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doi: 10.1097/
Features: Recovery Room

Cardiac Rehab: It's Not Just “Working Out”

Prentice, Kathleen

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Recovering From A Heart Problem Takes Specialized Care

After a heart attack or other serious cardiac problem, patients leave the hospital with a laundry list of recommendations: Eat healthy foods. Be physically active. Quit smoking. Lose excess weight. Reduce stress. Take medications. A cardiac rehabilitation program can address them all. In fact, successfully completing rehab can reduce risk of death after cardiac illness by 20 to 25 percent.

“The concept behind outpatient intensive cardiac care is that patients don't stay in the hospital very long anymore. They go home very quickly, often without knowing what's going on. The intensive care has shifted to outside the hospital,” says Paul Thompson, M.D., Director of Preventive Cardiology, Hartford Hospital in CT.

Cardiac rehab isn't just for people who have had a heart attack. Rehab can help improve and manage heart-related conditions including stable angina and heart failure. Doctors may also refer patients to cardiac rehab after angioplasty, stenting, heart valve replacement, implantation of a pacemaker or defibrillator and heart transplant.

A rehab program can help patients improve overall health and quality of life while helping to reduce the likelihood of a subsequent fatal or nonfatal heart attack. “The patient feels better [and that's] the number one benefit,” says Marjorie King, M.D., Director of Cardiac Pulmonary Rehabilitation at Helen Hayes Hospital in West Haverstraw, NY. “They can do more, are stronger.”

“If I hadn't gone to a rehab where they hooked me up to a monitor and said, ‘Your heart is doing fine,’ I would have been scared to death to go to a gym and get on a treadmill,” admits Kathy Dineen, clinical nurse educator at Meriter Hospital in Madison, WI, who had cardiac catheterization and stent implantation in 2007 when she was 53 years old. “Exercising on the monitor gave me all the confidence in the world.”

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“Women, minorities and the elderly are less likely to get to cardiac rehab, but all do well once enrolled,” says King.

Despite the benefits, fewer than 30 percent of eligible patients take part in cardiac rehab — and for patients 65 and older, participation is just 14 percent, according to a 2007 joint study by the American Heart Association (AHA), American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and American College of Cardiology. Among the barriers the study identified: low referral rate, cost, lack of motivation, inadequate insurance reimbursement and accessibility.

The cost of cardiac rehab is typically paid by private health insurance or Medicare — though the patient is often on the hook for a 20 percent co-pay, unless he or she has supplemental insurance to cover the “gap.” Without coverage, the out-of-pocket cost for each session can range from $150 to $300.

In some cases, patients who are referred to a rehab program don't enroll because the classes are offered at inconvenient times — during working hours, for instance — or are difficult to get to using public transportation.

A shortage of programs is also a factor in low enrollment, says Susan D'Agostino, R.N., Manager of Cardiovascular Rehabilitation/Prevention at Miami's Baptist Cardiac and Vascular Institute. Some patients have to travel upwards of 50 miles each way to attend a certified cardiac rehab program, particularly in a small and/or rural state. For instance, there are no certified cardiac rehab facilities at all in New Mexico and the District of Columbia, and only one in Nevada and two in Alaska.

“Patients have to come in two to three times a week, and if it's not close and the patient is elderly and ill, it's difficult to get there,” says Marie Bass, Executive Director of the AACVPR in Chicago.

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At the first visit, the staff will get a patient's complete medical history, including past and current medications; conduct a basic physical exam, including blood pressure and an electrocardiogram (EKG); make a referral to a smoking cessation program, if applicable; and will discuss individualized recovery goals, especially if a patient has diabetes or another medical condition that complicates recovery. “Everyone can get something out of cardiac rehab,” King says. “The worse off you are, the higher percent of improvement you'll get.”

Each patient's rehab plan is a custom job, King explains. “We look at medical risks, like if their sternum was cut and how that affects exercise. We might get an older woman who might not have the arm strength to do her own shopping. Someone else's goal might be to get back to golf, get back to work as an auto mechanic or being in charge of a battalion of soldiers.”

Ann de Velasco, RN, a nurse at Baptist Cardiac and Vascular Institute who suffered a heart attack in 2000, credits her rehab program with teaching her about what equipment would help her reach her treatment goals, and “how each exercise affects my heart.” She also learned about the importance of warm-ups and cool-downs every time she exercises. She was so impressed with the staff's level of expertise and what rehab was able to do for her that she left a clinical research position at the University of Miami School of Medicine so she could work with cardiac rehab patients herself. “I found it was difficult for me to keep up with my cardiac exercise because of my work schedule, so after three months I quit [my job] to devote time to rehab. I stayed on as a volunteer, then I was hired.”

Having gone through cardiac rehab herself, de Velasco brings a special insight to her current job. “When I talk to patients, it's instant camaraderie. When they see me active, working, that's a validation from someone who has been there that they can do activities and not have discomfort, and that's empowering.”

After the initial assessment, patients are grouped into one-hour classes that meet two to three times a week at a designated time. Each class starts with a weigh-in (by staff or self) and blood pressure check. To enable a nurse or other staff member to monitor heart rhythm and rate while they exercise, patients attach leads to the chest and abdomen that connect to a monitor worn around the neck or clipped to a pocket.

After a few minutes of warm-up exercises, patients move on to treadmills, stationary bicycles, rowing machines and walking tracks for 20 to 30 minutes of continuous cardiovascular activity, during which blood pressure is checked again. The session ends with a few strength-training exercises using weights, a cool-down period and a final blood pressure check.

The staff is also keeping an eye out for such problems as fluid retention in heart failure patients, and side effects of new medications the patient is taking to recover from a cardiac event. “If someone is having a problem, a call is made to the doctor right then instead of waiting for the next office visit,” de Velasco says.

In addition to supervised physical activity, cardiac rehab programs also offer counseling and support groups — some of which welcome a patient's spouse or other family members — that cover everything from healthy cooking techniques to incorporating physical activity in your daily routine to when it's safe to resume sexual activity. Some programs also teach relaxation techniques, such as meditation and yoga.

“I felt like I left the hospital with no tools to deal with what happened to me,” de Velasco says. Cardiac rehab changed that. “At first I felt apprehensive, but as I was able to do more, I had more confidence. When you have a heart attack, you feel very much out of control. When I got my confidence back, I felt very much back in control of my life.”

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How To Choose A Cardiac Rehab Facility

Your first step is to check that the program is certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). (Visit and click on “Searchable Certified Program Directory,” which is found under the Resources tab.)

There are roughly 2,600 cardiac rehab centers nationwide, according to AACVPR's Marie Bass; of these, her organization has certified 1,432 centers.

The answers to these questions will help you rule in or rule out facilities that you will want to take a look at in person:

□ Does staff include trained cardiac nurses, exercise specialists, dietitians, mental health specialists?

□ Is there a doctor on the premises?

□ Is the staff ratio one for every four patients?

□ Is staff certified for basic and advanced life support skills (BLS and ACLS)?

□ Does the program offer workshops and counseling?

□ Are assessments and treatment plans individualized?

□ Will someone on staff file your insurance claim?

□ Will the staff stay in regular contact with your cardiologist?

□ Is there an open-ended post-rehab program that allows patients to continue to exercise at the facility for a fee?

When you're visiting a facility, look for these features:

□ Is there a variety of equipment like treadmills, elliptical trainers, stationary bicycles and step machines?

□ Are some pieces of equipment modified for elderly patients?

□ Are free weights, wall pulleys and rowing machines available?

© 2009 American Heart Association, Inc.