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CREST

CLINICAL RESOURCE EFFICIENCY SUPPORT TEAM

GUIDELINES FOR
CARDIAC REHABILITATION
IN
NORTHERN IRELAND

May 2006
These guidelines have been published by the Clinical Resource Efficiency Support Team (CREST),
which is a small team of health care professionals established under the auspices of the Central
Medical Advisory Committee in 1988. The aims of CREST are to promote clinical efficiency in
the Health Service in Northern Ireland, while ensuring the highest possible standard of clinical
practice is maintained.

The guidelines have been produced by a sub-group of health care professionals from varied
backgrounds including Medical (Primary and Secondary care), Nursing, Management and Public
Health, Chaired by Professor Gary McVeigh. CREST wishes to thank them and all those who
contributed in any way to the development of these guidelines.

Further copies of this booklet and an executive summary may be obtained from:

CREST Secretariat
Room D1
Castle Buildings
Stormont
BELFAST
BT4 3SQ

Telephone 028 90 522028


Fax 028 90 523206
E-mail christine.smith@dhsspsni.gov.uk

Or you can visit the CREST website at: www.crestni.org.uk

ISBN 1-903982-18-9

Executive Summary ISBN 1-903982-19-7


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CONTENTS: Page no:

Members of the Cardiac Rehabilitation Sub-Group 2

Executive Summary 4

Milestones for CREST Guidelines on Cardiac Rehabilitation 6

Chapter 1 – Introduction 7

Chapter 2 – Educational and Psychological Interventions 9

Chapter 3 – Exercise 15

Chapter 4 - Target Patient Groups 21

Chapter 5 - Secondary Prevention: Use of Medication 24

Chapter 6 - Cardiac Rehabilitation in Primary Care 26

Chapter 7 - Implementation and Audit / Data Collection 29

References 32

Appendices 41
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MEMBERS OF THE CARDIAC REHABILITATION SUB-GROUP

Professor Gary McVeigh


Professor of Cardiovascular Medicine
Dept of Therapeutics & Pharmacology
Queen’s University of Belfast

Ms Gerry Bleakney
Head of Health Promotion Commissioning
EHSSB

Dr Margaret Cupples
Department of General Practice
Queen’s University of Belfast

Ms Bernie Downey
Cardiac Nurse Specialist
Mater Hospital

Ms Siobhan Doyle
Clinical Lead Physiotherapist
Mater Hospital Trust

Ms Donna Hanna
Cardiac Liaison Nurse, Coronary Care Unit
Causeway Hospital

Dr Niall Herity
Consultant Cardiologist
Belfast City Hospital Trust

Dr Anne Kilgallen
Consultant in Public Health Medicine
WHSSB

Dr Jackie McCall
Specialist Registrar in Public Health Medicine
EHSSB

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Ms Roisin O’Hare
Clinical Pharmacist
Royal Victoria Hospital

Dr Clive Russell
Consultant Physician
Tyrone County Hospital

Secretariat

Maureen Henderson BCH

CREST Secretariat

Mr Gary Hannan
Mr Jim McKee
Mrs Christine Smith

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CARDIAC REHABILITATION GUIDELINES

EXECUTIVE SUMMARY

Coronary artery disease imposes a large burden on health and health care resources in
Northern Ireland. Cardiac rehabilitation with an exercise component is often offered to
patients with coronary artery disease. Comprehensive cardiac rehabilitation programmes
incorporate an exercise programme in combination with other secondary measures such as
coronary artery disease risk factor management, patient education and psychological
interventions.

The evidence indicates that a comprehensive cardiac rehabilitation programme which


includes exercise has beneficial effects on cardiac mortality and total mortality. The benefits
compare favourably with standard coronary artery disease secondary prevention practice
(e.g. beta-blocker, anti platelet and statin therapy) in reducing cardiac and all-cause
mortality. The evidence is also consistent in showing that cardiac rehabilitation is cost
effective and may reduce cost to health care systems due to reduced rehospitalisation and
drug utilisation. Despite the beneficial effects of participating in cardiac rehabilitation, that
approximate to those that can be achieved with standard pharmacological interventions,
participation in rehabilitation programmes remains sub-optimal.

Under the auspices of CREST, an expert panel was convened to review the evidence for
cardiac rehabilitation with an exercise component for secondary prevention of coronary
artery disease in terms of clinical effectiveness and cost effectiveness. An additional
objective was to focus on the impact of the evidence on the future direction and
development of cardiac rehabilitation services for the secondary prevention of coronary
artery disease in Northern Ireland. The panel included health care professionals from varied
backgrounds including medical (primary and secondary care), nursing, management and
public health and was chaired by Professor Gary McVeigh.

RECOMMENDATIONS

1. Given the strong evidence base for efficacy and cost effectiveness all Trusts should
ensure that eligible patients are offered the opportunity to participate in a cardiac
rehabilitation programme.

2. Based on evidence patients known to benefit would include those post-myocardial


infarction, post-coronary revascularisation and selected patients with congestive
heart failure and stable angina.

3. A comprehensive cardiac rehabilitation programme is recommended. This can be


hospital or community based depending on patient needs. The programme should
contain an exercise component.

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4. Cardiac rehabilitation includes secondary prevention. It should be an integral part


of, and begin at, the acute stages of care and be continued in the community
setting. Cardiac rehabilitation is the responsibility of all health care professionals
involved in the care of cardiac patients.

5. Cardiac liaison nurses are ideally placed to identify and assess all eligible patients
in hospital, offer appropriate rehabilitation options, and provide discharge details to
the GP so that these patients are included in the practice based register for
coronary heart disease (CHD). They can liaise with other members of the
multidisciplinary team to ensure a holistic approach to patient care.

6. A designated staff member should be identified who carries overall responsibility for
coordinating cardiac rehabilitation in each Trust and a consultant cardiologist/
physician should hold clinical responsibility for cardiac rehabilitation.

7. Specific components of cardiac rehabilitation (e.g. supervision of exercise training,


dietary advice, and pharmacological advice) should be provided by suitably trained
and qualified staff.

8. Cardiac liaison nurses can provide integrated care and bridge the gap between the
primary and secondary settings to improve patient outcome.

9. Improvement in meeting secondary prevention goals may be achieved by integrating


cardiac rehabilitation services with secondary prevention clinics in primary care and
the collaborative working of nurses, pharmacists and general practitioners.

10. A system for identifying patients with characteristics, known to be associated with a
low uptake of cardiac rehabilitation, should be put in place to enhance uptake of
cardiac rehabilitation and should be audited.

11. Trusts should agree, implement and audit a detailed plan and protocol for identifying,
treating and following patients enrolled in the cardiac rehabilitation programme.

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MILESTONES FOR CREST GUIDELINES ON CARDIAC REHABILITATION

In addition to these recommendations the expert panel agreed the milestones that should
be attained for the provision of cardiac rehabilitation in Northern Ireland.

Milestone 1
Within six months:

Every cardiac rehabilitation service (whether hospital or community based) should have an
agreed protocol for the identification, assessment and management of patients post-
myocardial infarction, post-coronary revascularisation and selected patients with chronic
heart failure and stable angina.

