Cardiac RehabilitationCardiac Rehabilitation

Paula O’NeillPaula O’NeillCHD Nurse SpecialistCHD Nurse Specialist

Hammersmith/Charing Cross HospitalsHammersmith/Charing Cross Hospitals

2424thth September 2008 September 2008

Learning ObjectivesLearning Objectives

Components of cardiac rehabilitationComponents of cardiac rehabilitation

What is cardiac rehabilitation?What is cardiac rehabilitation?

Structure of cardiac rehabilitationStructure of cardiac rehabilitation

Ways of delivering cardiac Ways of delivering cardiac rehabilitationrehabilitation

The future of cardiac rehabilitationThe future of cardiac rehabilitation

Definition of Definition of Cardiac RehabilitationCardiac Rehabilitation

““The sum of activities required to ensure The sum of activities required to ensure

patients the best possible physical, patients the best possible physical,

mental and social conditions so that mental and social conditions so that

they may resume and maintain as they may resume and maintain as

normal a place as possible in the normal a place as possible in the

community”.community”.World Health OrganisationWorld Health Organisation

The EvidenceThe Evidence

Comprehensive help with lifestyle Comprehensive help with lifestyle modification modification

involving education and involving education and psychological input aspsychological input as

well as exercise training can reduce well as exercise training can reduce mortality bymortality by

20-25% over 3 years.20-25% over 3 years.Oldridge et al 1988; O’Connor et al 1989Oldridge et al 1988; O’Connor et al 1989

Target GroupsTarget Groups

CoronaryCoronary heart disease (CHD) heart disease (CHD)– Exertional angina .Exertional angina .– ACS (unstable angina or NSTEMI or ACS (unstable angina or NSTEMI or

STEMI) following medical/surgical STEMI) following medical/surgical management.management.

– RevascularisationRevascularisation– Stable heart failure and cardiomyopathyStable heart failure and cardiomyopathy

Those at high risk of developing CVD: totalThose at high risk of developing CVD: totalCVD risk > 20% over 10 years or diabetes CVD risk > 20% over 10 years or diabetes mellitus.mellitus.

Who should be involved?Who should be involved?

Patient

PharmacistNurse

ConsultantGP

PhysiotherapyPhysiotherapy

Dietician

Exercise instructor

Smoking cessation advisor

Social Services

Psychologist

District Nurses

Practice nurses

Health Visitor

Secondary care

Components of CR.Components of CR.

Lifestyle:Lifestyle:– Diet and weight managementDiet and weight management– Smoking cessationSmoking cessation– Physical activity and exercisePhysical activity and exercise

– Secondary preventionSecondary prevention– EducationEducation

Psychosocial carePsychosocial care Long-term management strategyLong-term management strategy

Physical ActivityPhysical Activity

Assess and risk stratifyAssess and risk stratify Develop individual exercise planDevelop individual exercise plan Teach FITT principleTeach FITT principle Regain/develop physical fitnessRegain/develop physical fitness Regain confidence in physical Regain confidence in physical

activityactivity Develop long-term activity planDevelop long-term activity plan Self monitoringSelf monitoring

Secondary PreventionSecondary Prevention

Cholesterol managementCholesterol management

BP managementBP management

Blood sugar managementBlood sugar management

Cardio-protective drug therapyCardio-protective drug therapy

EducationEducation

CHD as a diseaseCHD as a disease

Treatment including medicationTreatment including medication

Recovery processRecovery process

CHD risk factorsCHD risk factors

Symptom managementSymptom management

Living with CHDLiving with CHD

Psychosocial CarePsychosocial Care

Reduce fear and anxietyReduce fear and anxiety

Assist with adjustmentAssist with adjustment

Promote positive attitudePromote positive attitude

Facilitate behaviour changeFacilitate behaviour change

Identify need for further supportIdentify need for further support

Structure of Structure of Cardiac RehabilitationCardiac Rehabilitation

Phase 1:Phase 1: In-patient (1In-patient (1stst contact) contact)

Phase 2:Phase 2: Immediate post dischargeImmediate post discharge

Phase 3:Phase 3: 2-4 weeks post discharge2-4 weeks post discharge

Phase 4:Phase 4: Long-term, on-goingLong-term, on-going

Phase 1Phase 1

Understanding of conditionUnderstanding of condition Information & educationInformation & education Risk factor assessmentRisk factor assessment Personalised health planPersonalised health plan Psychological assessment/supportPsychological assessment/support ReferralReferral Drug therapyDrug therapy

Phase 2Phase 2

Home visits.Home visits.

