Cardiac Rehabilitation Introduction Heart failure is estimated to affect 4 to 5 million Americans, with 550,000 new cases reported annually. In the past 3 decades, both the incidence and prevalence of heart failure have increased. Factors that have contributed to this increase are the aging US population and improved survival rates in patients with cardiovascular disease due to advancements in diagnostic techniques and medical and surgical therapies. Background on Heart Disease! • Cardiovascular disease is the number one killer among all diseases in the United States of America. • Family genetics can be a predisposing factor. • Males have more risk for heart disease • Women after menopause lose cardiac protection due to non production estrogen . • African Americans, American Indians, Mexican Americans are at higher risk. What is Cardiac Rehabilitation? • It is defined as, “all measures used to help cardiac patients return to an active and satisfying life and to prevent re-ocurrence of cardiac events”. • Cardiac Rehabilitation includes exercise, education, and social and emotional support. • Rehabilitation can be hospital or home based. Barriers to Rehabilitation Lack of Knowledge Poor Motivation Insufficient understanding Lower perceived self-efficacy Forgetfulness, Decrease support from family and other care givers Cost Poor Patient referral by Nurses and Doctors Time conflict between work and rehabilitation program. Rehabilitation Outcome and Quality of Life • The benefits include psychological well being, reduction in mortality, improvement in quality of life, and lowering of hospital re-admission rates, with the prevention of reoccurrence of future cardiac events • Cardiac rehabilitation lowers the risk of death in survivors by 20-25% • Cardiac rehab also decreases the need for medication • Improves exercise tolerance, coronary risk factors, physiological well being and health related quality of life, as well as reducing long term mortality Complication due to Non- Rehabilitation • Reoccurrence of cardiac events • Re-hospitalization due to re-occurrence of cardiac event with high cost of treatment • Decreased quality of life • Increased need for medication • Increased risk of death • Increased risk for co-morbidity • Predisposition to blood clotting from stasis Standard Interventions • Cardiac rehab staff nurse will meet patient prior to discharge from hospital and address the rehabilitation program protocol. • In accordance with the American College of Sports Medicine guidelines for exercise prescription for rehabilitation ; rehabilitation consists of forty exercise sessions; 24 sessions (3/per week) endurance training on a cycle ergometer ( with 5 minute warm up) 20 min training with constant workload, 5 minute cool down, and 5 min post exercise monitoring. In addition 16, (2/per week) 1 hour sessions of stretching and flexibility exercises. Standard Interventions (Con’t) At discharge, patients receive risk factor management counseling, instructions on session procedures, and cardiovascular risk factor management during exercise. Patients also receive exercise prescriptions both home and hospital based, physical therapists are assigned for home visits to patients every other week. Information is also given to those patients who are in need of advice for smoking cessation, weigh loss in the overweight or obese, adequate physical activity, and lower dietary fat intake, in order to obtain optimal health benefits from engaging in positive health behavior. Goals for Rehabilitation Focus on 4 aspects of activities of daily living: i) Somatic goals – Teaching individuals to learn one’s optimal exercise limits ii) Social goals – helping individuals to reintegrate into family life with optimal reintegration regarding working, household, hobbies and leisure activities. Goals for Rehabilitation (Con’t) iii). Psychosocial goals – empowering individuals by evaluating anxiety levels and concerns towards cardiac exertion during exercise, that may lead to negative emotions. iv). Secondary prevention goals – helping individuals to modify risk behavior & reinforce compliance to therapy regimen Guidelines for Rehabilitation Being discharge Nurse ( Provide 1 on 1 consultation for patients) When discharging patients – Nurse will meet with patients (experimental group). Make sure patients are enrolled into an exercise program. Also contact rehab unit each day of exercise for patients’ performance update. Nurse will call patient twice before each exercise session to reassure and provide anticipatory guidance. Guidelines for Rehab (Con’t) Consider the age of the patient, and register patients in particular peer age group suitable for rehab ability & regimen thus increasing patients self esteem. Discharged Nurse Call patient 2 days before scheduled rehab ( to discuss with patients’ about their goals & outcomes reassurance, and to answer any questions or clear doubt) Guidelines for Rehab (Con’t) Give “advanced anticipatory guidelines” towards expectations including advantages, outcomes, side effects, possible complications, how to monitor their own pulse rates and maximum heart rates, and how to recognize symptoms of over-exertion (ex: muscle cramps, short of breath). Assess patient’s stress level, emotional status, and functional status every time the nurse calls (pre/post rehab sessions). Outcome measuring tools • Establish a baseline evaluation for cardiac rehabilitation. • vital signs, pulse ox • EKG • BMI • pulse ox with activities to monitor the need for oxygen. • Re-hospitalization do to reoccurrence of a cardiac event. • Establish daily patient journal to monitor patient impression of