Milestone 2
Within a further 12 months:

Every cardiac rehabilitation service should have, for all patients on their register, clinical
audit data no more than 18 months old covering the following areas:

• Percentage of patients discharged from hospital with a primary diagnosis of


myocardial infarction or post-coronary revascularisation with documentation that
phase 1 cardiac rehabilitation has been provided.

• Percentage of patients discharged from hospital with a primary diagnosis of


myocardial infarction or post-coronary revascularisation with documentation that
phase 2 cardiac rehabilitation has been provided, whether by telephone call,
outpatient appointment or home visit. Data should include age, gender and race.

• Percentage of patients discharged from hospital with a primary diagnosis of


myocardial infarction or post-coronary revascularisation invited to a phase 3
cardiac rehabilitation programme. Data should include age, gender and race.

• Percentage of patients invited to a phase 3 cardiac rehabilitation programme who


subsequently complete 50% or more of the programme. Data should include age,
gender and race.

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Chapter 1

INTRODUCTION

General Background

Cardiac disease is the leading cause of death in Northern Ireland and is the leading cause
of hospitalisation for both men and women. Cardiac rehabilitation programmes are
recognised as a way to enhance recovery following acute cardiac events and encourage
behaviour aimed at the secondary prevention of coronary artery disease. There are many
definitions of cardiac rehabilitation. The key elements of cardiac rehabilitation are contained
in the definition produced by the Scottish Intercollegiate Guidelines Network (SIGN):
“Cardiac rehabilitation is a process by which patients with cardiac disease, in partnership
with a multidisciplinary team of health professionals are encouraged and supported to
achieve and maintain optimal physical and psychological health”1. The key elements
included in most comprehensive rehabilitation programmes are:

• Education and risk factor management


• Exercise intervention
• Psychological interventions

The relative emphasis placed on each of these three elements differs in individual cardiac
rehabilitation programmes but it is widely agreed that the exercise training should form the
basis of cardiac rehabilitation provision.

A proposed pathway for cardiac rehabilitation is shown in Appendix 1.

“The Four Phases of Cardiac Rehabilitation”

Four phases of cardiac rehabilitation were defined by the British Association of Cardiac
Rehabilitation (BACR) and endorsed by the National Service Framework (NSF) for CHD in
England and Wales and SIGN for Scotland1,2. Each stage recognises different components
of care.

Phase 1

This phase occurs before discharge from hospital. During this phase reassurance and
education, correction of cardiac misconceptions, risk factor assessment, mobilisation and
discharge planning are the key elements.

Phase 2

This is the immediate post-discharge period and reinforces the information previously
supplied in phase 1. In this phase, support can be provided by home visiting, telephone
contact or by supervised use of The Heart Manual3. The Heart Manual is a self-help
programme for patients recovering from an acute coronary event that has been shown to
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reduce anxiety, depression and hospital readmission rate.

Phase 3

This phase incorporates elements of the early post-discharge period including education,
risk factor assessment, and correction of cardiac misconceptions plus structured exercise
sessions to meet the assessed needs of individual patients. This can be undertaken in the
hospital or community setting and employs a menu-based approach to tailor the delivery of
services to the individual. Patients who are unable to take part in formal exercise should
receive phase 3 education and advice on appropriate activities.

Phase 4

This phase involves the long term maintenance of physical activity and lifestyle change. The
evidence suggests that both components need to be sustained for cardiac benefits to
continue.

Cardiac Rehabilitation Programmes in Northern Ireland

The NSF for England and Wales standard for cardiac rehabilitation states that NHS Trusts
“should put in place agreed protocols / systems of care so that, prior to leaving hospital,
patients suffering from CHD have been invited to participate in a multidisciplinary
programme of secondary prevention and cardiac rehabilitation”. The aim of the programme
will be to reduce their risk of subsequent cardiac problems and to promote the return to a
full and normal life. Provision of cardiac rehabilitation services in Northern Ireland varies
from Trust to Trust depending on funding. These guidelines are an attempt to standardise
the provision of cardiac rehabilitation services throughout Northern Ireland.

The provision of a cardiac rehabilitation service for all eligible patients throughout Northern
Ireland is clearly desirable for health and economic reasons. It is recognised that only a
minority of eligible patients participate in cardiac rehabilitation services with women and
elderly patients less likely to be invited to attend programmes. The barriers to attendance
in the programmes are well recognised and include social deprivation, level of education
and negative attitudes towards rehabilitation from partners and families. The aim of this
document is to emphasise and promote the importance of cardiac rehabilitation and
address the issues that represent barriers to participation in cardiac rehabilitation
programmes. In particular, provision of outreach classes in health and community centres
to increase the uptake in rural areas may be especially beneficial in the Northern Ireland
context.

Appendix 2 shows the British Heart Foundation (BHF) / BACR data set record form for
cardiac rehabilitation.

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Chapter 2

EDUCATIONAL AND PSYCHOLOGICAL INTERVENTIONS

Cardiac rehabilitation describes a process which embraces different approaches to helping


individuals with cardiovascular disease return to as normal a life as possible and reduce the
risk of further cardiac events. It represents a structured programme that should be
incorporated as part of the care package for every cardiac patient. Patients should be able
to access services according to need and a menu-based approach to tailor the delivery of
services on an individual basis is advocated1.

The information provided should be clear, concise and based on individual need. The
educational approach should be based upon adult learning principles, be relevant to the
individual, involve dialogue, engage patients to be involved in the process, use visual aids
to support verbal instruction and allow for feedback and reinforcement1,2. Currently patient
education and psychological support is offered. However if this is not modelled on any
proven educational or behavioural principle then its effectiveness may be limited.

ASPECTS OF EDUCATION

One of the most common concerns for patients recovering from a cardiac event is their
ability to return to normal activity. With an ageing population and the increasing shift of
coronary syndromes from acute fatal events to a chronic disease state there is a growing
need for services that help patients improve their quality of life, increase functional capacity
and decrease disability.

Smoking

Smoking is one of the major modifiable risk factors for cardiovascular disease. Cigarette
smoking is responsible for about 17% of deaths from CHD3. Stopping individuals from
smoking represents the best and most cost effective way of improving health outcomes.
The risk of death from a myocardial infarction is reduced by 50% within 2 years of quitting4,5.
Brief intervention from a doctor/nurse or pharmacist can be highly effective in helping
patients to stop smoking6,7. The National Institute for Health and Clinical Excellence (NICE)
suggests that combining pharmacological treatment with advice and behavioural support
has been shown to be the most effective way to help smokers quit and that nicotine
replacement therapy (NRT) and the use of bupropion is a cost effective intervention in terms
of life years gained8, although side effects may limit use.

Hypertension

High blood pressure is one of the most preventable causes of premature morbidity and
mortality in developed and developing countries. In non-diabetic populations with
hypertension, optimal BP treatment goals are; SBP <140mmHg and DBP <85mmHg. In
diabetic patients with hypertension these goals are lower; SBP<130mmHg and DBP
<80mmHg9. A combination of lifestyle and drug therapy measures is recommended.
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Lifestyle measures include weight reduction, reduced salt intake, limited alcohol
consumption, increased physical activity, increased fruit and vegetable intake and reduced
total fat and saturated fat intake. Drug treatments are covered elsewhere in the guidelines.

