Clinical Review - Cardiac rehabilitation

Contributed by Professor Bob Lewin, professor of rehabilitation, British Heart Foundation Care and Education Research Group, University of York, and Professor Patrick Doherty, professor of rehabilitation, York St John University.

Very few patients with angina, acute coronary syndrome or heart failure receive rehabilitation
Very few patients with angina, acute coronary syndrome or heart failure receive rehabilitation

Section 1: What is cardiac rehabilitation?
According to a recent publication cardiac rehabilitation (CR) services are 'comprehensive, long-term programmes involving medical evaluation, prescribed exercise, cardiac risk factor modification, education and counselling'.

They are 'designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilise or reverse the athero-sclerotic process and enhance the psychosocial and vocational status of selected patients'.1

CR is one of the most highly evidenced, cost-effective, life prolonging and enhancing treatments available to a patient with CHD.2

Were it to be invented now, it would be described as chronic disease management for cardiovascular disease (CVD) and would be at the cutting edge of the health service agenda.

Unfortunately, its benefits are not widely known and it is often confused with an exercise programme or, because of the word 'rehabilitation', with helping disabled people after a period of hospitalisation,3 which may be why it is greatly under used.

The development of CR
When CR started in the 1960s, it was restricted to a hospital-based exercise programme designed to get men back to work post-MI, after the (universal) six weeks of bed rest.

By the late 1970s, research had shown that physical training and lifestyle advice were often not enough to change a patient's health behaviour or reduce the psychogenic consequences such as a fear of physical activity, anxiety and depression.

Simple exercise programmes were extended to become 'comprehensive', that is, to include attention to psychological and social recovery, as well as the medical and behavioural aspects of secondary prevention.

By the 1990s, the WHO definition of CR also acknowledged that the task was one of helping patients achieve optimal 'self-management' of their disease, rather than simply telling them what to do.

Delivery
Since CR is about facilitating change in individuals with varying needs and social circumstances there will never be one definitive 'best method' for delivery. However, the most common delivery method is still in group, hospital-based programmes lasting six to 12 weeks with patients attending one to three times per week.

It is clear that a rehabilitation programme needs the skills of several disciplines, including nursing, physiotherapy, dietetics and psychology.

Increasingly, programmes are offering patients a choice of a home-based rehabilitation programme, the Heart Manual, which has been shown to be as effective and preferred by a significant proportion of patients. 4

A choice of evidence-based options is key to improving uptake of CR and ensuring best outcomes for patients.

Section 2: Effects of cardiac rehabilitation
Effect on mortality and morbidity

The most recent meta-analysis included 8,940 patients from 48 randomised controlled trials and found that, compared with usual care, CR produced a 20 per cent relative reduction in all-cause mortality (OR=0.80; 95% confidence interval (CI): 0.68 to 0.93) and a 26 per cent reduction in cardiac mortality (OR=0.74; 95% CI: 0.61 to 0.96).3

This was accompanied by a greater reduction in total cholesterol levels (weighted mean difference, -0.37mmol/l (-14.3mg/dl); 95% CI: -0.63 to -0.11mmol/l (-24.3 to -4.2mg/dl)), systolic BP (weighted mean difference, -3.2mmHg; 95% CI: -5.4 to -0.9mmHg) and lower rates of self-reported smoking (OR=0.64; 95% CI: 0.50 to 0.83).1

Cost-effectiveness
CR is neither costly nor difficult to provide. The median cost for hospital- or home-based rehabilitation is £5,673 per patient.

In the UK, NICE estimated the incremental cost-effectiveness ratio for CR after acute MI to be about £7,860 and £8,360 per Quality Adjusted Life Year gained for men and women respectively.5 This is well within the normal range for funding of treatments in the NHS.

To put this into context, a paper that compared the cost-effectiveness of a number of cardiovascular interventions from 2000 to 2010 found that aspirin and beta-blockers for secondary prevention in angina or heart failure cost <£1,000 per life year gained; CR cost £1,957; CABG £3,239, angioplasty £3,845-£5,889; while primary angioplasty for MI cost £6,054-£12,057, according to age.6

The NIAP 2008 report recommends CR following angioplasty,7 yet research has shown that referral to CR has dropped, possibly because patients and cardiologists erroneously perceive rapid treatment as a cure for MI.8

Section 3: Participation
The NSF for CHD,9 the SIGN guideline in Scotland and equivalent recommendations in Wales and Northern Ireland, the NICE post-MI secondary prevention10 and heart failure guidelines11 concur that the great majority of 'stable' cardiac patients should take part in CR.

