A comprehensive cardiac rehabilitation program has to offer to the patient all the constitutive parts that have been defined by the World Health Organization and included in the differ- ent European or American specific guidelines.
This section gives the “state of the art” in specific aspects of cardiac rehabilitation: the role of nurses, factors influencing return to work, counseling of the patient, long-term maintenance programs, national foundations or heart net- works, and new perspectives in caring and support.
Cardiac rehabilitation includes prevention and heart failure rehabilitation programs. In Europe, these programs are usually led by medical doctors (most often cardiologists), as advised by the ESC working group’s recently published guidelines on cardiac rehabilitation and exercise physiology. Nurses are thus part of the multidisciplinary team, which also includes physiotherapists, nutritionists, psy- chologists, social workers and others, as available given local circumstances, who deliver cardiac rehabilitation programs. Nurses are, in some settings, the main team who deliver these cardiologist-led programs. These aspects of nurse-led programs will be described by A. Cahill (Chapter 36) and A. Strömberg (Chapter 37).
The medical and socio-professional factors involved in work resumption after myocar- dial infarction or after coronary interventions (J. Perk) will be analyzed in Chapters 38 (J. Perk) and 39 (J. Perk). Return to work rate remains suboptimal and socioeconomic factors seem to
play a major role, often more than medical factors.
Sexuality is a part of quality of life; so sexual counseling of the cardiac patient is an important goal, which may be offered to patients before resuming sexual activity (Chapter 40, T. Jaarsma and E. Steinke).
The last part of this section will deal with new perspectives in cardiac rehabilitation and prevention. There are in some patients some discrepancies between symptoms and objective evaluation of the patient. These symptoms may have a detrimental effect on quality of life and work resumption. The objective of cognitive behavioral rehabilitation in patients with angina (Chapter 41, R.J. Lewin) is to decrease the symptoms by educating patients to analyze their beliefs and by changing their symptom-related behavior.
S. Logstrup and colleagues (Chapter 42) will report on the role of national heart foundations (in Finland and Switzerland) and the European Heart Network in prevention of cardiovascular disease.
The importance of long-term maintenance pro- grams in the field of cardiac rehabilitation main- taining the results obtained during the initial program is well known. M. Mendes (Chapter 43) will analyze the objectives, the methods, and the necessary means for such long-term maintenance programs.
Finally, new models of care and support, involv- ing nurses, trained lay volunteers, or even internet will be proposed by J.F. Pattenden and R.J. Lewin (Chapter 44).
Section VII
Social and Caring Support
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Main Messages
Chapter 36: Prevention Programs: The Role of the Nurse
International guidelines dictate multifactorial and multidisciplinary delivery of cardiac rehabilita- tion services. However, cardiac rehabilitation pro- grams can often fail through a lack of appropriate coordination. Skilled coordination of programs is necessary to ensure an effective and efficient service. Nurses, who constitute the largest employee population of the health service work- force, are often recruited into these positions.
The coordination of the cardiac rehabilitation program requires the ability to work with patients and their families and also the ability to liaise with and coordinate other disciplines. The skills required of a program coordinator are varied and are dictated by the particular requirements of each phase of the program.
Chapter 37: Heart Failure Rehabilitation:
The Role of the Nurse
Nurses’ participation in heart failure rehabilita- tion has increased in Europe during the last decade. When evaluated in meta-analyses, heart failure programs, often nurse-led, have been shown to effectively reduce mortality and mor- bidity and improve self care in patients with chronic heart failure. In this chapter structural elements (setting, education, financing) and process of care (referrals, components, interven- tions) as well as the advantages and disadvantages with different models of nurse-based heart failure programs are discussed.
Chapter 38: Returning to Work after Myocardial Infarction
Assisting the patient to resume work after a myocardial infarction is one of the main aims of a comprehensive rehabilitation program after myocardial infarction. A majority of patients will be able to return to work but non-medical factors are more important predictors than medical factors of the likelihood of resuming work. Yet, through vocational counseling, adapted training models and adequate communication with work-
place medical services cardiac rehabilitation can play an important supportive role.
Chapter 39: Return to Work after Coronary Interventions
Improving the work resumption rate after coro- nary interventions is an important goal of a cardiac rehabilitation program. The available data show us that the return to work rate is not optimal, that unless the presence of symptoms, the severity of heart disease has little impact, but that socioeconomic factors, including age, play a major role.
The specific role of cardiac rehabilitation after coronary interventions on work resumption remains to be clearly demonstrated.
Chapter 40: Sexual Counseling of the Cardiac Patient
Cardiovascular disease is a common cause of sexual dysfunction. Patients and their partners may experience sexual problems as a result of anxiety, symptoms or sexual dysfunction. They worry about the effect of the condition on sexual activity, the effect of sex on the heart, symptoms that may occur during sexual activity and possi- ble effects of medication.
Healthcare providers may have difficulty addressing the issue but should take the initiative to bring up the topic of sexual functioning. There are several prerequisites to implementing success- ful sexual counseling. Environmental issues, communication issues, and confidentiality are important. Open-ended basic questions can be used to facilitate discussion and to assess patient concerns. In addition, specific questions are asked during this discussion, moving from general ques- tions to more specific issues or problems as the counseling session continues. Health professionals are in key positions to provide this teaching and facilitate successful return to sexual activity after a cardiac event.
Chapter 41: Cognitive Behavioral Rehabilitation for Angina
Cognitive behavioral (CB) disease management programs are new techniques that can be applied
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in cardiac rehabilitation. Using the example of angina, this chapter will demonstrate the applica- tion of these techniques, and a brief practical description of the “Angina Management Pro- gramme” is presented.
Chapter 42: National Heart Foundations, European Heart Network
Heart Foundations in Europe fulfill many roles in their work to prevent cardiovascular diseases. An important role is to lend support to cardiovascu- lar patients and their families.
This chapter presents two case studies, from Finland and Switzerland, illustrating patient education and rehabilitation programs offered by Heart Foundation in those countries. The chapter also describes recent EU developments on cross border patient mobility, on the High Level Group on Health Services and Medical Care and on the European Parliament report on patient mobility.
Chapter 43: Long-Term Maintenance Programs
After a phase II cardiac rehabilitation program the challenge is to keep the patients committed to risk factor control and regular exercise. Only long- term intervention can have positive consequences
for the patient’s prognosis, since the benefits achieved in the earlier phases will quickly vanish if the program is not continued.
Although the maintenance phase program is the logical continuation of the previous program, it is very difficult to keep the patient committed to it, outside the protective atmosphere of the reha- bilitation center, experiencing time confiicts due to job resumption and at risk of leaving the program for financial reasons. In this chapter, readers will find advice on how to design the exer- cise and risk factor control program, strategies to keep the patients motivated and coping with this comprehensive intervention in the long term, the only way to give patients a better and longer life.
Chapter 44: New Models of Care and Support
As the number of people living with cardiovascu- lar disease continues to rise, new models of care and support need to be developed to integrate patient care between primary, secondary, and social care. This chapter describes some emerging methods: specialist nurse-led care; nurse facili- tated self-management programs; lay-led pro- grams of education, advice and support; and eHealth applications including web-based pro- grams and use of internet resources.