Healthy Eating
The British Dietetic Association has recently updated their evidence based guidelines on
diet in secondary prevention of cardiovascular disease10. These guidelines advise a
Mediterranean diet which includes:

• Increased omega-3 fat intake (from dietary or supplemental fish oils)


• Increased intake of fruit and vegetables (at least five portions a day)
• Reduction in saturated fats and total or partial replacement by unsaturated fats
(rapeseed or olive oil)
• Reduction in processed foods

Alcohol
Recent research suggests that modest alcohol consumption (1 to 2 units / day) can provide
cardiovascular protection. In general, alcohol consumption should be restricted to these
moderate levels, given the myocardial depressant properties of alcohol11. Heavier
consumption of alcohol increases the prevalence of hypertension and the risk of
cerebrovascular disease. Heavy drinking increases the risk of sudden death12.

Serum Lipids
Serum cholesterol and LDL cholesterol continue to be risk factors for recurrent CHD events
after MI13. A full lipid profile should be recorded for each patient. Since the publication of the
4S study in 1994, the CARE and LIPID studies have confirmed that in patients with known
coronary disease treatment with statins reduces non fatal and fatal event rates by 23% and
33%14. The Heart Protection Study indicates that statin therapy is effective at all baseline
levels of serum cholesterol. However the full lipid profile may indicate the need for other
drug therapies in combination with statins or on their own. Patients should be aware that
this may be a long term therapy. Dietary advice should be given to all patients.

Diabetes
Diabetic patients should receive education regarding the need for good glycaemic control,
target blood pressure and lipids to reduce the risk of further cardiac events. In Type 1
diabetes glucose control requires appropriate insulin therapy and concomitant professional
dietary advice. In Type 2 diabetes, professional dietary advice, weight reduction and
increased physical activity should be incorporated in the treatment plan. Drug treatment is
added if these measures do not achieve excellent glucose control15.

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Advice Regarding Medication


Education and advice regarding medication administration is essential to improve
compliance. The health care professional should advise the patient regarding the name,
dose, timing and route of administration. Desired effects and potential side effects should
be discussed. The importance of adherence to therapeutic regimen should be emphasised.
Patients should be advised to contact their health care professional if they have side effects
from the medication.

Physical Activity
A sedentary lifestyle is associated with an increased risk of cardiovascular disease.
Maintenance of regular physical activity and good physical fitness protects against
cardiovascular disease16,17.

Regular aerobic exercise has favourable effects on body weight, plasma lipids, blood
pressure, glucose tolerance and insulin sensitivity. Furthermore exercise has favourable
psychological effects. Exercise regimens need not be intensive to bring benefits, but must
be sustained.

Sexual Activity
Many cardiac patients are concerned about resuming sexual relations. Some patients worry
that sexual activity will put too much strain on the heart. Partners of heart patients often
worry about these issues even more so than the patient. As a result of these concerns,
many couples are reluctant to resume sexual activity.

There are no definitive guidelines, but if patients are able to walk one mile or climb two
flights of stairs without symptoms it is generally safe to return to sexual activity. This equates
to 5-6 Mets of energy expenditure. General advice includes the avoidance of sex in stressful
situations, in an uncomfortable environment or with an unfamiliar partner18. However,
specific recommendations for resuming sexual relations depend on a number of factors,
including the degree of residual heart function.

Erectile dysfunction in cardiac patients is extremely common and occurs in 50-75% of


patients. All current available treatment for erectile failure is suitable for a cardiovascular
patient and, if used according to the instructions, does not increase the cardiovascular risk18.

Driving
Most people are permitted to drive after 4 weeks following a myocardial infarction and 4-6
weeks following cardiac surgery. After a non ST elevation myocardial infarction driving may
recommence 1 week after successful angioplasty, if no other disqualifying condition exists.
Driving may resume 1 week following percutaneous coronary intervention (PCI). For
patients with angina, driving may recommence when satisfactory symptom control is
achieved19.

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Advice for group 2 license holders is more stringent and details are available from the Driver
and Vehicle Licensing Northern Ireland (DVLNI). As the guidelines are constantly updated,
it is advised that the health professional refers to current DVLNI guidelines. It is the patient’s
responsibility to inform the DVLNI of their cardiac condition.

Flying

Patients are advised not to fly for 2-3 weeks post-myocardial infarction, 3-5 days post-
angioplasty, 10-14 days following cardiac surgery. Long haul flights are generally not
advised for 3-6 months20. Airlines usually only request medical clearance when fitness to
travel is in doubt21.

Return to Work
Patients with an uncomplicated recovery from a myocardial infarction and who have a
sedentary job may be able to return to work within 6 weeks. Those with manual jobs are
commonly advised not to return to work for 8-12 weeks22. In practice, discussion should take
place between the patient and the multidisciplinary team prior to return to work. An
increasing trend is for the earlier return to work especially following an uncomplicated
myocardial infarction.

Depression - Psychological Adjustment


Poor psychological adjustment is predictive of subsequent mortality but is not related to the
severity of the cardiac illness. Depression is associated with increased mortality in cardiac
patients especially in post-myocardial infarction and unstable angina patients. Depression
can also interfere with and decrease the effectiveness of secondary prevention
interventions to reduce cardiovascular disease. All members of the multidisciplinary team
need to be alert to the signs and symptoms of depression in patients with cardiovascular
disease.

Anxiety
High levels of anxiety may have an adverse effect on outcome22,23. Anxiety is generally at its
highest during the first few hours after myocardial infarction, reducing as the patient’s
condition is stabilised. These levels may rise again prior to discharge. This anxiety can be
reduced by providing information and advice on how to manage their condition post-
discharge.

Psychological Interventions
Psychological distress and poor social support are known to be powerful predictors of
outcome following an acute coronary event, independent of the degree of physical
impairment1. Psychological distress is an important predictor of rehospitalisation. Costs
following a cardiac event and total health care costs are linked to anxiety and depression.
The prevalence of depression after an acute cardiac event ranges from 15%-45%1.
Depression is associated with a 3-4 fold increase in cardiac mortality and is predictive of
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poor symptomatic and functional outcome at 3 and 12 months. High levels of anxiety have
also been shown to have an adverse effect on outcome in the inpatient setting and during
longer term follow up1.

Specific psychological challenges for CHD patients include the experience of a frightening
life threatening event, the prospect of continued symptoms, reduced life expectancy, the
fear of a future event and the prospect of family or a partner being left alone. They also
include threats to employment and financial status and of being treated differently by other
people24, the need to take medications, the prospects of possible medication side effects
and lifestyle changes in relation to smoking, diet and activity. Although the details of chronic
illness management will depend on the illness in question, many of the principles of
effective management are common to all chronic conditions24.

Most of the day to day responsibilities for the care of chronic illness fall on patients and their
families. Medical care must be delivered in collaboration with patients and their families, and
to enable patients to play an active role in their care and improve their knowledge and self
management skills. The common elements of an effective chronic illness management
programme include collaboration between service providers and patients, a personalised
written care plan, tailored education in self management, planned follow up, monitoring of
outcome and adherence to treatment, targeted use of specialist consultation of referral and
protocols for stepped care24. These principles are embodied in the United Kingdom “expert
patient programme”: the expert patient: a new approach to chronic disease management for
the 21st century25.

