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HEART Insight:
doi: 10.1097/01.HEARTI.0000437024.79561.fe
Features: Recovery Room

Take Your Recovery to Heart

Eidlitz, Elizabeth

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Cardiac rehabilitation programs can help reduce the risk of future heart problems

It's 36 sessions,” I was told in mid-July of last year. I thought I might die of old age before I could finish the Monday-Wednesday-Thursday 12-week cardiac rehab program at Emerson Hospital in Concord, Mass. But accepting the program that my cardiologist recommended after my aortic valve replacement, I committed to sessions starting at 7:15 a.m., getting it over with before it could wreck the day.

Cardiac rehab patien...
Cardiac rehab patien...
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My first day in cardiac rehab began with a weigh-in, blood pressure reading and warm-up exercises with resistance bands. I expected to ease into the individual aerobic exercise routine, but on that first day I was expected to spend 15 minutes on the treadmill and then 15 minutes pedaling a stationary bike—a boring half hour of moving continuously but going nowhere.

Knowing that what I was doing was good for me and my health, I focused on increasing exertion level settings on the equipment and pursued conversation with the congenial fellow on the elliptical machine next to me.

Once the aerobic exercise was completed, we began a 15-minute meditation session. I relaxed on the provided mat, pillow and fresh pillow case and visualized an ocean scene while a staff member read a parable aloud: “A Cherokee chief told his grandson, ‘Two wolves live inside me. One is the bad wolf, full of greed and laziness, anger, self-pity, false pride and regret. The other is the good wolf, full of joy, peace, love, humility, kindness and faith.’ ‘But grandfather,’ the young boy said, ‘Which wolf will win?' The grandfather answered, ‘The one I feed.’”

Maybe this cardiac rehab wasn't going to be so bad after all, I thought. And I came back on Wednesday, and Friday, and before I knew it my 12-week program was nearly completed.

In addition to workouts and meditation, I participated in hour-long weekly lectures on topics including exercise and activity, strength training, stress management, nutrition, medications and heart disease. When you already count calories, check nutrition labels, know the difference between systolic and diastolic, and that drugs with ‘OL’ endings are beta blockers, it's easy to assume this educational component of the cardiac rehab program is unnecessary.

But I was humbled. I didn't know the difference between saturated, monounsaturated and trans fats. Or that certain body movements can cause an increase in energy use and the structured, repetitive movements of exercise can improve physical fitness.

Everyone should restrict sodium to 1,500 milligrams or less per day, but would you suspect that one cup of homemade potato salad (1,323 mg) and one cup of canned tomato sauce (1,482 mg) edge that limit? Or that one packet of dehydrated onion mix soup (3,493 mg) has more sodium than a two-day quota?

The lectures that I attended at rehab corrected faulty assumptions and major illusions that I had about my condition and rehab. I now had clean coronary arteries and a new aortic valve. My sinus rhythm had been restored by a procedure called cardioversion that treated my atrial fibrillation. Wouldn't my cardiovascular disease be history once I finished cardiac rehab?

No. Cardiac rehab can stabilize, slow or even reverse the progression of heart disease, and it also helps the recovery process and promotes wellness through lifestyle changes. I would still need to make lifestyle changes once the program was over. Cardiac rehab programs include coordinated interventions that optimize physical, psychological and social functioning, reducing future cardiac events and saving lives.

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Busting the myths about cardiac rehab

The national average for eligible people who actually attend cardiac rehab is as low as 10 to 20 percent. See if any of these myths about cardiac rehab have kept you from taking part.

Myth #1 “I'm scared to work out. What if I have another cardiac event?”

It's natural to feel skittish, but the chances of having another cardiac event when you return to exercising in a supervised setting are very low.

Myth #2 “I have a job, and I can't take time off to go to rehab.”

Most cardiac rehab programs offer session times throughout the day to accommodate your schedule, and plans can be customized to the individual.

Myth #3 “I can't afford it”

Medicare covers cardiac rehabilitation for many conditions, and in 2010 was expanded to include intensive cardiac rehabilitation. Most private insurance companies follow Medicare reimbursement roughly but may require co-payment. The essential benefit package established under health reform will improve access to cardiac rehabilitation for low-income and underinsured populations when implemented in 2014.

