Standard Cardiac Rehabilitation Program

Staff. The standard cardiac rehabilitation program has a manager (director) who is a doctor. The rehabilitation team also includes a full-time nurse and other nurses, or personnel trained in conducting and monitoring TF and conducting patient education. In accordance with the requirements of insurance companies in the United States, programs for Stage 2 cardiac rehabilitation are carried out only in the presence of a doctor. In addition, to receive insurance payments to patients during each program visit, an ECG must be performed, which should be recorded and interpreted.

There is no definition of the term “physician’s presence at the time of TF”, but it is usually meant that the doctor must be somewhere close to be able to provide assistance in acute situations. The entire staff of the program should be trained in the rules of cardiac resuscitation. During FT, a nurse should also be there to intervene in acute conditions and apply medications. The recommended staffing level is: 1 employee per 5 patients in the programs of stage 2 and 1 employee per 10-15 patients in the programs of stages 3-4.

Structure and stages of the cardiac rehabilitation program

Cardiac rehabilitation programs are usually divided into 3 or 4 stages in accordance with the clinical status of patients. Stage 1 includes programs conducted in the hospital shortly after an acute coronary event or intervention. Stage 1 cardiac rehabilitation programs are currently not very common due to the short hospital stay, however, in some European countries, they still have inpatient cardiac rehabilitation programs that can last several weeks.

Even with the short duration of hospitalization of cardiac patients, the stage 1 cardiac rehabilitation program remains useful for activating elderly patients after complicated cardiac events and in many patients after cardiac surgery. Stage 1 cardiac rehabilitation programs in the United States are often performed by the physiotherapy departments of hospitals or by special personnel trained in the principles of cardiac rehabilitation.

Stage 1 is also an excellent period to familiarize the patient with the concept of cardiac rehabilitation and to facilitate his involvement in this program.

Stage 2 includes outpatient cardio-rehabilitation programs in the presence of a doctor. Control by the doctor and ECG control in these programs are mandatory conditions imposed by the majority of insurance companies when issuing compensation. Historically, patients in the programs of stage 2 train 3 times a week for 3 months.

Other approaches to cardiac rehabilitation include simple, self-controlled home programs, home programs with a nurse visit, and home programs with telephone ECG monitoring. A comparison was made of these approaches in the framework of scientific research and standard medical practice. It turned out that the physical performance of patients improves more with physical training (TF) at home, although this improvement may be due to a tendency to reveal positive results.

Another duration of rehabilitation programs was also studied, for example, 1 lesson per week for 1 year. Such a program can improve the physical performance of patients and contribute to adaptation to ongoing physical rehabilitation, however, standard 12-week programs are most common, because insurance companies only cover these programs.

The programs of stage 3 cardiac rehabilitation are carried out without a doctor and an ECG cat. These programs are supportive; they are provided by the same institutions as the programs of stage 2. Some insurance companies partially reimburse the costs of the programs of stage 3.

Phase 4 programs for cardiac rehabilitation are carried out without medical supervision (usually in health clubs and fitness centers). In the United States, insurance companies do not reimburse Stage 4 programs.

Effectiveness of cardiac rehabilitation in heart failure

As in the case of coronary heart disease (CHD), there is not a single research that is sufficiently powerful to judge the effect of physical training (TF) on survival rates in patients with HF. The HF-ACTION study (Heart Failure and a Controlled Trial Investigating Outcomes of Exercise Training), funded by the National Institutes of Health, aims to study the effect of PT on heart morbidity and mortality in patients with systolic dysfunction.

The study included 3 thousand patients randomly assigned to the TF group and a group of patients who were recommended to participate in the cardiac rehabilitation program.

Meta-analysis confirms the positive effects of physical training (PT) in heart failure (HF). Smart N. and Marwick T.N. analyzed the results of 81 studies in which 2387 patients with HF were included. In trained patients, VO2 increased by 16%.

The same results were obtained in 622 trained patients and 575 patients from the control group. The overall frequency of adverse outcomes over 5.9 months of follow-up in the training and control groups did not differ. At the same time, in the FT group there were 29% less deaths (p = 0.06).