Although psychological interventions have been diverse in nature and incompletely


described in the literature meta-analysis suggests that intervention can result in significant
reductions in morbidity and mortality post-myocardial infarction. No consensus exists on the
most appropriate instrument for measurement of psychological wellbeing or the timing of
administration but SIGN has recommended that screening for anxiety and depression
should take place at discharge, 6-12 weeks post event and be repeated thereafter if
appropriate1.

Behavioural Interventions

Many patients have some idea about what they should be doing but have problems
deciding how to translate the health messages into practical strategies to improve health
outcomes1. Achieving behaviour change is not easy and an understanding of the principles
of behaviour change is essential. There are many models and theories that have been
shown to be effective in achieving behaviour change. Not all health professionals will be
trained in the psychological principles of behaviour change and motivational interviewing,
that can be used in consultations with patients. It is important to be realistic and understand
that telling people what to do is not effective in altering behaviour1,2.

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Care needs to be taken in explaining the impact of certain behaviours in relation to health
and offering options for change without attributing blame or guilt. Advice needs to be
prioritised. Making lifestyle changes is difficult and it is important not to invite failure by
overburdening patients with advice. Simple instruction and consideration of cultural, social
and economical factors when giving advice is key. A positive approach that addresses the
major risk factors is most likely to succeed in producing favourable health outcomes.

Cardiac rehabilitation:

• Empowers the patient to make lifestyle changes to reduce some and


eliminate other risk factors
• Further increases the knowledge of their condition and addresses cardiac
misconceptions
• Enables the patient to resume their daily activities with confidence
• Assists the patient and their partner to attain psychological wellbeing
• Assists the patient to return to their employment where appropriate
• Promotes adherence to secondary prevention medication
• Provides a review of patients’ symptoms, clinical measurements and general
recovery

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Chapter 3

EXERCISE

The World Health Organisation’s (WHO), Global Strategy on Diet, Physical Activity and
Health26 indicates that:

• Physical inactivity is estimated to cause about 22% of ischaemic heart disease


• The risk of developing a cardiovascular disease increases by 1.5 times in people
who do not follow minimum physical activity recommendations

WHO states that regular physical activity not only reduces the risk of heart disease but also
improves glucose metabolism, reduces body fat, lowers blood pressure, improves
musculoskeletal health, controls body weight and reduces symptoms of depression.

A Cochrane review27 concluded that exercise-only cardiac rehabilitation reduced all-cause


mortality by 27% and cardiac mortality by 31%. An updated meta-analysis on exercise
based cardiac rehabilitation programmes for coronary artery disease by the Canadian Co-
ordinating Office for Health Technology Assessment confirmed the earlier findings of the
Cochrane Review28. Exercise based cardiac rehabilitation was responsible for relative risk
reduction in all-cause mortality of 24%, and cardiac mortality of 23%. Taking the ‘usual care’
mortality as the baseline risk, the data suggest that 66 and 49 patients need to receive
exercise based cardiac rehabilitation to prevent 1 overall death and 1 cardiac death
respectively, over an average of 28 months follow up. This estimate compares favourably
with the numbers needed to treat per year from all-cause mortality of accepted / standard
coronary artery disease secondary prevention practices such as beta-blocker therapy
post-MI (NNT=84) anti platelet therapy post-MI (NNT=306), and statin therapy (NNT=11 to
56). Importantly, there was no statistical evidence of a difference in treatment effect
between the time periods of the meta-analysis. This would indicate that the beneficial
effects of cardiac rehabilitation on mortality appear to have been retained even with the
advent of new treatments and technologies. A further recent study29 found that not only was
participation in cardiac rehabilitation associated with decreased mortality after MI but also
with lower risk of recurrent MI.

Ades et al30 analysed baseline physical functioning in a population of patients with CHD
entering a cardiac rehabilitation programme and determined the subsequent response of
physical function score to exercise rehabilitation. They found that physical function score
increased substantially (+22%) along with increases in peak VO 2 (+16%), peak exercise
capacity (+50%), leg strength (+28%) and upper body strength (+17%), and a decrease in
depression score (-54%). Patients with the lowest baseline physical function score were
the most likely to show an improvement in this measure after rehabilitation.

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Assessment Before Exercise Training


The majority of patients with stable cardiac disease will benefit from a prescribed exercise
programme. Those patients deemed unstable would be excluded from exercise training.

Exercise should be delivered by experienced staff with training in exercise physiology and
prescription.

Prior to participation in exercise training patients will be assessed and risk stratified into low,
medium and high risk categories using one of the recognised classifications such as the
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) as
recommended by American College of Sports Medicine31.

• Clinical risk stratification is sufficient for low to moderate risk patients undergoing
low to moderate intensity exercise1.

• Exercise testing and echocardiography are recommended for high risk patients
and/or high intensity exercise training (and to assess residual ischaemia and
ventricular function where appropriate)1.

• Functional exercise capacity should be evaluated before and on completion of


exercise testing using a valid and reliable measure such as the Shuttle Walking
Test 1,32.

Exercise Content

All sessions should include:

• Warm-up
• Conditioning phase
• Cool-down
• Relaxation

Warm-Up

The warm-up period should include graduated low intensity aerobic exercise and short
dynamic stretches to increase myocardial blood supply, soft tissue flexibility and mobilise
joints33. A minimum of 15 minutes should be allowed for warm-up34.

Conditioning Phase

All patients participate in a progressive exercise training programme, which is modified to


meet individual need.

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Frequency

Supervised exercise should be twice weekly for a minimum of 8 weeks1,2. In addition


patients should be given a home exercise programme.

Intensity

Low to moderate intensity exercise31,34 is most suitable to meet the needs of a broad range
of patient groups. Individual patients should be prescribed target heart rate ranges and/or
Borg rating of perceived exertion35 (Appendix 3) based on assessment and risk stratification.

Time

Optimum training effect is achieved with 20 – 30 minutes of continuous aerobic activity 31,33.

• Progression of conditioning phase depends on initial functional capacity,


age and health status.
• Interval type training may be more appropriate for more deconditioned
patients31.

Type

Aerobic type activities (such as cycling, walking) have been found to be most beneficial27,31.
Aerobic exercise should include simple repetitive movements of large muscle groups.

Monitoring

Exercise intensity should be monitored and modified using the Borg RPE scale and/or heart
rate monitoring.

• Limitations exist when each of these methods is used individually. Heart rate
response to exercise can be altered by medication and co-existing pathology.
• In addition RPE scores are subjective and have been shown to be underrated by
cardiac patients compared to age matched controls 36.

Cool-Down

The conditioning phase should be followed by a minimum of 10 minutes cool-down.


Cool-down should include low intensity exercise and muscle stretching.

• Patients should be supervised for a minimum of 15 minutes following cool-down


phase33.

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Resistance Training
Cardiac patients may require resistance training to facilitate a return to physically
demanding activities. This is only appropriate for low – moderate risk patients and should
not be introduced until 4–6 weeks of supervised aerobic exercise have been completed31.

Relaxation
Exercise sessions should be followed by a period of relaxation.

Long Term
By the end of phase 3 rehabilitation of all patients’ long term exercise plans are agreed and
arrangements should be made for transference of care37.

