programme –Videos/dvds –Evening classes

14. Any Questions?

15. References 1. Heart Stats Website http://www.heartstats.org/http://www.heartstats.org/ (2005) accessed on the 25th July 2005. http://www.heartstats.org/ 2. Department of Health (2000) The National Service Framework for Coronary Heart Disease, London: HMSO. 3. Crouse, J. and Hagaman, A. (1991) Smoking Cessation in relation to Cardiac Procedures, Amercian Journal of Epidemiology, 134 (7), pp. 699-703. 4. Hlatky, M. Charles, E. Norbrega, F. Gelmen, K. Johnstome, I. & Melvin, J. (1995) Comparison of Coronary Bypass Surgery with Angioplasty in Patients with Multi-Vessel Disease (BARI), New England Medical Journal, 335, pp. 217-25. 5. Tuniz, D. Bernardi, G. Molinis, G. Valente, M. D’Odorico, N. Mirolo, R. Morocuttl, G. Spedicato, L. & Fioretti, P. (2004) Ambulatory Cardiac Rehabilitation with Individualised Care after Elective Coronary Angioplasty: One Year Outcome, European Heart Journal Supplements, 6 (A), A1-10. 6. Bethell, H. Turner, S. Evans, M. & Rose, L. (2001) Cardiac Rehabilitation in the United Kingdom. How Complete is the Provision?, Cardiopulmonary Rehabilitation, 21 (2), pp. 111-15. 7. Turner, S. Bethell, H. Evans, J. Goddard, J. & Mullee, M. (2002) Patient Characteristics and Outcomes of Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation, 22, pp. 253-260. 8. Lau-Walker, M. (2004) Relationship between Illness Representation and Self-Efficacy, Journal of Advanced Nursing, 48 (3), pp. 216-225. Contact details for further information: escarle@glos.ac.uk eve.scarle@glos.nhs.uk