These results indicate that physical training not only increases physical performance, but can also reduce heart mortality in patients with systolic heart failure. However, final conclusions can be made after completing the HF-ACTION study.

Effectiveness of cardiac rehabilitation after percutaneous transluminal coronary angioplasty (PTCA)

In several large studies, the effectiveness of cardiac rehabilitation based on physical training (PT) has been studied in patients after percutaneous transluminal coronary angioplasty (PTCA). In the ETICA study (Execise Training Intervention after Coronary Angioplasty), the effect of PT on clinical outcomes was studied in 118 patients who underwent PTCA with one CA (n = 81) or two CA (n = 37).

Patients were randomized to the group in which they performed FT, and the group of routine practice. Physical training (FT) (3 times a week for 6 months) consisted of physical exertion (FN) on an exercise bike (30 min) and gymnastics (15 min). At the beginning and at the end of the study, a stress test was carried out, the stopping criteria for which were patient fatigue, the achievement of the target heart rate or ST-segment depression> 1 mm.

Indicators of VO2max and quality of life increased by 26% (p <0.001) only in the FT group. The frequency of angiographically confirmed CA restenoses (narrowing> 50%) for 6 months of observation did not differ in the two groups (29% vs 33%), but the intracavitary diameter of the CA at the intervention site in the TF group was 30% higher (p <0.05) .

Progression of the disease and new lesions in large CA (narrowing> 20%) in the TF group were observed much less frequently. Cardiac ischemia, which was assessed by the presence of defects during waist perfusion during myocardial scintigraphy, was also observed less frequently in trained patients. The observation period after the completion of the intervention was 33 ± 7 months. During this time, no deaths occurred in any of the groups, however, in the TF group, AMI (1 vs 3) was less frequently noted (p <0.008) and percutaneous transluminal coronary angioplasty (PTCA) was performed (4 vs 11) or CS ( 2 vs 5).

This study was conducted prior to the widespread use of stents during PTCA and the use of drug-eluting stents. Thus, only 19 patients from the FT group and 18 patients from the control group had stents installed.

In addition, they did not use lipid-lowering therapy because they evaluated the effect of TF on lipid levels. Consequently, it is not clear that PT would have given a similar slowdown in the development of atherosclerosis and a reduction in the frequency of cardiac events if they performed comprehensive modern therapy. In addition, it is not clear to what extent the improvement of the condition of the coronary artery (CA) occurred due to structural changes in atherosclerotic plaques, and to which due to the improvement of endothelial function.

Effectiveness of cardiac rehabilitation in myocardial infarction

In 4 meta-analyzes, the effect of cardiac rehabilitation based on physical training (PT) on clinical outcomes was studied. All of them showed similar results, since based largely on the same research.

The most recent analysis summarized 48 studies with a total of 8940 included patients, randomized or in cardiac rehabilitation groups, or in routine practice groups. Total mortality and mortality from cardiac causes were lower in the cardiac rehabilitation groups by 20 and 26%, respectively (p <0.05 for both indicators). Repetitive MIs were noted 20% less frequently, but this difference was not statistically significant.

Most of the studies included in this meta-analysis were conducted prior to the development of modern strategies for revascularization, so it is possible that many patients in these early studies showed residual coronary stenosis and inducible ischemia. At present, such patients are usually given PTCA or CSH.

Even with the established positive effect of cardiac rehabilitation on myocardial ischemia, due to the widespread use of myocardial revascularization interventions, there is no certainty that cardiac rehabilitation will show a similar decrease in cardiac mortality. The most recent meta-analysis revealed no differences in studies conducted before and after 1995, therefore, the positive effects of cardiac rehabilitation can be considered legitimate for modern cardiological practice.

There were also no differences between the effect of physical training (PT) and more comprehensive rehabilitation programs, which confirms the role of PT in reducing heart mortality.

The results of meta-analyzes confirm the positive effect of physical training (PT), however, none of the studies had sufficient statistical power to confirm the reduction in cardiovascular mortality after cardiac rehabilitation.

