In the meta-analysis on cardiac rehabilitation (CR) after myocardial infarction published by Oldridge and coworkers,1a reduction rate of 24%
in all-cause death was found for CR as a whole.
The rate was larger for programs with a duration of 36 or more months, where a 38% all-cause death reduction was found, higher than the reduction by programs below 12 weeks (8%) or between 12 and 52 weeks (24%).
Cardiac rehabilitation programs produce benefits through different pathways: an increase in physical working capacity, reduction of myocardial demands, increase in myocardial oxygen supply and risk factor control, protection against arrhyth- mias and blood coagulation, and modulation of autonomic nervous system (ANS) activity, among others. More recently, an ant-inflamatory effect of exercise training was described2 and a near- normalization of endothelial function was detected which seems to be a very important mechanism to explain many exercise benefits and why myocardial perfusion gets better without any new collaterals or apparent regression of coronary stenosis.3
Although it is known that the increase in functional capacity and the trend for endothelial function normalization take around 4 to 6 weeks to emerge after the beginning of an exercise program, it is not known for how long it is sustained after discontinuation of the exercise program. The benefits may well subside within weeks.
Control of risk factors for atherosclerotic disease is a crucial component in decreasing the pace of coronary artery disease (CAD) progres- sion. The need to keep the disease under control, with a healthy lifestyle (with an exercise program)
and with medication, is the rationale behind maintaining participation in the different forms of cardiac rehabilitation for as long as feasible.
CR Maintenance Phase Difficulties
Today’s patients with acute myocardial infarction (AMI) experience a lower physical limitation due to the early reperfusion strategy, anti-remodeling medication, complete revascularization frequently obtained by percutaneous coronary interventions (PCI), and short in-hospital stay. This is in con- trast to former decades where large myocardial necrotic zones, frequent residual ischemia, and several weeks of immobilization were the rule.
However, the present short in-hospital stay is less optimal for professionals teaching patients and relatives about secondary prevention measures as recommended in the guidelines.
These and other difficulties, such as lack of motivation, financial problems, the need for speedy job resumption or timetable conflicts, also prevent patients’ participation in the earlier phases of a classical CR program which should be the first step in a lifetime intervention.
Health systems’ and insurance companies’
financial restrictions have lowered the payment and reimbursement for CR in the last decades, which has consequently shortened the interven- tion from the typical 3–6 months to some weeks, a time period insufficient to promote long-lasting behavior change.
EUROASPIRE II4 showed, in real life clinical practice, that there is a large potential and need
43
Long-Term Maintenance Programs
Miguel F. Mendes
347
for secondary prevention implementation, because many patients are not taking the medica- tions recommended in clinical guidelines, nor have they adopted the appropriate lifestyle.
Many CAD patients, frequently old people, sometimes with low educational and socioeco- nomic levels, may be reluctant to abandon unhealthy behaviors.
Cardiac rehabilitation, a comprehensive sec- ondary prevention program, is considered to be the appropriate intervention to promote the adop- tion of a healthy lifestyle, stress management, and risk factor control in CAD patients.5Today’s chal- lenge is to promote a comprehensive long-lasting program, including exercise, education, and sec- ondary prevention interventions, that is afford- able and likely to be maintained in the long run.
Maintenance Phase – A Long-Term Approach
The maintenance phase follows the in-hospital and transition phases of CR. In this phase patients should be autonomous, being in charge of their own personal healthcare program as recom- mended by a cardiologist. This must include a clear definition of the usual medication, exercise program and the goals to be reached in terms of tobacco cessation, blood pressure, glycemia, lipids, body weight, waist circumference, and stress control.
The clinical priorities, the intermediate and ultimate targets, should be discussed between doctor and patient and every secondary preven- tion goal must be reached progressively after a previously agreed period of time – 6–12 months.6 To maintain a healthy behavior for many years it is important that health professionals assist the patient and family using specific education and communication skills in order to commit and cope with the program. The patient’s commitment to self-care can be achieved through the educa- tional program, promotion of the feeling of belonging to a group with similar problems, and friendly and frequent contact with the CR staff.