Participation targets
The NSF for CHD states that the initial priority is to make sure that people who have survived an MI or who have undergone coronary revascularisation are offered CR and that, once this was well established, the service should be extended to all cardiac patients.

The initial target was for 85 per cent of MI and revascularisation patients to be receiving CR by 2002.

The most recent National Audit of Cardiac Rehabilitation (NACR) annual report showed that in 2007/8 only approximately 34 per cent of MI patients, 68 per cent of CABG and 30 per cent of angioplasty patients received CR.

Who takes part?
Three NACR annual reports have shown that, with isolated islands of excellence, CR remains a classic Cinderella service, little understood, underfunded and patchily distributed around the UK.

About 38 per cent of MI, 30 per cent of percutaneous coronary intervention and 68 per cent of CABG patients attended CR in 2007/8.

Patients with heart failure made up less than 1 per cent, and few people with implanted cardiac devices or acute coronary syndrome take part.3

Low uptake
Given all of the evidence, clinical guidelines, the fact that services are relatively easy to provide and represent great value, coupled with the drive to manage chronic illness better, it seems strange that the majority of patients do not receive CR.

Despite large improvements in other aspects of cardiac provision since the NSF for CHD was published, there has been little additional investment or improvement in the uptake of CR. Severe under-provision is greatly reducing the potential for CR to save lives and improve patients' quality of life.

Section 4: What should PCTs commission?
The NSF for CHD makes it clear that the PCT is responsible for ensuring sufficient good CR for its population.

Minimum Standards

1. A co-ordinator who has overall responsibility for the CR service.

2. A CR core team of professionally qualified staff with appropriate skills and competences to deliver the service.

3. A standardised assessment of individual patient needs.

4. Referral and access for targeted patient population.

5. Submission of data to the National Audit for Cardiac Rehabilitation.

6. A CR budget appropriate to meet the full service costs.

UK national minimum standards
The core components that must be present in a service have been defined in clinical guidelines of the British Association of Cardiac Rehabilitation, a standard that has been adopted as part of the NICE CR service commissioning guidance.

The minimum standards are shown in the box above.

In some parts of the country, innovative schemes are now being developed.

A better approach
Until recently, cardiac services have been organised as if heart disease was a series of acute events; the reality is that CHD is a chronic illness, intimately connected to diabetes, hypertension and stroke, punctuated by episodes where acute care is appropriate.

The current drive for prevention through the Health Check Programme, to improve the management of chronic and long-term conditions by establishing registers and incentives to reduce re-admission and use of acute services could all be greatly served by incorporating the expertise, skills and knowledge of local CR teams into the PCTs' chronic disease management strategies.

Core Components

1. Lifestyle interventions for:

I) physical activity and exercise

II) diet and weight management

III) smoking cessation

2. Education

3. Risk factor management

4. Attention to psychosocial adjustment

5. Cardio-protective drug therapy and implantable devices

6. A long-term management strategy

Resources

1. AACV/ACC/AHA 2007 performance measures on cardiac rehabilitation. J Am Coll Cardiol 2007; 50; 1,400-33.

2. Taylor RS, Brown A, Ebrahim S et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomised controlled trials. Am J Med 2004; 116: 682-92.

3. National Audit of Cardiac Rehabilitation Annual Report, University of York, 2009, http://www.cardiacrehabilitation.org.uk

4. Dalal HM, Evans PH, Campbell JL et al. Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms. Cornwall Heart Attack Rehabilitation Management Study (CHARMS). Int J Cardio 2007; 119: 202-11.

5. Skinner A, Cooper G, Feder S, on behalf of the Guideline Development Group. Secondary prevention for patients following a myocardial infarction: summary of NICE guidance. Heart 2007; 93: 862-4.

6. Fidan D, Unal B, Critchley J, Capewell S. Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000-2010. QJM 2007; 100: 277-89.

7. DH Vascular Programme Team. Treatment of Heart Attack National Guidance, Final Report of the National Infarct Angioplasty Project (NIAP). October 2008.

8. Astin F, Closs S J, McLenachan J et al. Primary angioplasty for heart attack: mismatch between expectations and reality? J Adv Nurs 2009; 65: 72-83.

9. Department of Health. National Service Frameworks. Coronary Heart Disease. Department of Health, London 2000.

10. NICE Clinical guideline 48: MI: secondary prevention in primary and secondary care for patients following a myocardial infarction. London, NICE, 2007. www.nice.org.uk/CG48

11. NICE Clinical guideline 5: Chronic heart failure. London, NICE, 2003. www.nice.org.uk/CG5

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