Meta-analyzes are often criticized because of their tendency to focus on positive research results. On the other hand, the inclusion of studies based only on TF in meta-analyzes can lead to an underestimation of the effectiveness of complex cardio-rehabilitation. To address these concerns, two large-scale comprehensive cardiac rehabilitation studies are currently underway.

The study GOSPEL (Global Secondary Prevention Strategies for Limit Events after Myocardial Infarction) included 3241 patients from 78 centers in Italy. All patients after 3 months of the standard rehabilitation program will be randomly assigned to a group of 3-year intensive rehabilitation program and a standard observation group in the district clinic.

In the intensive rehabilitation group, they will conduct physical training (TF), lifestyle counseling and RF, and regular clinical examinations once a month for 6 months and then 2 times a year until the end of the study.

In a study of DANREHAB (Danish Cardiac Rehabilitation) with 770 patients with IHD, HF, or those at high risk of developing IHD, an intensive hospital cardiorehabilitation program is carried out for 6 weeks, followed by outpatient observation for 12 months. The program includes TF, nutritional recommendations, counseling on RF, smoking cessation and clinical examinations. Supposed to recruit 1800 patients. When the results of the study will be presented and whether it will be possible to include such a number of patients in the study is unknown.

Effectiveness of cardiac rehabilitation in angina pectoris

Currently, most patients with angina pectoris can cope with the symptoms of the disease using drug therapy or myocardial revascularization with PTCA or CS. Most of the evidence (with rare exceptions) that physical exercise (PT) increases exercise tolerance (TFN) in patients with angina pectoris, was obtained before 1990. FT increases the duration of FN before the onset of angina pectoris or completely eliminates angina pectoris by at least least two mechanisms.

First, physical training (PT) reduces the oxygen demand of the myocardium during submaximal FN. FT endurance increase VO2max. Since the change in HR and SAD during an FN is associated more with the degree of increase in VO2max (depending on the nature of the FN, and not from its absolute value), an increase in VO2max with FT leads to a decrease in the increase in HR and SAD per submaximal load. This reduction in double work reduces myocardial oxygen demand and retards the onset of an attack of angina.

Secondly, physical exercise (TF) reduces ED. Normal CAs in response to FNs expand, and for atherosclerotic-affected CAs, ED is manifested, which is manifested in FN by vasoconstriction. According to continuous coronary angiography performed on the background of the introduction of endothelial acetylcholine agonist to patients, FN reduce ED. The fact that in some patients at the very beginning of the FN an increase in blood pressure is observed also confirms the concept of the significance of endothelial function.

Physical training (FT) is considered to be shown (at least in the USA) to patients with angina in cases where it is impractical or impossible to perform surgical interventions on spacecraft. However, a recent clinical study led to a reconsideration of this approach. Hambrecht S. et al. studied the dynamics of physical performance, anatomical features of spacecraft and clinical outcomes in 101 men <70 years old with stable angina, who were randomized into 2 groups: in the first group, PT was performed during the year, and the second group of patients underwent PTCA.

Physical training (FT) was performed for 2 weeks, 6 days a week. TF included a 10-minute FN with training heart rate = 70% of the maximum in combination with daily 20-minute home TF iodine weekly 60-minute controlled TF.

In each group, 47 patients completed the study. The level of physical performance increased by 30% in trained patients and by 20% in those who underwent PTCA. Moreover, the differences were not significant, however, the increase in the maximum physical performance (20% vs 0%) and VO2max (16% vs 2%) were significantly higher in the trained patients. In the latter, the degree of spacecraft lesion did not change, and among patients who underwent PTCA, only 15% had restenosis, defined as a narrowing (> 50%) of the vessel at the site of angioplasty.

The progression of coronary heart disease (CHD), as measured by angiography, was lower in the FT group. 88% of patients from the PTCA group and only 70% of the patients from the TF group suffered acute Ssob, including myocardial infarction, stroke, revascularization procedure, or hospitalization for angina pectoris. Moreover, the difference was statistically significant. These results require confirmation. Due to the specificity of the selection criteria, they cannot be applied to all patients with stable angina. However, these results clearly demonstrated that PT can make a definite contribution to the treatment of patients with angina.