During the early phases of the CR there is a structured approach with formal exercise and educational sessions led by the health staff. In the maintenance phase, the program becomes less
structured and patients may be encouraged to return less frequently to the program (e.g. once a month). Exercise will be performed alone (at home or outdoors), in a group like a coronary club, a community program, a gymnasium, a swimming pool, a dancing group, a golf club, or in a walking or jogging program.6,7
During the maintenance phase program, the important issues are: an exercise program and its safety, education/risk factor control, and adher- ence to healthy life habits.
Exercise Program and Safety
The exercise program must be adapted to the patient’s personal preferences, physical capacity, co-morbidities, and convenience in terms of costs, transportation, and timetable.8A total of 1000 kcal should be accumulated in 3–5 exercise sessions per week with at least two interpolated rest days to avoid fatigue and permit muscular recovery.
This level of exercise is frequently insufficient to reach the 1000 kcal/week goal; thus an increase in physical activity in occupational and leisure-time activities must be promoted as larger benefits can be obtained with a global training volume of 2000 kcal/week.
Even in the maintenance phase exercise should be medically prescribed according to the patient’s cardiovascular limitations and co-morbidities, balancing the need to provide effective training with the need of a low cardiovascular and ortho- pedic risk.9,10
Exercise prescription starts with a medical eval- uation where the patient’s clinical status should be considered stable in terms of symptoms (angina and/or heart failure), ECG (ischemia and arrhyth- mias), and LV function. The usual contraindica- tions for exercise should be ruled out. Afterwards, a maximal symptom-limited graded exercise test, performed under the patient’s ongoing medica- tion, will be performed for training heart rate (HR) calculation, for the possible detection of an exercise risk threshold (myocardial ischemia, arrhythmias, or blood pressure drop), and for choosing modes of exercise.
Exercise intensity must be moderate, which means between 50% and 80% of peak VO2 and always 10–20 beats/min below the risk threshold.
Besides aerobic training, all other aspects of phys- ical training, like range of motion, flexibility, and muscular strength, should be promoted with the exception of speed in training.
Muscular strength or resistance training should be performed two to three times a week, after the aerobic training period, exercising the most important muscle groups of the upper and lower body for 20–30 min using elastic bands, small weight or weights machines, through one to three sets of 8–15 repetitions at 50% of the maximum tolerable load.
Program Safety
Direct medical or paramedical supervision is not the rule in the maintenance phase because it is a time to promote the individual’s autonomy.
The patient should be in a stable clinical situation, knowing from the previous program phases all the information needed to reduce the exercise risk and must be able to self-monitor exercise.
In special situations, such as people with neuro- muscular disabilities, the assistance of a phy- siotherapist or medical supervision may be needed.6,7
Exercise safety should be considered in cardiac and musculoskeletal terms. The appropriate session format should be respected, always respecting warm-up and cool-down periods of 5–10 min duration, keeping the duration of aerobic training under 45 minutes and offering resistance training two to three times weekly, both of moderate intensity. The probability of occur- rence of ventricular fibrillation or tachycardia (VF/VT) should also be very low: if there is significant risk, training should be conducted under ECG monitoring and in the presence of per- sonnel trained in cardiopulmonary resuscitation.
In these cases high-intensity exercise is not advisable.
To lower the risk of program-induced muscu- loskeletal injuries, which can easily occur in older people engaged in high-intensity programs, certain activities may be avoided: running, bas- ketball, volleyball, jumping, rope skipping, aerobic dancing, downhill skiing whereas walking, cycling, swimming, rowing, cross-country skiing can be promoted.6,7,9,10
Program safety, even in this phase, remains the responsibility of the program director although it is known that the usual rate of cardiac arrest in medical supervised programs is very low:
1/109,500 patient hours.11 A larger risk may be expected for patients with:
• a history of prior myocardial infarction or ven- tricular fibrillation
• a history of heart failure and/or an ejection frac- tion below 40%
• residual myocardial ischemia and/or three- vessel disease, ST depression below 120 beats/min
• peak exercise systolic blood pressure
<130mmHg, exertional hypotension and/or functional capacity <5METs
• non-adherence to prescribed exercise intensity and to recommended session format.