daily improvement and level of performance of ADL. • Pre, intra, post –echocardiogram to evaluate ejection fraction. Research Finding • Mortality rate caused by cardiovascular disease is 8.2% for patients who participate in cardiac rehabilitation program and patients not participating (control group) is 15.3% (Hedback, Perk, Hornblad, Ohlsson, 2001). • Percentage of patients who had a recurrent cardiac events was 18.4% in experimental group compared to 34.7% in the control group. (Hedback, Perk, Hornblad, Ohlsson, 2001). Research Finding (Con’t) • Only less than 25% of approximately 1 million myocardial patients each year actually enroll in cardiac rehabilitation program (Thomas, Miller, Lamendola, Berra, Hedback, Durstine, Haskell, 1996). • 12.7 % of patient are more likely to be referred to a cardiac rehabilitation program when seen by a cardiologist verses 6.2% of patient who are see by their primary physician (Barber, Stommel, Kroll, Holmes-Rovner, McIntosh, 2001). Conclusion Ensuring patients enrollment into cardiac rehabilitation program post myocardial event and ensuring participation in a rehab program by providing anticipatory guidance, monitoring improvement using measuring tools weekly for the first 6 weeks then monthly for one year, to show improvement in quality of life through increased endurance, return to work, increased self-esteem, and increase social and emotional integration into family life will be an area of research. References • Marchionni, N., Fattirolli, F., Fumagalli, S., Oldridge, N., Del Lungo, F., Morosi, L., Burgisser, C., & Masotti, G. (2003). Improved exercise tolerance and quality of with cardiac rehabilitation of older patients after myocardial infarction: Result of a random control trial. Journal of the American Heart Association, 107; 2201-2206. • Thomas, R. J., Miller, N. H., Lamendola, C., Berra, K., Hedback, B., & Durstine, J. L. (1996). National survey on gender differences in cardiac rehabilitation programs: Patient characteristics and enrollment patterns. Journal of Cardiac Rehabilitation, 16(2) 402-412. • Roblin, Douglas PhD; Diseker, Robert A. III MPH; Orenstein, Diane PhD; Wilder, Myrtle CNP, MPH; Eley, Melanie RN. (2004). Delivery of Outpatient Cardiac Rehabilitation in a Managed Care Organization. Journal of Cardiopulmonary Rehabilitation, 24(3), 157-164. References Con’t • Caulin-Glaser, Teresa MD, FACC; Blum, Michael MD, FACC; Schmeizl, Renae RN, BSN, BS; Prigerson, Holly G. PhD; Zaret, Barry MD, FACC; Maxure, Carolyn M. PhD. (2001). Gender Differences in Referral to Cardiac Rehabilitation Programs after Revascularization. Journal of Cardiopulmonary Rehabilitation, 21(1), 24-30. • Donker, Frank. (2000). Cardiac rehabilitation: a review of current developments. Clinical Psychology Review, 20 (7), 923-943. • Goble AJ, Worcester MUC. (1999). Best practice guidelines for cardiac rehabilitation and secondary prevention: a synopsis. Heart Research Centre. • Daoud, E. G., Dabir, R., Archambeau, M., Morady, F., & Strickberger, S. A. (2000). • Randomized, double-blind trial of simultaneous right and left atrial epicardial pacing for prevention of post-open heart surgery atrial fibrillation. Circulation. 102, 761-765. References Con’t • Barber, K., Stommel, M., Kroll, J., Holmes-Rovner, M., & McIntosh, B. (2001). Cardiac rehabilitation for community-based patients with myocardial infarction: Factors predicting discharge recommendation and participation. Journal of Clinical Epidemiology. 54(10), 1025-1030. • Hasnain,. D ,Philip,H.E & John, L.C (2004) Recent development in secondary prevention and cardiac rehabilitation after acute myocardial infarction. BMJ Publishing Group. 328, 693-697. • Kate,J.R.(2003) Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularization: design and rationale of the Birmingham rehabilitation uptake maximization study: a randomized controlled trial. BioMed Central Cardiovascular Disorders. 3 (10) p.1471- 2261 • Evenson, K.R., Johnson, A., & Aytur, S.A. (2006). Five-year Changes in North Carolina Outpatient Cardiac Rehabilitation. [Electronic Version]. Journal of Cardiopulmonary Rehabilitation, 26, 366-376. References Con’t • Mittag, O., China, C., Hoberg, E., Juers, E., Kolenda, K., Richardt, G., Maurischat, C., & Raspe, H. (2006). Outcomes of Cardiac Rehabilitiation with versus without Follow-up Intervention Rendered by Telephone (Luebeck Follow-up Trial): Overall and Gender- specific Effects. [Electronic Version]. International Journal of Rehabilitation Research, 29, 295-302. • Pierson, L. M., Norton, H. J., Herbert, W. G., Pierson, M. E., Ramp, W. K., Kiebzak, G. M., Fedor, J. M., Cook, J. W. (2003). Recovery of self-reported functional capacity after coronary artery bypass surgery. Chest, 123(5), pp.1367-1374. • Goodman, J. M., Pallandi, D. V., Reading, J. R.; Plyley, M. J.; Liu, P. P., Kavanagh, T. (1999). Central and peripheral adaptations after 12 weeks of exercise training in post-coronary artery bypass surgery patients. Journal of Cardiopulmonary rehabilitation, 19(3), pp. 144-150. References Con’t • Evenson, K.R., Johnson, A., & Aytur, S.A. (2006). Five-year Changes in North Carolina Outpatient Cardiac Rehabilitation. [Electronic Version]. Journal of Cardiopulmonary Rehabilitation, 26, 366-376. • Mittag, O., China, C., Hoberg, E., Juers, E., Kolenda, K., Richardt, G., Maurischat, C., & Raspe, H. (2006). Outcomes of Cardiac Rehabilitiation with versus without Follow-up Intervention Rendered by Telephone (Luebeck Follow-up Trial): Overall and Gender-specific Effects. [Electronic Version]. International Journal of Rehabilitation Research, 29, 295-302.
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