Physiology of physical activity and training for heart disease

a) Maximum oxygen consumption. Aerobic and static loads increase the body’s need for oxygen to provide energy to working muscle groups. The amount of energy used during FN is determined through oxygen consumption (VO2). The modified Fick formula: CB = VO2 / L (A – B) 02, where CB is a cardiac output, VO2 is oxygen consumption, Δ (A – B) O2 is the difference in 02 between arteries (A) and veins (B). In other words, the oxygen consumption depends on the CB and Δ (A – B) O2.

Thus, the metabolic needs when performing FN require an increase in oxygen delivery, which is provided by an increase in Δ (A – B) O2 and an increase in CB, which, in turn, depends on the heart rate and stroke volume (EI) of the heart. Δ (A – B) O2 during the execution of FN increases due to the redistribution of blood and, accordingly, oxygen from non-working tissues (for example, the kidneys and organs of the abdominal cavity) to working muscles. In addition, in working muscles, blood viscosity increases due to the transition of a certain part of blood plasma into the interstitial space. An increase in CB during FN is closely related to VO2. Thus, an increase in VO2 per liter leads to an increase in the total nitrogen concentration by = 6 l.

The maximum power of FN is defined as the maximum oxygen consumption (VO2max) that is transported in a person when performing FN until the moment when it is stopped due to fatigue or shortness of breath. Individual VO2max is a stable and reproducible indicator of physical performance. It is expressed either in absolute terms (l / min) or relative to MT (ml / kg / min). The maximum increase in Δ (A – B) O2 is a fixed value and is = 15-17 vol%. Since the intensity of the FN determines the oxygen consumption, which depends on the CB and Δ (A – B) O2, and the maximum Δ (A – B) O2 is a relatively constant value, the maximum power of the FN and VO2max indirectly indicate the maximum myocardial contractility (or maximum CB) and PP).

b) Myocardial oxygen consumption. Oxygen consumption by the myocardium (MVO2) is determined by the levels of HR and SBP through the so-called dual product: HR (beats / min) x CAD (mm Hg). Human physical performance depends on the consumption of oxygen and CB, and the degree of increase in heart rate and SBP during the FN is determined by the increase in oxygen demand (as a percentage of VO2max). Consequently, for any absolute value of the FN, a person with a large VO2max uses less of his reserve and, at a high FN, has a lower heart rate and an AAD. The key point: the myocardial oxygen demand is determined not only by the severity of the FN, but by the ratio of the severity of the load to the maximum physical performance.

c) Respiratory threshold. Carbon dioxide emissions (VCO2) with FN also increase. The increase in VO2 and VCO2 occurs in parallel, but the intensity of the release of CO2 increases faster. The amount at which an increase in oxygen demand is not accompanied by a further increase in carbon dioxide emissions is called a respiratory threshold (VT). This discrepancy is due to the formation of lactate, the buffering of H + lactate ions with bicarbonate and the subsequent formation of additional CO 2. The respiratory threshold is also called the anaerobic threshold and the onset of lactate accumulation in the blood. Since CO2 stimulates the respiratory center, a nonlinear increase in the respiratory rate occurs at the respiratory threshold and moderate shortness of breath appears. The respiratory threshold during FN is usually marked at 50% of VO2max in untrained people and makes up a higher percentage of VO2max in trained individuals. Respiratory threshold is an important indicator of TFN, because it reflects the maximum sustainable level of performance that can be achieved during submaximal loads.

d) The effect of heart disease on physical performance. Physical performance in some cardiac patients may be normal and age and sex, while others may be limited if the heart’s CR decreases, the heart rate response to the FN is disturbed, there is myocardial ischemia, which, in turn, limits the FA of patients or increase in PP at peak FN. Drugs such as β-AB, which limit the changes in heart rate during FN, as well as the limitations of FA in patients with heart disease, which cause the effect of detraining, make a definite contribution to the reduction of TFN.

e) The effect of physical training on physical performance. The main purpose of FT (aerobic or static) is to increase the physical performance of patients with heart disease. With static loads, an increase in muscle strength and endurance occurs in a trained muscle. The main effect of aerobic exercise is to increase VO2max. This provides a lower percentage of VO2max at submaximal FN, which reduces the increase in heart rate and SBP during FN and myocardial oxygen demand. Increased endurance also increases both the absolute respiratory threshold and the respiratory threshold as a percentage of VO2max.

