Cardiac rehabilitation had its beginnings in Canada in the late 1960s; since then it has gained in strength and stature until today there are 130 comprehensive multidisciplinary programs across the country. The province of Ontario, with 11 million inhabitants, most of whom live within 200 km of the United States border, is the most popu- lated and has the largest number of full-service and partial-service programs. Of the remainder, the majority are in western Canada (the provinces of British Columbia, Alberta, and Manitoba), with fewer in Quebec and the Maritime Provinces.
Unfortunately, as is the case in most countries, only about 20–30% of potential candidates for cardiac rehabilitation services in Canada actually receive them. Apart from the customary preju- dices against referral, e.g. female sex, age over 70 years, co-morbid conditions, there is also the skepticism (or lack of awareness) of some physi- cians as to the efficacy of cardiac rehabilitation.
Obviously for those living in rural or remote northern communities, difficult access to rehabil- itation services is a major obstacle, although the introduction of a telehealth system, involving 34 different networks across Canada, may help in this regard.
The need for a national body to document and validate all programs as well as establish best- practice guidelines was realized in 1990 with the formation of the Canadian Association of Cardiac Rehabilitation (CACR). The Guidelines document, drawn up in accordance with the European Appraisal of Guidelines Research and Evaluation (AGREE) formula, was first published in 1998, with the second edition in 2004.1This has become
the CACR reference for those working in the field, and thus much of what follows is based on its content.
The very close working relationships between Canadian and American health professionals result in similar approaches to cardiac rehabilita- tion, and there is inevitably considerable overlap in program fundamentals. Nevertheless, there are dissimilarities, driven largely by philosophical dif- ferences in healthcare funding.
The Canada Health Act legislates that the provinces provide access to universal healthcare.
Consequently, most large hospital or rehabilita- tion center-based programs are supported by an allocation from the various provincial Ministry of Health institutional budgets. Additional monies may be obtained through fund-raising events or, in the case of maintenance programs, direct patient payments; these supplemental sources of income are essential in those provinces where cardiac rehabilitation is a low medical priority.
Program Structure
This varies slightly across the country depending upon a particular province’s population distribu- tion and availability of appropriate health profes- sional staff. However, despite regional differences there are broad principles which apply to all pro- grams. Shorter hospital stays have tended to curtail the relevance and effectiveness of in- hospital programs for the vast majority of patients recovering from an uncomplicated myocardial infarction or coronary artery bypass graft surgery.
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Cardiac Rehabilitation: Canada
Terence Kavanagh
37
38 T. Kavanagh
In the short time available, often only 5 or 6 days, the emphasis has to be on mobilization as well as identification of risk factors and the steps to elim- inate them. The latter is achieved largely by the use of audiovisual aids and handouts. Patients are given advice on the principles of exercise training, encouraged to gradually increase their level of physical activity after discharge, and provided with information on cardiac rehabilitation ser- vices in the community.
Currently, outpatient programs predominate.
The major sources of referrals are family physi- cians, cardiologists, and cardiac surgeons; a minority of programs allow self-referral. Typi- cally, attendance is two to three times weekly for an average of 6 months, with a range of 2 months to 1 year. The Toronto program, the largest in Canada with 1400 to 1600 new referrals annually, is “hybrid” in structure. Over a 6-month period patients attend the center once weekly for educa- tion, counseling, behavioral modification, a super- vised exercise training session, and then work out a further four times weekly away from the center.
Thereafter, attendance is monthly for between 3 and 6 months. This approach has been shown to be at least as effective and no more costly than the typical 12-week, three attendances weekly, regimen.2
The case management approach is an alterna- tive outpatient model. A cardiovascular trained nurse interfaces with the patient, specialist physi- cian, and rehabilitation team, and assumes responsibility for the patient’s care. This method has been shown to be very effective in some Amer- ican jurisdictions, but does not lend itself to the Canadian healthcare system of funding, and therefore is rarely seen.
