Physicians should aggressively encourage patients to exercise and follow cardiac rehabilitation and secondary prevention protocols to prevent recurrent heart attacks, the American Heart Association recommends in its updated scientific statement on cardiac rehabilitation and secondary prevention of coronary heart disease.
The revision of the association’s 1994 scientific statement emphasizes the components of an optimal rehabilitation and risk factor modification program for preventing recurrent heart attacks, and offers recommendations for future research on rehabilitation, including home, Internet or community-based therapies.
“Cardiac rehabilitation programs remain underused in this country, with only 10 to 20 percent of the 2 million eligible patients a year who experienced heart attack or underwent cardiac revascularization procedures participating,” said Arthur Leon, M.D., chairman of the writing group and Henry L. Taylor professor in exercise science and health enhancement at the University of Minnesota in Minneapolis.
“In addition to a low physician referral rate, factors contributing to underuse of the services include poor patient motivation and inadequate third-party reimbursement. We need to motivate physicians to be more progressive in educating and referring patients to cardiac rehabilitation programs and motivate insurance companies to cover them.”
In addressing the components of an optimal cardiac rehabilitation program, the statement emphasizes the benefits of exercise-based rehabilitation. It includes a summary of research findings that shows average cardiac death was 26 percent lower in rehabilitation patients who were exercise-trained compared with those who received “usual care.” There were also 21 percent fewer nonfatal heart attacks, 13 percent fewer bypass surgeries and 19 percent fewer angioplasties in the exercise-trained people.
Leon said the specific benefits of the exercise training component are improved functional capacity for the patient, improved blood vessel function, improvement in cardiovascular risk factors, improved coronary blood flow, improved electrical stability of the heart muscle (thus reducing the risk of a fatal heart rhythm disturbance), reduced risk of blood clots and reduced cardiac work and oxygen requirements.
In addition to exercise training, an optimal cardiac rehabilitation program includes:
Baseline and follow-up patient assessments;
Aggressive strategies for reducing modifiable risk factors for cardiovascular disease; that include managing lipid (cholesterol) levels, diabetes, blood pressure and weight;
Nutritional and smoking cessation counseling;
Encouragement to adherence to prescribed drug therapy;
Psychosocial and vocational/occupational counseling.
The group’s recommendations for areas of future research include evaluating community, home and Internet-based interventions and care management by non-physician health care professionals to complement the physician’s services. The group also said that future research should include comparing the cost-effectiveness of traditional supervised programs versus these alternative interventions related to improving patients’ functional capacity, self-efficacy, independent living, risk factor modification, long-term use of therapy, re-hospitalization rates and quality of life. This type of study could affect third-party reimbursement.
They say additional research is required to study the effects of endurance and resistance exercise on modifying risk factors. This research should include the effects of exercise on artery function, blood flow, inflammation and other biological processes. The amount of exercise should be examined as well.
The committee urges trials that would further define the role and effect of exercise therapy among older, female and ethnic minority patients – groups that are typically under-represented in clinical trials
Studies should clarify the independent and additive benefits of lifestyle modification in preventing recurrent cardiovascular events. In addition, the writing group recommends that research should evaluate the use of cardiac rehabilitation programs as centers for intensive lifestyle management for weight loss, physical activity, nutrition, and psychosocial support for people with additional chronic medical conditions such as type 2 diabetes or the metabolic syndrome. “Preventing these conditions from following their natural course into acute and chronic vascular disease would be lifesaving and economically beneficial,” the authors write.