Many mechanisms contribute to the increase in TFN after FT, including PP and Δ (A – B) O2, although the magnitude of the latter has clear physiological limitations.

The degree of increase in VO2max during static loads depends on a number of factors, including the patient’s age, the intensity and duration of PT, the genetic characteristics of the patient and the clinical condition, as well as whether similar exercises are used in FT and testing. Usually the degree of increase in TFN is greatest in young people who have been intensively trained. The degree of increase in VO2max in patients after cardiac rehabilitation averages 11–36%, but depends on the severity of the underlying disease. For example, in patients with significantly reduced cardiac contractility, an increase in physical performance can be achieved by increasing Δ (A – B) O2, although in some patients after 12 months of TF an increase in CV is also observed.

In addition to increasing the maximum physical performance, endurance exercises increase stamina due to the effect on the respiratory threshold. This influence is extremely important because increased submaximal physical performance reduces shortness of breath with submaximal fn and provides for the implementation of most daily tasks, none of which require maximum effort.

The history of the rehabilitation of patients in cardiology

Prolonged (several weeks) hospitalization and restriction of physical activity over the subsequent months were the standard treatment for myocardial infarction until the early 1950s. But in the early 1970s. patients after myocardial infarction were usually hospitalized for 3 weeks.

Exercise-based cardiac rehabilitation programs have been put into practice since the 1950s. and had the goal to overcome the state of detraining and reduced physical performance in patients caused by prolonged hospitalization and deliberate restriction of FA.

Physical training (FT) is considered as key elements in overcoming the state of de-training and cardiac rehabilitation, since physical training (FT) was among the few interventions that had proven effectiveness in preventing attacks of angina pectoris, and long before the use of β-AB, calcium antagonists, coronary artery bypass surgery and percutaneous transluminal coronary angioplasty (PTCA).

The reduction in the length of stay of patients in the hospital, as well as effective medications and interventions for the correction of myocardial ischemia influenced the structure and design of cardiac rehabilitation programs. FT continues to be one of the key elements of cardioreabilitation, however, according to the requirements of today, rehabilitation must be comprehensive.

Other key elements of a comprehensive cardiac rehabilitation are training and counseling patients in order to improve their psychological state, quit smoking, increase adherence of patients to therapy and diet. These educational components are so important that their knowledge is necessary when obtaining accreditation from the American Association of Cardiovascular and Pulmonary Rehabilitation.

Physical training (FT) continues to be considered the most important component of cardiac rehabilitation programs due to the fact that FT increases TFN; reduce pain syndrome (stenocardia) and reduce myocardial ischemia caused by FN, and also correct such FR as serum lipid levels, arterial hypertension and endothelial dysfunction. This chapter is about cardiac rehabilitation in general, but with an emphasis on physical training.

Recommendations for the prevention of coronary heart disease

Recommendations for the prevention of coronary heart disease

Most preventive interventions target one risk factor (RF), but several have attempted to simultaneously change several RFs. Theoretically, the possibility of synergism among RFs can lead to a significant reduction in the risk of cardiovascular diseases (CVD).

Multifactorial interventions have greatly contributed to the understanding of cardiovascular risk (CCP), as well as increased knowledge of the effectiveness or ineffectiveness of intervention strategies, but their results were different. It is obvious that multifactorial intervention can reduce the level of FR, and this reduction can be long-lasting. In the Belgian study, which was part of the World Health Organization European Collaborative Trial in the Multifactorial Prevention of Coronary Heart Disease, the intervention program consisted of staff counseling on nutrition, smoking and FA and led to a significant reduction in predictors of coronary risk compared to the control group . This effect has been persistent for 5 years.

The overall result of multifactorial interventions is a change in the levels of DF or indicators of total risk scales in the intervention group. However, these changes did not always translate into a reduction in the frequency of events. These discrepancies can be explained by the fact that the intervention was too small or the patients in the control group also changed their lifestyle for the better over time. However, it is clear from these studies that by using simultaneous multifactorial interventions, CCP can be reduced if the planned interventions are large enough and adequately implemented.