Historically, cardiac rehabilitation had its origins in the care of myocardial infarction sur- vivors, and these individuals still constitute a sig- nificant proportion of all referrals. However, as the treatment of cardiovascular disease has advanced, the spectrum of patients referred to cardiac reha- bilitation has broadened to include patients who have undergone revascularization procedures and cardiac transplantation. Chronic heart failure patients, previously advised to avoid all forms of physical exertion, are now found to benefit from an aerobic, and in some cases, a resistance train- ing program. As the population ages, the number
of patients receiving pacemakers is rising, and this is also a group suitable for exercise-based rehabil- itation. The use of implantable cardioverter defib- rillators to prevent sudden death is increasing, and with it the referral of such patients to cardiac rehabilitation. Most programs are still gaining experience in this area,3but it is becoming appar- ent that the training benefits include an improve- ment in self-confidence, increased functional capacity, and an enhanced quality of life.
Program Staffing
Comprehensive full-service programs which are located in hospitals have ready access to pro- fessional, technical, and administrative staff.
Community free-standing clinics or rehabili- tation centers, however, typically appoint a full-time or part-time medical director, nurse coordinator/manager, health professionals trained in the exercise sciences, exercise testing techni- cians, and a part-time dietician, psychologist, and social worker (or make provision for access to these latter three). Each of these individuals, in addition to a high level of competence in their profession, is required to possess a core of knowl- edge common to all and specific to the discipline of cardiac rehabilitation. This is usually gained in the practical setting, and is similar to the core functions and program personnel recommenda- tions published by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Heart Association (AHA), and the American College of Sports Med- icine (ACSM).
Program Content
Inasmuch as the essence of comprehensive cardiac rehabilitation is to determine the patient’s level of cardiovascular risk, and then intervene to reduce that risk, it is essential to set treatment goals which are accepted nationally and are scientifi- cally sound. Accordingly, the targets set out in the Canadian Guidelines were arrived at in close collaboration with the Canadian Associations for diabetes, hypertension, dyslipidemia, exercise physiology, and tobacco control. This ensured that
7. Cardiac Rehabilitation: Canada 39
the guidelines’ targets are consistent with recom- mendations published by each of the major car- diovascular health and risk factor interest groups.
As for the lifestyle interventions and behavior modification techniques, it is now apparent that these are essentially the same for each of the major risk factors. The various approaches recom- mended include the transtheoretical model of behavior change, motivational interviewing, and a variety of counseling styles, e.g. preacher, director, educator/instructor, counselor/consultant.
Current Canadian practice calls for all entrants to a cardiac rehabilitation program to undergo a risk stratification procedure. The guidelines propose that, after a full clinical assessment, the degree of disease progression is calculated using the Framingham Risk Score (FRS),4 which takes into account age, gender, lipid profile, systolic blood pressure, smoking history, as well as pres- ence or absence of diabetes. The Duke Treadmill Score5 is then obtained from a graded exercise test, and this is then combined with the FSHSRS to estimate whether the patient is at high, inter- mediate, or low risk for a recurrent event. This approach allows for the matching of the degree of cardiovascular disease to the level of intervention, and thus a cost-effective application of rehabilita- tion resources. It also provides the patient with information conducive to program adherence and successful lifestyle modification.
An alternative to the FRS is the European Sys- tematic Coronary Risk Evaluation Score (SCORE) equation.6The 2004 Canadian Guidelines discuss the relative merits of both and, on balance, find SCORE to have more merit. Advantages include the use of only fatal cardiovascular disease end- points, separate prediction models in high- and low-risk populations, the ability to show changes in outcomes based on changes in risk factor values, and the fact that the model can be cali- brated to specific populations if outcomes data and major risk factor data are available for the population of interest. However, its disadvantages are that it is unfamiliar to North American health- care professionals, is not currently calibrated for Canadian populations, and has not been validated in people with documented cardiovascular disease. The FRS system is simple, and has recently been adjusted for age, gender, and the presence of cardiovascular disease; for these
reasons it is included in the current recommen- dations. However, it is important to point out that the Canadian Cardiovascular Society is currently sponsoring an evaluation of SCORE in Canada, and this therefore remains an attractive option for future guidelines.
