Cardiac Rehabilitation: Mending the Heart

Heart Disease

Cardiac rehabilitation. Learning to live again, one step at a time.

If you have been sidelined by a heart attack, heart surgery, or another heart or blood vessel problem, you may worry whether you’ll ever get back on your feet. The road to recovery can be challenging, but a cardiac rehabilitation program can help. Cardiac rehab can help:

Recovery (for example after a heart attack or heart surgery)
Reduce your chances of future heart problems
Restore your confidence and quality of life
Cardiac rehab isn’t just about exercise. That’s usually an important part, but, there’s much more to it. Being in cardiac rehab also means you will take part in supervised medical programs that address all aspects of recovery. Programs typically include counseling and support for needed exercise, nutrition, and lifestyle changes. You may also be evaluated for depression and stress – which often follow a serious health event like a heart attack. Research shows that people who actively take part in cardiac rehab programs live longer and have a better quality of life than those who don’t.

Cardiac rehabilitation is helpful for people who have these conditions or procedures:

  • Heart failure
  • Chest pain
  • Heart attack
  • Atrial fibrillation or other heart rhythm problems
  • Peripheral arterial disease (problems with circulation in your legs)
  • Bypass surgery, angioplasty, or heart valve surgery
  • Placing a pacemaker or other cardiac device
  • Heart transplant

Cardiac rehab programs are typically designed in several phases. This stepped approach safely and gradually gets you back on your feet and helps you learn how to make healthy life choices. Rehab often starts while you are still in the hospital. Members of your health care team may begin the step-by-step process of getting you moving again. While in the hospital, that may mean just getting out of bed, getting dressed, or taking a shower.

As you get better, your rehab goals progress with you. You may receive cardiac rehab services in your home or an outpatient facility. In any setting, you’ll be closely monitored and coached by trained health professionals. As you recover, you will gradually be able to do more on your own and with less supervision.

Adapting to life with a heart condition can be overwhelming. It takes time for your body to heal and you’ll be faced with many changes and new things to learn. To help you with this, cardiac rehab is usually paced over several weeks to months. As you’re ready, you’ll work with dietitians and counselors to learn how to make heart-healthy food choices and explore ways to make important lifestyle changes. These may include quitting smoking and reducing your blood pressure and cholesterol levels. Your cardiac rehab team may also help you learn how to take your medications and manage stress.

Finally, a key part of cardiac rehabilitation is learning about your heart condition and understanding your limitations. Your cardiac rehab team will help you recognize symptoms that require immediate action and what changes to report to your doctor. With time and support, you’ll soon regain the strength and self-reliance to live an active and healthful life.

Cardiac Rehabilitation

Heart Disease

History and Definition of Cardiac Rehabilitation

In the 1930s, patients with myocardial infarction (MI) were advised to observe 6 weeks of bedrest. Chair therapy was introduced in the 1940s, and by the early 1950s, 3-5 minutes of daily walking was advocated, beginning at 4 weeks. Clinicians gradually began to recognize that early ambulation avoided many of the complications of bed rest, including pulmonary embolism (PE), and that it did not increase the risk. However, concerns about the safety of unsupervised exercise remained strong; this led to the development of structured, physician-supervised rehabilitation programs, which included clinical supervision, as well as electrocardiographic monitoring.

In the 1950s, Hellerstein presented his methodology for the comprehensive rehabilitation of patients recovering from an acute cardiac event.[9] He advocated a multidisciplinary approach to the rehabilitation program. His approach was adopted by cardiac rehabilitation programs throughout the world. Despite multiple advances, Hellerstein’s original ideas have not been improved upon significantly. However, due to changing patient demographics, many more patients now have the opportunity to receive the benefits offered by cardiac rehabilitation. Multifactorial intervention, including aggressive risk factor modification, has become an integral part of present day cardiac rehabilitation.

According to the US Public Health Service (USPHS), a cardiac rehabilitation program is defined as a program that involves the following:

Medical evaluation
Prescribed exercise
Counseling of patients with cardiac disease
Cardiac rehabilitation has to be comprehensive and, at the same time, individualized. The main goals of a cardiac rehabilitation program are noted below.

Short-term goals are as follows:

“Reconditioning” the patient sufficiently enough to allow him/her to resume customary activities
Limiting the physiologic and psychological effects of heart disease
Decreasing the risk of sudden cardiac arrest or reinfarction
Controlling the symptoms of cardiac disease
Long-term goals are as follows:

Identification and treatment of risk factors
Stabilizing or reversing the atherosclerotic process
Enhancing the psychological status of the patients
Physiology of Exercise and Cardiovascular Benefit
Coronary vasodilatation is mainly driven by the bioavailability of nitric oxide (NO), which is produced by the activities of the endothelially derived enzyme NO synthase and is metabolized by reactive oxygen species. This fine-tuned balance is disturbed in people with CAD. This form of impairment of NO production, along with excessive oxidative stress, results in the loss of endothelial cells via apoptosis. Further aggravation of endothelial dysfunction ensues, which triggers myocardial ischemia in persons with coronary artery disease (CAD). In healthy individuals, an increased release of NO from the vascular endothelium in response to exercise training results from changes in endothelial NO synthase expression, phosphorylation, and conformation.