Telephone Telephone support.support.

ClinicsClinics

Phase 3Phase 3

Reassess health & risk factors first.Reassess health & risk factors first.

Health EducationHealth Education

ExerciseExercise

RelaxationRelaxation

Phase 4Phase 4

Maintenance of exercise/activityMaintenance of exercise/activity

On-going lifestyle supportOn-going lifestyle support

Challenges for the Pt and FamilyChallenges for the Pt and Family

Challenges for the Pt and Family

•Frightening, life threatening event (MI, major surgery)

•A chronic illness, reduced life expectancy, symptoms

•Altered identity - an invalid, walking time bomb

•Fears for family and partner being left alone

•Threat to employment and financial status

•Medication side effects (lethargy, impotence)

•Being treated differently by other people

•Neurological impairement (esp. cardiac arrest pats.)

•Making lifestyle changes, smoking, diet, activity

Delivering CRDelivering CR

Can be done individually or in a groupCan be done individually or in a group

Venue:Venue: HomeHome

CommunityCommunity

ClinicsClinics

Menu: Mixing up of all 4 phases too Menu: Mixing up of all 4 phases too provide an individualised package of provide an individualised package of care.care.

Other services / Professions1.1. Sexual medicine clinicSexual medicine clinic2.2. Welfare rights bureauWelfare rights bureau3.3. Social workerSocial worker4.4. Marriage guidance servicesMarriage guidance services5.5. Specialist heart failure nurseSpecialist heart failure nurse

Sample Cardiac Rehabilitation MenuSample Cardiac Rehabilitation MenuActivity / Fitness

• hosp exercise grouphosp exercise group• home exercise programmehome exercise programme• advice on resumption of active lifeadvice on resumption of active life• Age Concern Health MentorAge Concern Health Mentor• Walk for HealthWalk for Health• Phase 4 exercise programmePhase 4 exercise programme• Tai Chi classesTai Chi classes

Smoking• Willpower aloneWillpower alone• smoking cessation clinicsmoking cessation clinic• Nicotine replacementNicotine replacement• Referral for medicationReferral for medication• Internet programmeInternet programme

Diet / Weight loss• Self-management of diet / medicationSelf-management of diet / medication• dietetics referral dietetics referral • Weight WatchersWeight Watchers• Internet programmeInternet programme• Coach ProgrammeCoach Programme

Education

• Hospital educational programmeHospital educational programme• Home educational programmeHome educational programme• Mentor / volunteer / lay-workerMentor / volunteer / lay-worker• InternetInternet

Psychological adjustment• Self help advice materialsSelf help advice materials• Stress management classStress management class• Stress management on tapeStress management on tape• Counselling psychologistCounselling psychologist• Clinical Psychology / PsychiatryClinical Psychology / Psychiatry

Social support• Buddy systemBuddy system• Patient support groupPatient support group• Mentoring schemeMentoring scheme

Angina PlanAngina Plan

WHAT?WHAT?

Self help Self help packagepackage

A CBT A CBT programmeprogramme

WHO?WHO?

Recent anginaRecent angina

1 year since 1 year since diagnosisdiagnosis

www.anginaplan.org.uk

Using the Angina PlanUsing the Angina Plan

Advice tape & information sheetAdvice tape & information sheet

30 minute appointment30 minute appointment

4 phone calls over 3 months (5-10 4 phone calls over 3 months (5-10 mins)mins)

Pro & Cons of the Angina PlanPro & Cons of the Angina Plan

RestrictionsRestrictions

Must be literateMust be literate Must be motivatedMust be motivated CostCost Time commitmentTime commitment

Advantages (RCT)Advantages (RCT)

Less medicationLess medication Less GP/hospital visitsLess GP/hospital visits anxiety/depressionanxiety/depression MI treated quicklyMI treated quickly incidence of CHDincidence of CHDLewin R et al (2002) A Randomised controlled Lewin R et al (2002) A Randomised controlled

trial of a selftrial of a self

management plan for patients with newly management plan for patients with newly diagnosed angina.diagnosed angina.