In the analysis of 7 multifactorial interventions, changes in the multiple logistical risk function were compared with a reduction in the risk of CHD. A strong linear relationship suggests that if the risk factor (DF) does change, the frequency of events will also decrease.

Types of evidence on risk factors

Types of evidence on risk factors

Evidence on risk factors (RF) is obtained from various sources. Studies on autopsy have shown that atherosclerosis can begin to develop even at an early age, if there are the same RF CVDs as in adults. Establishing a link between cause and effect is a major step in determining predictors, and the results of several studies are needed to select a preventive intervention. Fundamental studies of human physiology made it possible to penetrate into the mechanisms of atherogenesis and helped to establish the biological probability of a potential intervention in order to change these effects.

Observational studies involving people (cohort, prospective, case-control) are extremely useful in determining the attributive risk of a particular factor. Randomized trials can help confirm a causal relationship and are necessary for choosing interventions to reduce risk.

Each of these strategies has strengths and weaknesses. Descriptive studies (for example, the description of a single observation, a series of observations, cross-sectional, cross-cultural studies, the study of population temporal trends) have considerable value because of the ability to generate hypotheses. However, their design does not adequately control potential factors that may obscure obvious associations. Observational studies (eg, cohort, prospective, case-control) can better control potential inaccuracies.

Observational studies are particularly important in determining the attributable risk of a particular factor, when this factor has a great effect, as in the case of smoking and lung cancer. However, when small or moderate effects are studied in observational studies, the number of uncontrollable distorting factors can be as great as the probable risk itself.

In such cases, randomized studies are needed to confirm causality. When the causal relationship between RF and the disease is confirmed, appropriate intervention should be selected and applied. Even if the causal relationship is beyond doubt, research will help quantify the effect of the intervention. When the question arises about the choice between risk and benefit of intervention, randomized studies are needed to determine its net clinical effect.

This provision is important because the degree of associated risk is not necessarily related to the magnitude of the benefits obtained as a result of the intervention. This lack of correlation may be due to the inability of a specific intervention to achieve the desired effect, or the magnitude of the change may not lead to a corresponding change in risk. An example is the difference between the risk of an increase in blood pressure pa 1 mm Hg. st. and less than expected benefit for CHD while reducing blood pressure by the same amount. Similarly, elevated Gmc is considered to be FR KBS, and folic acid reduces Gmc levels, but randomized studies have shown that lowering Gmc levels with folic acid does not reduce the risk of KBS.

Meta-analysis allows a better assessment of the risk associated with a specific risk factor (RF), or the benefit of an intervention. For example, an assessment of the benefits of aspirin in secondary prophylaxis was obtained as a result of a large meta-analysis of data from 300 clinical studies, which demonstrated that in patients with CVD, aspirin reduces the risk of major SSSob by 25%.

After obtaining acceptable assessments of the benefits and risks for a specific risk factor (RF), a cost-effectiveness analysis can help develop guidance for an intervention. To compare interventions, a single currency is used, calculating QALY or a year of life adjusted for disability (disability-adjusted life-year, DALY). The estimates obtained from this analysis depend on the assumptions made in this analysis. Due to the fact that preventive measures are long-lasting (lasting for decades), the consequences of the initial assumptions regarding these measures may be more important than with short-term interventions. However, the cost-effectiveness indicators of interventions for CVD prevention are important because the prevalence of CHD and the cost of treating it are high.

The cost-effectiveness indicator is calculated as the ratio of the net cost to the increase in life expectancy. Interventions with a cost-effectiveness ratio <$ 40,000 for QALY are comparable to other permanent interventions, such as control of hypertension and hemodialysis. Interventions with a cost-effectiveness indicator of <$ 20 thousand for QALY are welcome, while with an indicator of> $ 40 thousand for QALY are usually perceived by insurers as intervention above an acceptable level. The economic costs of ineffective primary prevention measures for persons with modifiable DFs> 2 in the United States annually amount to $ 13.2 billion.