By the same token, exercise training has assumed a role in the cardiac rehabilitation of patients with CAD, because it reduces mortality and increases myocardial perfusion. This has been largely attributed to the exercise training–mediated correction of coronary endothelial dysfunction in persons with CAD. In persons with CAD, regular physical activity leads to a restoration of the balance between NO production by NO synthase and NO inactivation by reactive oxygen species, thereby enhancing the vasodilatory capacity in various vascular beds.

Because endothelial dysfunction has been identified as a predictor of cardiovascular events, the partial reversal of endothelial dysfunction achieved by regular physical exercise appears to be the most likely mechanism behind the exercise training–induced reduction in cardiovascular morbidity and mortality in patients with CAD.

The amount of exercise in the year before cardiac surgery has been linked to the incidence of postoperative atrial fibrillation during rehabilitation according to a study by Giaccardi et al. The incidence of atrial fibrillation during rehabilitation was significantly higher in patients who performed low-intensity physical exercise the year before surgery compared with those who performed moderate-intensity exercise. The occurrence of atrial fibrillation during the patients’ hospital stay, a larger left atrial volume, and a lower left atrial emptying fraction were independent predictors of atrial fibrillation during rehabilitation.[10]

Cardiac rehabilitation programs include walking as part of the exercise regimen. Gremeaux et al studied the minimal clinically important difference for the 6-minute walk test and the 200-meter fast-walk test for 81 patients with acute coronary syndrome.[11] Results before and after an 8-week cardiac rehabilitation program, and at the 6th and 12th sessions, were reviewed. Patients were asked to rate the change in their walking ability between these two tests. Physiotherapists, who supervised the training, also gave their input. The minimal clinically important difference and mean change in the 6-minute walk test distance was 25 m; no difference was found in the 200-meter fast walk test. These results should help physicians interpret the changes made by their patients in a clinical context and also be used in further studies that use 6 MWD as a measure.

Life After a Heart Attack

Heart Disease

Many people survive heart attacks and live active, full lives. If you get help quickly, treatment can limit damage to your heart muscle. Less heart damage improves your chances for a better quality of life after a heart attack.

Medical Followup

After a heart attack, you’ll need treatment for coronary heart disease (CHD). This will help prevent another heart attack. Your doctor may recommend:

  • Lifestyle changes, such as following a healthy diet, being physically active, maintaining a healthy weight, and quitting smoking
  • Medicines to control chest pain or discomfort, high blood cholesterol, high blood pressure, and your heart’s workload
  • A cardiac rehabilitation program

If you find it hard to get your medicines or take them, talk with your doctor. Don’t stop taking medicines that can help you prevent another heart attack.

Returning to Normal Activities

After a heart attack, most people who don’t have chest pain or discomfort or other problems can safely return to most of their normal activities within a few weeks. Most can begin walking right away.

Sexual activity also can begin within a few weeks for most patients. Talk with your doctor about a safe schedule for returning to your normal routine.

If allowed by State law, driving usually can begin within a week for most patients who don’t have chest pain or discomfort or other problems. Each State has rules about driving a motor vehicle following a serious illness. People who have complications shouldn’t drive until their symptoms have been stable for a few weeks.

Anxiety and Depression After a Heart Attack

After a heart attack, many people worry about having another heart attack. Sometimes they feel depressed and have trouble adjusting to new lifestyle changes.

Talk about how you feel with your health care team. Talking to a professional counselor also can help. If you’re very depressed, your doctor may recommend medicines or other treatments that can improve your quality of life.

Joining a patient support group may help you adjust to life after a heart attack. You can see how other people who have the same symptoms have coped with them. Talk with your doctor about local support groups or check with an area medical center.

Support from family and friends also can help relieve stress and anxiety. Let your loved ones know how you feel and what they can do to help you.

Risk of a Repeat Heart Attack

Once you’ve had a heart attack, you’re at higher risk for another one. Knowing the difference between angina and a heart attack is important. Angina is chest pain that occurs in people who have CHD.

The pain from angina usually occurs after physical exertion and goes away in a few minutes when you rest or take medicine as directed.

The pain from a heart attack usually is more severe than the pain from angina. Heart attack pain doesn’t go away when you rest or take medicine.

If you don’t know whether your chest pain is angina or a heart attack, call 9–1–1.

The symptoms of a second heart attack may not be the same as those of a first heart attack. Don’t take a chance if you’re in doubt. Always call 9–1–1 right away if you or someone else has heart attack symptoms.

Unfortunately, most heart attack victims wait 2 hours or more after their symptoms start before they seek medical help. This delay can result in lasting heart damage or death.