People with stable coronary disease should be encouraged to continue regular moderate
intensity aerobic exercise. Some people may devise their own exercise programmes, return
to previous sports, or use a home based exercise programme. Others prefer formal class
based cardiac exercise programmes.

Phase 4 is a community based activity which follows immediately after the completion of the
phase 3 programme. The key aim is long term compliance to exercise and thus the
programme must be enjoyable and convenient38. Regular supervised training sessions are
provided and exercise prescription is individualised for additional unsupervised physical
activity. Phase 4 provides a regular review of the patient’s progress, for which the exercise
prescription can be altered accordingly. In the case of deterioration in functional capacity, a
referral can be made back to the primary care team. Phase 4 exercise programmes are run
by suitably trained staff with the appropriate knowledge and skill to prescribe and deliver
safe and effective exercise. A phase 4 training course, which has been developed by BACR
supported by BHF, is available. Strong links have been formed between clinical specialists
and exercise professionals within this field of rehabilitation to ensure a high standard of care
for the cardiac patient.

The BACR have given the following guidelines for the delivery of phase 4:

Inclusion Criteria for Patients

• Significant improvement in functional capacity since MI/cardiac event


• Psychological adaptation to chronic disease
• Commitment to long term lifestyle change
• Ability to exercise according to prescription
• Ability to monitor and moderate exercise intensity
• Ability to recognise signs and symptoms of possible myocardial ischaemia
• Ability to identify goals in relation to risk factor modification

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Referral

• Patient has attended phase 3 and is assessed by the physiotherapist on completion


• A relevant referral form is completed
• Written consent should be gained from the patient for their discharge summary to be
made available to phase 4 staff

Exercise Prescription

• An individual exercise prescription is developed in partnership with the patient. This


will follow the same principles as phase 3
• Warm-up and cool-down will be included similar to phase 3
• All patients should be reassessed when there is any change from the initial
assessment

Health and Safety

Requirements for Phase 3 and 4

1. It is recommended that patients should not exercise if they are generally unwell,
symptomatic or clinically unstable on arrival e.g. if they present with:

• Fever and acute systemic illness


• Unresolved/unstable angina
• Resting blood pressure systolic>180mmHg and diastolic >100mmHg
• Significant unexplained drop in blood pressure
• Tachycardia >100 bpm
• New or recurrent symptoms of breathlessness, palpitations, dizziness
• Swelling of ankles or significant lethargy

If any of these signs or symptoms are present the patient should be seen by their general
practitioner and/or cardiologist39.

2. Prior to exercise patients should be fully inducted in safe use of all equipment.

3. All staff should be trained in basic life support procedures and regularly updated
according to local protocols.

4. Appropriate resuscitation equipment including a defibrillator, with at least one


member of staff trained in its use and advanced life support should be available at
every supervised exercise session.

5. Protocols for the management of medical emergencies must be available.

6. Rapid access to emergency services must be available e.g. crash team or


ambulance.

7. Equipment must be maintained on a regular basis.


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8. Venue must be suitable i.e. adequate space, temperature (65 – 72 0F,


18 – 23 0C), ventilation, humidity 65%.

9. Drinking water should be available.

STAFFING
Phase 3
Current guidelines recommend two trained staff should be present at all times during
exercise training with a patient to staff ratio of not more than 5:1.

Phase 4
In the absence of guidelines for staffing levels in phase 4, recommendations for phase 3
should be followed.

There is a perception that exercise training for cardiac patients is dangerous but if the above
safety issues are implemented, available data suggest that cardiac rehabilitation
programmes result in very few complications and the incidence of death is one per 1.3
million exercise hours39.

LOCATION
Phase 1
Hospital inpatient.

Phase 2

Early discharge period – support can be provided by home visits, telephone contact and by
supervised use of The Heart Manual.

Phase 3
Low to moderate intensity exercise training can be carried out in the hospital setting or
community (including non-health sector settings such as leisure centres), as long as agreed
standards are adhered to. Exercise training for high risk patients and for those who require
high intensity exercise should be hospital based or in a venue with full resuscitation
facilities.

Phase 4
Long term maintenance of physical activity and lifestyle changes in the community.

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Chapter 4
TARGET PATIENT GROUPS
While cardiac rehabilitation has been defined as relevant to all patients with heart disease
most of the research concerns middle-aged white males with a recent myocardial infarction.
There is an increasing body of evidence that the benefits of exercise rehabilitation extend
to other cardiac groups beyond low risk post-myocardial infarct patients. These include
patients post-coronary artery bypass grafting (CABG), post-angioplasty and patients with
angina pectoris. Unfortunately women and older patients continue to be underrepresented
in clinical trials. The percentage of females included in 1995 and before is 6.8% and post
1995 is 13.6%27. In respect of age, the mean age across trials 1995 and before is 54.4 years
and post 1995 is 56.7 years.

Post-Myocardial Infarction
It is in this patient group that the strongest evidence linking cardiac rehabilitation with
improved outcomes exists. Meta-analyses of randomised clinical trials showed that in both
exercise-only and comprehensive cardiac rehabilitation programmes, total mortality,
cardiovascular mortality and fatal reinfarction were significantly and substantially reduced 40-
42
. Comprehensive cardiac rehabilitation has also been shown to improve psychological
function43, return to work44 and biological risk factors 45.

Worldwide, the clinical presentation of myocardial infarction has been changing in recent
years. Increasing numbers of patients with small myocardial infarctions are being
diagnosed as a result of sensitive cardiac marker assays. Similarly, the number of patients
presenting with ST segment elevation myocardial infarction is falling46. In the Northern
Ireland population, most patients with myocardial infarction present without ST segment
elevation on the initial electrocardiogram.

Recommendations
Comprehensive cardiac rehabilitation is recommended for all patients following ST segment
and non ST segment elevation myocardial infarction.

Post-Coronary Revascularisation
Initial studies of the benefits of cardiac rehabilitation in this setting were predominantly
conducted in patients CABG. Within recent years however, the number of patients
undergoing CABG has been static while the number of patients undergoing PCI has been
increasing logarithmically. Currently approximately twice as many patients undergo PCI in
the United Kingdom compared with CABG47.

Proven beneficial effects of cardiac rehabilitation after CABG have included measures of
quality of life, return to work and cardiovascular risk factors48,49.

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After PCI, randomisation to an exercise based programme improved quality of life and
reduced cardiovascular events and the likelihood of readmission. No difference in
restenosis was observed50.

Recommendation

Comprehensive cardiac rehabilitation is recommended for patients who have undergone


coronary revascularisation including all patients who have had percutaneous coronary
revascularisation.

Congestive Heart Failure

Patients with congestive heart failure have been underrepresented in trials of cardiac
rehabilitation as well as in clinical cardiac rehabilitation programmes51. Nonetheless trials
that have addressed whether patients with heart failure benefited from exercise based
rehabilitation showed improvements in exercise capacity, quality of life, mortality and the
need for hospital admission52.

Separate comprehensive disease management programmes for heart failure have been
shown to reduce hospital attendance and to improve quality of life and medication
compliance53,54. Most of these programmes did not include an exercise component. Such
disease management programmes have been widely established throughout Northern
Ireland and have provided a major source of psychological as well as educational support
for patients with chronic heart failure.