Myth #4 “I know what I need to do.”

Most people can recite the right things to do. But to accomplish them, people actually need the tools and the support to do it. A formalized cardiac rehab program gives them those tools.

Myth #5 “I feel fine! I don't need rehab.”

No matter how you feel, after a cardiac event, your lifestyle requires some changes. The rehab process is not only about learning how to change your lifestyle. It's also a source of emotional support.

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Analysis of Medicare records has shown a 35 percent reduction in mortality among people who attend cardiac rehab compared to those who don't. Other research studies show a 15 to 25 percent reduction in the number of recurrent heart attacks in people who have been to cardiac rehab.

Despite the clear benefits for eligible patients, however, only 14 to 35 percent of heart attack survivors and 31 percent of patients who have had coronary bypass grafting surgery participate in cardiac rehabilitation programs. Why do so many patients avoid cardiac rehab, when numerous studies have shown that it helps patients live better lives? They may think they don't have the time, can't fit it into their schedules or can't afford it. Or that it's just too hard or could be dangerous. But these misconceptions are just that—misconceptions. Cardiac rehab programs are safe places psychologically and physically. Heart rate and oxygen levels are continually monitored during exercise. The staff is trained in CPR and advanced cardiac life support, and a hospital code team and doctor are immediately available for emergencies. See Busting the myths of cardiac rehab on page 10 to see if any of these common excuses are stopping you from attending cardiac rehab.

And it may not be just the patients who are hesitant. One study found that only 56 percent of heart patients were referred by their doctors for cardiac rehab, and that older adults were even less likely to be referred. Study researcher Gregg C. Fonarow, M.D., a professor of cardiology at the David Geffen School of Medicine at UCLA, believes doctors should endorse and prescribe cardiac rehab for more patients, more often. “There is no upper age limit for participation,” he says.

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At Emerson Hospital's cardiac rehab program, where physicians refer their patients following a heart attack, bypass surgery, valve surgery or a coronary stent, the ages of patients range from early 20s to 95. Nationally certified by the American Association of Cardiovascular and Pulmonary Rehabilitation in 2009, the program averages 8,000 visits a year from those who recognize the importance of a demanding rehab option, supervised by a dedicated team of physicians, registered nurses, physical therapists, exercise physiologists, dietitians and social workers.

“About 70 percent of our participants are men and almost one-third are women,” says Virginia Dow, R.N., B.S.N., B.C., the cardiac rehabilitation and prevention department manager at Emerson. “Less than 10 percent drop out, usually because commitment to this program and to their work becomes too difficult. Seventeen percent elect to continue on a maintenance program once or twice a week, remembering that they still have a heart problem and need to keep making the right changes.”

“Of course it's important to get people to exercise and to recognize dietary restrictions that can still be tasty and satisfying,” says cardiologist Steven Herson, M.D., instrumental in establishing Emerson's program in 1981 and serving as its medical director, “but the main function of cardiac rehab is to achieve a balanced lifestyle and to encourage people with a significant experience in common to support each other emotionally.”

Beyond weekly conversational opportunities during aerobic exercise sessions, patients can network in a monthly support group, where they can meet a walking buddy, share heart-healthy recipes, adjust expectations because individuals progress at different paces, confide their fears and find comfort and affirmation.

“There are benefits to being in a room of people who all have had similar medical problems,” says John D. Bisognano, M.D., Ph.D., director of cardiology outpatient services at the University of Rochester Medical Center in N.Y. “There's camaraderie. It gives you the support to make changes successfully. That support not only makes it easier to implement change but also helps prevent depression.”

Widening the circle of support, spouses and other family members are welcome to attend lectures with the patient, increasing their understanding of lifestyle and other changes, like maintaining a healthy eating plan and quitting smoking, which need to continue beyond the 12-week program. Getting the whole family involved in lifestyle changes is an important step in making the changes stick. Mutual support and encouragement can make a big difference, so be sure to ask for help and support from loved ones.

Patients committed to the cardiac rehab program have their hearts in the right place, as do the rehab team members committed to helping individuals live a full life. They certainly helped me continue on my road to recovery and living a heart-healthy life.

© 2013 by the American Heart Association


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