Cardiopulmonary exercise testing is practiced in only a handful of programs, although measured peak oxygen intake has been shown to be a powerful predictor of survival in over 12,000 men with coronary heart disease referred for rehabili- tation and followed for a median of 8 (4–29) years.7
Depression has been shown to be a risk factor for cardiovascular disease, and the presence of persistent depression following a myocardial infarction may be a marker for a recurrence. The mechanism may be physiological and/or the adverse influence depression has on behavior modification and program adherence. Anxiety, chronic psychological stress, social isolation, and a high hostile/anger personality profile have all been associated in various degrees with adverse cardiovascular outcomes. In light of this it is rec- ommended that patients undergo a psychosocial screening. This need not be time-consuming, and can be incorporated into the initial assessment. As part of a pilot project conducted in the province of Ontario in 2002,8the use of various question- naires such as the Beck Depression Scale, the Hospital Anxiety and Depression Scale, and the Medical Outcomes Study (MOS) Short Form 36 was found to be expeditious and effective.
Progressive aerobic type training is the corner- stone of the cardiac rehabilitation process. With regard to the mode intensity, frequency, and dura- tion aspects of the training prescription, Canadian practice adheres closely to the recommendations of the ACSM, the AACVPR, and the AHA. Similarly with resistance training, although original work in this area carried out by researchers from McMas- ter University has engendered even greater enthu- siasm for this approach.9
Program Safety
The initial risk stratification helps to identify patients at risk for sudden cardiac death, and thereby allows for a proactive approach. Consid-
40 T. Kavanagh
risk factor, and 1 in 10 has three or more, the need for cardiac rehabilitation and secondary preven- tion programs can only increase.
References
1. Stone JA, ed. Canadian Association of Cardiac Reha- bilitation Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention. Winnipeg: Cana- dian Association of Cardiac Rehabilitation; 2004.
2. Hamm LF, Kavanagh T, Campbell RB, et al. Timeline for peak improvements during 52 weeks of outpa- tient cardiac rehabilitation. J Cardiopulm Rehabil 2004;24:374–382.
3. Kamke W, Dovifat C, Schranz M, et al. Cardiac reha- bilitation in patients with implantable defibrillators:
Feasibility and complications. Z Kardiol 2003;92(10):
869–875.
4. Califf RM, Armstrong PW, Carver JR, et al. Task force 5. Stratification of patients into high, medium, and low risk subgroups for purposes of risk factor man- agement. J Am Coll Cardiol 1996;27(5):1007–1019.
5. Mark DB, Shaw L, Harrell FE Jr, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325(12);849–853.
6. Conroy RM, Pyorala K, Fitzgerald AP, et al. Estima- tion of ten-year risk of fatal cardiovascular disease in Europe: The SCORE project. Eur Heart J 2003;24(11):987–1003.
7. Kavanagh T, Mertens DJ, Hamm LF, et al. Prediction of long-term prognosis in 12,169 men referred for cardiac rehabilitation. Circulation 2002;106:666–671.
8. Suskin, N, MacDonald S, Swabey T, et al. Cardiac rehabilitation and secondary prevention services in Ontario: Recommendations from a consensus panel.
Can J Cardiol 2003;19(7):833–838.
9. McCartney N. Role of resistance training in heart disease. Med Sci Sports Exerc 1998;30(Suppl):S396–
S402.
eration can be given to pharmacological interven- tions, revascularization procedures, or implanta- tion of a cardioverter defibrillator. While not recommended for routine use, telemetry can provide valuable information when exercising high-risk patients. Furthermore, these individuals should be seen in classes where the ratio of staff to patient is no greater than 1 to 5. In the final analysis, however, ensuring that patients adhere strictly to their exercise prescription, are familiar with the Borg rating of perceived exertion, can take an accurate pulse, and can recognize the significance of adverse signs and symptoms such as an erratic pulse, excessive breathlessness, light- headedness,“blackouts,” etc. is probably the great- est insurance against adverse events.
Conclusions
Exercise-based comprehensive cardiac rehabilita- tion has made steady progress in Canada over the past 50 years, and its place in the continuum of car- diovascular care is now largely accepted. However, programs are unevenly distributed across the country and in some areas are disproportionate to population requirements. Provincial health net- works need to consider their cardiac rehabilitation needs and develop a delivery infrastructure based on health service funding. Greater attention has to be given to the elderly, especially women, and dif- ferent ethnic groups. Currently, program length has been chosen empirically and more research is required to determine optimal duration, cost- effectiveness, and outcomes.2 When one realizes that, despite the efforts of public health authori- ties, 8 out of 10 adult Canadians suffer from one