Although patients with congestive heart failure may derive benefit from exercise based or
comprehensive cardiac rehabilitation, the evidence is less robust compared with patients
post-myocardial infarction and post-revascularisation42.

Recommendation

Patients with congestive heart failure may be suitable for cardiac rehabilitation
programmes, but this should only be undertaken when adequate provision has been made
to include all patients with recent myocardial infarction and recent coronary
revascularisation. Patients with congestive heart failure should not be excluded from
exercise based cardiac rehabilitation regimes if they are otherwise deemed suitable.

Stable Angina

In the setting of stable coronary artery disease, exercise based and comprehensive cardiac
rehabilitation programmes have shown improvements in exercise capacity and symptoms
as well as retarding progression of disease. Benefits have also been shown in terms of
quality of life and on cardiovascular risk factor status55,56 but not mortality or acute
cardiovascular events.
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Recommendation

Cardiac rehabilitation is not recommended for every patient with stable angina but may be
suitable for selected individuals with disabling symptoms.

Patients Post-Cardiac Transplantation or Post-Valve Surgery; Patients with


Congenital Heart Disease; Patients with Implantable Cardioverter Defibrillators
(ICD's):

In each of these patient groups there is limited evidence to support the benefits of cardiac
rehabilitation57-60. In many cases the number of patients involved is small and it might be
counterproductive to target these patients as a group. Instead an individualised approach
should be taken as the need arises.

Many patients with ICD's will also fall into the categories of congestive heart failure,
previous myocardial infarction, previous revascularisation or stable coronary artery disease.
It is recognised that patients with ICD's have some of the greatest psychological morbidity
of all patients with cardiovascular disease and individuals may benefit from the support
offered by a comprehensive or menu-based cardiac rehabilitation61.

Women, Older Patients and Ethnic Minorities

As with many other forms of treatment for cardiovascular disease, such patient groups have
often been underrepresented in cardiac rehabilitation trials and programmes62-64. There is no
reason to believe that these groups would benefit from cardiac rehabilitation programmes
to a lesser extent than other members of the target population.

Recommendation

Patients should not be excluded from cardiac rehabilitation programmes on the basis of
age, gender or ethnicity.

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Chapter 5

SECONDARY PREVENTION: USE OF MEDICATION

The ability to implement effective and appropriate secondary prevention to patients with
CHD is a challenge. Evidence shows that several interventions reduce the risk of recurrent
disease and death. The responsibility for secondary prevention straddles primary and
secondary care and two recent government initiatives support implementations in both
settings:

1. The NSF for CHD advocates the use of registers for patients with CHD to facilitate
long term follow up and it also sets standards / milestones for secondary
prevention.
2. The General Medical Services (GMS) contract encourages primary care teams to
implement evidence based care.

Drugs and Secondary Prevention


The benefits of secondary prevention medication pre and post cardiac event have been
demonstrated in large randomised trials that have resulted in publication of national
guidelines for the management of dyslipidaemias, hypertension, obesity, smoking
cessation, diabetes mellitus and most recently, heart failure.

Anti-Platelet Therapy
Aspirin has become a standard of care for secondary prevention in post-MI patients. In
patients with acute ST elevation myocardial infarction, 160mg of aspirin reduced 35 day
mortality by 23%, compared to a 25% reduction with streptokinase. Together the
interventions displayed a synergistic effect. The benefit was evident in all groups, including
the elderly65. The four-year mortality follow up data showed a significant long term benefit
among those allocated aspirin. In addition to reducing mortality, aspirin also reduced the
incidence of strokes and reinfarction. A recent meta-analysis supported the long term use
of low dose aspirin (75-150mg daily) in secondary prevention66. Higher doses are no more
effective and are associated with gastrotoxicity.

Clopidogrel 75mg is an effective but expensive alternative in patients with genuine allergy
or proven gastric intolerance to aspirin67. The addition of clopidogrel to aspirin patients with
acute coronary syndromes, with or without ST segment elevation, is beneficial in preventing
future coronary events68,69.

Beta-Blockers
Beta-blockers reduce the risk of death, non fatal recurrent myocardial infarction and sudden
cardiac death and are recommended in national guidelines70,71. The use of beta-blockers as
a coronary prevention measure remains sub-optimal72.

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Beta-blockers are often implicated in producing adverse events. A recent review showed no
significant increased risk of depression and small increases in the risk of sexual dysfunction
and fatigue73. The contraindication of beta-blockers in patients with asthma and chronic
obstructive pulmonary disease (COPD) has also been questioned by a Cochrane Review
that indicated they do not produce adverse respiratory effects in patients with mild to
moderate airways disease74. Care must be taken but the drugs should not necessarily be
withheld. A study of 46,000 survivors of MI with asthma or COPD showed a 40% reduction
in mortality with beta-blockers, with benefits extending to the elderly and those with heart
failure. Beta-blockers also appear to have little effect on the peripheral circulation in patients
with less severe forms of peripheral vascular disease (PVD)75.

ACE Inhibitors

Angiotensin converting enzyme ACE inhibitors after acute myocardial infarction have been
recommended for patients with signs of heart failure or confirmed left ventricular
dysfunction76.

Recent trials have assessed the effects of ACE inhibition in “low risk” patients with stable
coronary artery disease, but no clinical heart failure77,78. One trial showed a reduction in
cardiovascular end-points with ACE inhibition while the other trial was essentially negative.
Importantly there was little difference in cardiovascular events documented in the placebo
arms in each of these studies. ACE inhibitors should be endorsed post-MI and in patients
with impaired left ventricular systolic function and congestive heart failure. The use of ACE
inhibition is more contentious in stable CHD. Angiotensin II antagonists have been
advocated when patients are intolerant to ACE inhibitors79.

HMG-CoA Reductase Inhibitors

Statins decrease the risk of coronary events and all-cause mortality in patients after a
myocardial infarct80. The benefits apply to both sexes, older individuals and the relative
reduction in risk is independent of initial cholesterol concentrations81.

Statins should be prescribed to survivors of a myocardial infarction irrespective of initial


cholesterol concentration. Compliance with therapy can be a problem with a recent study
indicating a 60% non-adherence rate in elderly patients 2 years after a coronary event82.

A recent cohort study examined the effects of combinations of drugs in the secondary
prevention of all-cause mortality in patients with ischaemic heart disease. Combinations of
statins, aspirin and beta-blockers improved survival in these high risk patients but the
addition of an angiotensin converting enzyme inhibitor conferred no additional benefit83.

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Chapter 6

CARDIAC REHABILITATION IN PRIMARY CARE

Patient Held Record

Following an acute coronary event and the early stages of cardiac rehabilitation, continuing
provision of follow up care is dependent on a patient’s involvement with primary and
community services. Ongoing medical care, cardiac rehabilitation and secondary
prevention of CHD often overlap.3 A seamless transition between hospital provision of
cardiac rehabilitation and the continuing support provided by primary care practitioners
requires good communication between all involved in the care of patients with CHD. One
suggestion to enhance communication and involve patients in their own management is the
introduction of a patient held record. Such a record should include details of the patient’s
clinical diagnosis, hospital procedures, pharmacological treatments, cardiac rehabilitation
programme and plans for hospital review. Contacts with all health professionals should be
indicated in this record and it should allow tracking of changes in lifestyle, risk factors and
medication.