British Journal of General Practice 52: 476, 194-British Journal of General Practice 52: 476, 194-201201

The Heart Manual The Heart Manual (1)(1)

6 week, home based post MI 6 week, home based post MI rehab programme rehab programme

A work book, diaries, record A work book, diaries, record sheets and information sheets and information

2 audio tapes, advice for 2 audio tapes, advice for family, a stress family, a stress management course on management course on tapetape

A specially trained A specially trained ‘Facilitator’‘Facilitator’

The Heart Manual The Heart Manual (2)(2)

Exercise programme – walkingExercise programme – walking

Secondary prevention – written adviceSecondary prevention – written advice

Cognitive behavioural techniquesCognitive behavioural techniquesChange patients Change patients beliefs and attributions beliefs and attributions

(cardiac (cardiac misconceptions) misconceptions) Self help for psychological problemsSelf help for psychological problemsRelaxation and stress managementRelaxation and stress management

Initial face-to-face session, then phone calls or Initial face-to-face session, then phone calls or home/clinic visits at week 1, 4, 6 after discharge.home/clinic visits at week 1, 4, 6 after discharge.

Multi-centred RCT of HM vs. Hospital based. Equal gain on all measures including 2 Met gain in fitness, HM

fewer readmissions. Andrew Coats, Jenny Bell

Initial RCT - less anxiety & depression: better quality of life: fewer readmissions to hospital: less contact with

GP. Lewin B, Lancet, 1992.

The Heart Manual: Evidence BaseThe Heart Manual: Evidence Base

Recommended by - WHO: BHF: Department of Health: Scottish Office

CHD NSFCHD NSF•By 2009 85% of MI and revasc patients will be offered cardiac rehabilitation

•After that all except unstable angina patients should receive CR.

The RealityThe Reality

25-30% of 25-30% of patientspatients

getting cardiacgetting cardiac

rehab in 2006-rehab in 2006-7.7.

ProblemsProblems

InequalitiesInequalities – women, poor, ethnic minorities, – women, poor, ethnic minorities, depressed, smokers, elderly, all believed to be depressed, smokers, elderly, all believed to be under-represented, postcode lotteryunder-represented, postcode lottery

Failure to invite all indicated in NSFFailure to invite all indicated in NSF – angina, – angina, heart failure, ICD, arrhythmiaheart failure, ICD, arrhythmia

DropoutDropout – varies widely from programme to – varies widely from programme to programmeprogramme

StaffingStaffing – from single-handed, part-time, – from single-handed, part-time, coordinator for 600 patients to a full multi-coordinator for 600 patients to a full multi-disciplinary team. Only 50% of programmes have disciplinary team. Only 50% of programmes have an identifiable budget.an identifiable budget.

Cost of Cardiac RehabilitationCost of Cardiac Rehabilitation

The average cost per patient in 2006-7 The average cost per patient in 2006-7 was £413 was £413

Single day in a CCU costs £1,400 Single day in a CCU costs £1,400

Angioplasty (does not reduce mortality) Angioplasty (does not reduce mortality) costs £3,000 costs £3,000

Bypass surgery costs £8,000. Bypass surgery costs £8,000.

Remember the Evidence!Remember the Evidence!

Comprehensive help with lifestyle modification Comprehensive help with lifestyle modification

involving education and psychological input asinvolving education and psychological input as

well as exercise training can reduce mortality well as exercise training can reduce mortality byby

20-25% over 3 years.20-25% over 3 years.

Oldridge et al 1988; Oldridge et al 1988; O’Connor et al 1989O’Connor et al 1989

Cardiac Rehabilitation Cardiac Rehabilitation Saves Lives!Saves Lives!

No treatment in cardiac disease has stronger No treatment in cardiac disease has stronger scientific evidence or a significantly greater impact scientific evidence or a significantly greater impact on survival.on survival.

The scientific evidence has been reviewed by many The scientific evidence has been reviewed by many scientific and expert bodies over the last 30 years. scientific and expert bodies over the last 30 years. Every review has come to the same conclusion that Every review has come to the same conclusion that cardiac rehabilitation is an essential treatment.cardiac rehabilitation is an essential treatment.

CR is only form of chronic disease management CR is only form of chronic disease management with an evidence base. with an evidence base.

The SolutionsThe Solutions

NACRNACR National CampaignNational Campaign NICE GuidelinesNICE Guidelines CR QoFCR QoF TariffsTariffs CDM AgendaCDM Agenda