At the beginning of maintenance training, the probability of adverse events is very low as the patient previously has been exercising under supervision and has recently performed a maximal exercise test. However, as CAD pro- gresses over time, the risk may increase at a later stage. To counteract the increased risk, periodical medical controls should be scheduled including blood tests and repeated stress-testing whenever deemed necessary. In some cases patients may be offered a visit to the cardiac rehabilitation center for supervised sessions and refreshment of sec- ondary prevention measures on a more regular basis, though with larger time intervals.
The patient should be able to self-monitor his exercise intensity using the Borg scale, a heart rate monitor, or his own measuring of the heart rate.
Any symptoms or signs suggestive of myocardial ischemia or cardiac arrhythmias should be observed and if they occur the patient should dis- continue training and contact his doctor for a medical check-up. The program will only restart after the doctor’s formal permission.
Long-Term Education and Risk Factor Control
The education started in the earlier program phases (risk factor control, healthy lifestyle, and stress management) needs to be periodically
refreshed for patients and relatives. Regular per- sonal meetings, phone contacts, and periodical evaluations performed by a cardiac nurse, dieti- cian and cardiologist or general practitioner should only be tapered down gradually and adapted individually.
The patient, his family members (and the CR center staff) should be aware that maintenance is at least as important as the earlier phases of CR and needs reinforcement. An education program will never be finished because medical science is always developing. Furthermore, as time goes by patients may be prone to relapse to former unhealthy behaviors, reduc- ing their physical activity and allowing them- selves to consume less-advisable foodstuffs or beverages.
Adherence to Healthy Life Habits
The maintenance phase carries a significant risk of being quickly abandoned, being a long- lasting (years) intervention with significant financial and personal costs. Patients may be fre- quently asymptomatic, previously sedentary and not wishing to do any lifestyle change.12A pro- gressive decay in program compliance has been reported by Dorn and coworkers13 and by others. By 3 years after the start of the program only 13% of the participants were still exercising regularly!
To counteract the poor compliance rates it is recommended to identify patients at high risk for drop-out (Table 43-1). The patient and family should be informed about the benefits of CR and of the risk of poor adherence. The patient’s decision to discontinue the program
(as with any other treatment) is a “reasoned decision.” It is based on a personal judgment weighing the costs and risks of the treatment against the benefits according to personal per- ceptions and using the available information.12 A high quality professional relationship between the CR staff and patient and optimal program access in terms of transportation, time schedule, and fees are further important factors supporting compliance.14,15
Performing the exercise in groups might be pre- ferred for the maintenance phase as the patient will benefit from psychosocial support within the group. Here, patient organizations, voluntary organizations, coronary clubs, etc. are available in many countries. For practical reasons, for some patients home-based or work-site training is an alternative. Yet, regular contact with the CR center staff, phone calls or even via the internet are all helpful in supporting a continued healthy lifestyle.14
References
1. Oldridge NB, Guyatt GH, Fischer ME, et al. Cardiac rehabilitation after myocardial infarction. Com- bined experience of randomized clinical trials.
JAMA 1988;260:945–950.
2. Conraads VM, Beckers P, Bosmans J, et al. Com- bined endurance/resistance training reduces plasma TNF-alpha receptor levels in patients with chronic heart failure and coronary artery disease.
Eur Heart J 2002;23:1854–1860.
3. Hambrecht R, Wolf A, Gielen S, et al. Effect of exer- cise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000;342:454–460.
4. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug thera- pies in coronary patients from 15 countries.
Principal results from EUROASPIRE II. Euro Heart Survey Programme. Eur Heart J 2001;22:554–
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5. Kotseva K, Wood DA, De Bacquer D, et al. On behalf of the EUROASPIRE II survey. Cardiac rehabilita- tion for coronary patients: lifestyle, risk factor and therapeutic management. Results from the EUROASPIRE II survey. Eur Heart J 2004;6 (suppl J):J 17–J32.
6. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Pro- TABLE43-1. Drop-out factors
Factors
Patient Smoker, female gender, overweight, low motivation, previous physical inactivity, symptoms, more than one MI or concomitant disease
Program High intensity, poorly organized, unfriendly staff, inconvenient location or time schedule. Expensive Other Lack of social support (e.g. spouse) or work related.
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