Continuing Care

Evidence suggests that continued support is necessary for patients to maintain healthy
lifestyles and continue exercise programmes84. Whilst the main responsibility for compliance
with optimal management advice lies with the individual patient, this should be facilitated in
primary care. Practitioners should ensure that their patients are aware of the need to
continue leading a healthy lifestyle and adhering to therapeutic regimens in order to
maintain benefit for the reduction of risk of subsequent cardiac events. Provision of
secondary prevention of CHD is effective85-87 and in primary care it is enhanced by organised
programmes involving nurse-led clinics88,89. A proactive approach to monitoring patients’
progress is recommended and the value of specialist care for patients with complicated
disease must be acknowledged3.

Disadvantaged Groups

Little information has been published regarding levels of uptake of cardiac rehabilitation
services across Northern Ireland. Reports from other parts of the United Kingdom indicate
that those who are least likely to participate in cardiac rehabilitation include socially
disadvantaged groups, women and older people90-92. Appropriate resources should be made
available to primary care practitioners to enable them to assess the needs of these
individuals and address their concerns, doing so would enhance the likelihood of successful
involvement in cardiac rehabilitation93,94.

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Identifying Needs

There is evidence of a need to tailor services appropriately to the needs of individuals95,96.


Failure to take up cardiac rehabilitation contributes to a widening gap in health status across
the social classes. Improving access to cardiac rehabilitation should increase participation
rates, reduce health inequality97, increase life expectancy and increase the number of years
people are free from disability, which are goals of the Investing for Health Strategy in
Northern Ireland95. It is important that further information should be obtained about the
needs of individuals and of the needs and priorities of local communities. Primary care
practitioners are well placed to help identify these.

Multidisciplinary Communication

Good communications between all professionals involved in cardiac rehabilitation can help
alleviate suffering and concern, not only for the patients involved but also for their relatives
and friends. The primary care team, with detailed knowledge of an individual’s social and
medical background, includes professionals who are likely to be aware of the implications
of CHD for both the individual and their family. Accurate information should be shared
between the various members of multidisciplinary teams across both primary and
secondary care to help enable the early and appropriate involvement of family members in
rehabilitation programmes3.

Across the United Kingdom there is wide variation in the content of cardiac rehabilitation
programmes offered to patients93,98. For cardiac rehabilitation to be provided in an effective
manner across Northern Ireland there should be a co-ordinated communication network
between all providers of this care. In a recent project a cardiac liaison nurse was employed
to develop an integrated and seamless system for cardiac rehabilitation; patients were
offered a choice of home or hospital based rehabilitation and the report concluded that
integration of home and hospital based services improved the provision of secondary
prevention of CHD 99.

Cost Implications

There are cost implications100 in providing cardiac rehabilitation, both in respect of staff
required (which may include nurses, doctors, physiotherapists, dieticians, pharmacists,
psychologists, and audit and clerical staff) and resource materials, for example, in respect
of smoking cessation services. Good communication between staff involved in provision of
care should avoid unnecessary duplication of provision and promote best practice. It must
be recognised that increased uptake of cardiac rehabilitation may result in increased
prescribing costs within primary care and appropriate resources should be identified to
support this.

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Community Support

Within the community patients may find support from self-help groups but not all patients
may wish to attend groups or discuss their health with other people. The importance of
tailoring services to individuals’ personal needs must not be forgotten. For patients who do
not feel empowered to participate in formal rehabilitation programmes, opportunities for
promoting their health lie largely with primary care practitioners. There are, however, often
difficulties in engaging such patients. Alongside the limitations of health services in
improving the health of such individuals the potential for help from other sources of social
and community support in promoting physical and psychosocial health must be recognised.

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Chapter 7
IMPLEMENTATION AND AUDIT / DATA COLLECTION
The standards recommended for use are those of the NSF for CHD. Trusts should put in
place protocols/systems of care so that, prior to leaving hospital, people admitted to hospital
suffering from CHD will have been invited to participate in a multidisciplinary programme of
secondary prevention and cardiac rehabilitation. The aim of the programme will be to
reduce their risk of subsequent cardiac problems and to promote their return to a full and
normal life.

Implementation of the guidelines is the responsibility of each Trust and is an essential part
of clinical governance.

Mechanisms should be put in place to ensure that the care provided is reviewed against the
guideline recommendations and the reasons for any differences assessed and, where
appropriate, addressed.

The initial focus should be on ensuring comprehensive and high quality services post-MI
and for those undergoing revascularisation.

Equality is an important consideration. In particular, the inclusion of women, older people,


ethnic minorities and patients with a disability should be addressed.

Monitoring and Evaluation of the Programme


Trusts should carry out clinical audit using routinely collected data.

Long term goals can be monitored by observing changes over time in incidence and
mortality from CHD.

Resource Implications of Implementing the Guidelines


The SIGN Cardiac Rehabilitation Guidelines for Scotland outline the resource implication
for implementing their guidelines (www.sign.co.uk). This CREST document has adopted the
economic evaluations utilised by SIGN.

The SIGN review of the evidence available estimated that the cost per life year gained from
cardiac rehabilitation was £6,400 and the cost per QALY (Quality Adjusted Life Year) was
£2,700 (1999 prices). Cardiac rehabilitation was found to compare favourably in cost
effectiveness terms with other cardiovascular interventions such as treatment of
hypertension, hyperlipidaemia, use of thrombolytics for inferior myocardial infarction and
angioplasty for patients with severe angina and single vessel disease.

There has been minimal investment in the development of publicly funded services, with
much of the funding, to date, being derived from charitable sources. The Big Lottery is
currently funding a three-year cardiac rehabilitation project in the EHSSB area (2004–07).
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The economic implications of delivering a high quality cardiac rehabilitation service will vary
depending on how the service is to be delivered, and the associated quality standards, who
the service is to be delivered to and where it is to be delivered. The existing provision of
funded services and the associated costs of staff and facilities will also influence the
economic implications. The fact that much of the current funding is not from mainstream
recurrent funds complicates the analysis.

There will be potential economic effects on prescribing budgets, primary care costs, and
from potential demands on limited services such as psychology, dietetics, physiotherapy,
and pharmacy. The need for audit and review of services will have resource implications for
clinical audit departments in Trusts.

There are also potential economic consequences for patients who will need to attend
sessions such as the loss of their time in alternative economic or caring activities, the cost
of prescriptions and any shoes or clothing they might require for participation.

For leisure service providers there will be a potential new market of clients for phase 4
programmes but there will be associated economic consequences of training staff and
developing accredited programmes.

The SIGN guidelines developed an estimate of the staff resources required to deliver
multidisciplinary cardiac rehabilitation to 500 patients with a wide range of needs.

The following assumptions were made for their calculations:

• The 500 patients will be a mixture of post-MI, revascularisation, angina, and heart
failure patients, with post-MI and revascularisation patients predominating.

• All patients will be suitable for some form of rehabilitation, with 250 (50%) opting for
group exercise training, 150 (30%) preferring a home based programme, and 100
(20%) not interested in any rehabilitation.

• Patients attending phase 3 group classes and those who undertake home based
programmes will each have a formal assessment of functional capacity at the
beginning and the end of their programmes.

• Group exercise classes will run twice a week for eight weeks and will accommodate
12-15 patients at any one time. It follows that six separate classes will be required
each week.

• The population served will be predominantly urban, arbitrarily defined as 80% of


patients living within 10 miles of a district general or teaching hospital. For Health
Boards with a significant rural population, costs are likely to be higher because of
smaller class sizes and longer travelling times.
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• The first point of contact for patients with psychological distress will be a nurse
therapist with training in cognitive behaviour therapy, rather than a clinical
psychologist. A smaller number of clinical psychologist hours will then be required to
help those patients whose anxiety or depression does not resolve with the advice
and treatment provided by their nurse therapists.

Staff costs for 500 patients using assumptions in SIGN guidelines and costs as of 1 April
2005 (subject to change under Agenda for Change)

Staff Costs WTE Total (including employer costs)

G Grade Nurse 3.0 99,096

Senior 1 Physiotherapist 2.0 65,360

Senior 1 Dietician 0.3 9,804

D Grade Pharmacist 0.2 8,124

Clinical Psychologist (Grade A) 0.2 9,760

Admin and Clerical (Grade 3) 0.5 8,323

Rural supplement 0.5 16,516


G Grade Nurse
TOTAL 216,983

Cost of 500 patients with rural supplement = £216,983


Cost of 500 patients without rural supplement = £200,467

In Northern Ireland there is minimal home based rehabilitation.

In 2003/04, the number of patients admitted to hospitals in Northern Ireland with CHD was
15,888.

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APPENDIX 1

PATHWAY FOR CARDIAC REHABILITATION

Admission with MI, or for PTCA patient identified patient recruited from
revascularisation after the intervention surgery waiting list for
‘prehabilitation’

patient identified from GP rehabilitation process patient recruited from


cardiac register by assessment of rapid access chest pain
community based rehabilitation needs by
specialist or liaison nurse rehab specialist - leading
(eg heart failure specialist to - discussion of needs
nurse, community cardiac and menu choices of GP referral, patient self
rehabilitation nurse) delivery methods referral

Examples of possible menu choices

Smoking cessation Nicotine Dietetics


Home based
clinic replacement

Individual exercise Community based Hospital based


Healthy living centre
prescription programme exercise programme

Psychology Stress management Phase 4 local gym Stress management

Reassess and make other


choices if necessary

Adapted from the Cardiac Rehabilitation Audit Project

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APPENDIX 2
BHF/BACR Data Set Record Form
Demographics (ethnic group by patient self completed questionnaire, as recorded for UK national census)
Name: NHS Number: Prog. Name:
Date of Birth: Postcode: Date of Death (if known):
Gender: Not Known Male Female Unspecified Mortality: alive deceased

Marital Status: Single Married Permanent partnership Divorced Widowed Unknown


White (British) White (Irish) White (other)
Mixed white/black Caribbean Mixed white/black African Mixed white/Asian Mixed other Indian
Pakistani Bangladeshi Other Asian Black Caribbean
Black African Black other Chinese Other Ethnic Group
Not stated

Initial Event (most recent event leading to referral to rehabilitation, dates, reasons for not attending programme)
Myocardial Infarction Acute Coronary Syndrome Bypass Surgery Angioplasty
Cardiac Arrest Angina Other Surgery Heart failure
Pacemaker ICD Congenital Heart Transplant
LV Assist Device Other Unknown

Date of Initiating Event: Date Referred: Date Invited to Join:


Agreed to Rehab Prog: Yes No Date Rehab Started: Date Completed:
Patient not interested/refused Ongoing investigation Too far to travel
Physical incapacity Returned to work Local exclusion criteria
Language Barrier Holidaymaker Mental incapacity No transport
Died Not referred Other
Unknown

Previous Events (any other acute events prior to the current reason for attending)
Myocardial Infarction Acute Coronary Syndrome Bypass Surgery
Angioplasty Cardiac Arrest Angina
Other Surgery Heart failure Pacemaker
ICD Congenital Heart Transplant
LV Assist Device Other Unknown

Comorbidity (from case notes or patient completed questionnaire)


Angina Arthritis (osteoarthritis) Cancer
Diabetes Rheumatism (rheumatoid arthritis) Stroke
Osteoporosis Chronic bronchitis Emphysema
Asthma AIDS Claudication
Chronic Back Problems Other Comorbid Complaint
Admin. (assessment number 1 = pre rehab, 2 = 12 weeks after starting rehab, 3= 12 months after starting)
Assessment Date: Assessment Number:
Rehabilitation Type: Home based Hospital based Community based Other
Risk Assessment: Low Moderate High Unknown Rehab Programme Completed: No Yes Partially Unknown
Percentage Completed: 0% 1-25% 26-50% 51-75% 76-99% 100%
Did not attend – unknown reason Returned to work Left this area Achieved aims
Planned/emergency intervention Too ill Died Other
Unknown

Menu / Sessions Attended / Onward Referral (record of the elements of rehab patient experienced, 50% attendance required to qualify)
Group exercise classes Individual exercise programme Home exercise plan
Lifestyle education – written Lifestyle education – talks/video Dietary – group class
Dietary - individual Relaxation training Psychological – group talk
Psychological – individual counsellor Individual clinical psychology OT groups sessions
OT individual referral Vocational assessment Heart manual
Papworth manual Angina plan Other home based programme
Home visits Other
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Drugs (case record or patient self completion questionnaire)


Aspirin or other antiplatelet agent ACE inhibitor Beta Blocker Statin
Psychological (HAD) & Physical Activity (Hospital Anxiety & Depression Scale, Modified brief leisure time questionnaire, NSF question)
Anxiety Score: Depression Score: 1a. Vigorous: 1b. Moderate: 1c. Mild
2a. Often 2b. Sometimes 2c. Never/Rarely

Physical Activity – 30 min duration 5 times a week: Yes No

Qualify of Life (Dartmouth COOP charts and UK national Census data for economic activity)

Physical Fitness: Feelings: Daily Activities:


Social Activities: Pain: Change in Health:
Overall Health: Social Support: Quality of Life:
Employed full-time Employed part-time Self-employed full-time
Self-employed part-time Unemployed looking for work Gov. training course
Looking after family/home Retired Permanently sick/disabled
Temporarily sick or injured Student Other reasons
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APPENDIX 3

Borg Scale

Rating of Perceived Exertion (RPE) Rating Of Perceived Exertion (RPE)

BORG’S RPE 6-20 SCALE BORG’S CR-10 SCALE

6 No exertion at all 0 Nothing at all


7 Extremely light 0.3
8 0.5 Extremely weak / Just noticeable
9 Very light 1 Very weak
10 1.5
11 Light 2 Weak / Light
12 2.5
13 Somewhat hard 3 Moderate
14 4
15 Hard (heavy) 5 Strong / Heavy
16 6
17 Very hard 7 Very strong
18 8
19 Extremely hard 9
20 Maximal exertion 10 Extremely strong

44
ISBN1-903982-18-9

Executive Summary ISBN 1-903982-19-7