Cardiac Rehabilitation Outside the Hospital: a Way to Control and Prevent Cardiovascular Diseases in Africa Flavio Burgarella 3rd Asian Preventive Cardiology & Cardiac Rehabilitation Conference Hong Kong, China 11-14 December 2010

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Cardiac Rehabilitation Outside Hospital This guideline provides reccomandations for best practice in cardiac rehabilitation in African Countries. It is primarly concerned with rehabilitation following myocardial infarction (MI) or coronary revascularization, but also addresses the rehabilitation needs of patients with angina or heart failure. Cardiac rehabilitation has much in common with secondary prevention.

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Cardiac rehabilitation Cardiac rehabilitation is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and mantain optimal physical and psychosocial health.

Cardiac rehabilitation after the acute disease It takes the form of a structured exercise programme in a hospital setting with educational and psychological support and advice on risk factors. Increasingly it is recognised that both components can be undertaken safely and successfully in the community. Membership of a local cardiac support group, which involves exercise in a community center such as a gym, or a healthy farm, or a field outside hospital may help mantain physical activity and behavioural change.

Psychological and educational interventions Comprehensive cardiac rehabilitation consists of exercise training together with education and psychological support. The purpose of these interventions is to facilitate a return to normal living and to encourage patients to make lifestyle changes in order to prevent further events. Educational and psychological support is also necessary to deal with psychological distress, which is common following MI.

Psychological predictors of risk Estimates of the prevalence of depression in MI patients range from 15% to 45%. Depression is associate with a 3 to 4 fold increase in cardiac mortality and it is strongly predictive of poor symptomatic, psychological, social and functional outcome at 3 and 12 months. Depression

Psychological predictors of risk High levels of anxiety may also have an advertise effect on outcome. Anxiety while in the coronary care unit is associated with an increased risk of acute coronary sindrome and arrhythmic events over the following 12 months. Anxiety

Educational interventions include individual and group education on Coronary Heart Disease (CHD), healthy eating and diet, smoking cessation, hypertension, exercise, self monitoring diaries, booklets, medication advice and vocational counselling. Effectiveness of educational interventions

Cardiovascular outcomes A meta-analysis of 8988 patients in 37 trials found that cardiac rehabilitation programmes including psychological and/or educational interventions resulted in a 34% reduction in cardiac mortality and a 29% reduction in recurrent MI at 1-10 years follow up.

Educational principles Analysis of studies of health education in cardiac patients has found that the most important determinants of effectiveness is the quality of the intervention, defined as adherence to the 5 principles of adult learning.

Principles of adult learning Relevance (tailored to patients’ knowledge, beliefs, circumstances) Individualism (tailored to personal needs) Feedback (informed regarding progress with learning or change) Reinforcement (rewarded for progress) Facilitation (provided with means to take action and/or reduce barriers).

Exercise training The exercise component of cardiac rehabilitation has evolved from the recognition that physical deconditioning occurs following MI and the knowledge that regular physical exercise protects against cardiovascular disease. Structured exercise as a therapeutic intervention is central to cardiac rehabilitation. Daily exercise should also be encouraged as part of an active living philosophy.

Benefit of exercise training A Cochrane review of men and women of all ages with previous MI, revascularisation or angina found that exercise-only cardiac rehabilitation reduces all cause mortality by 27%, cardiac death by 31% and a combined end point of mortality, non fatal myocardial infarction and revascularisation by 19%.

Assessment before exercise training (1) From most patients, clinical risk stratification based on history, examination and resting ECG combined with a functional capacity test such as a 6 minutes walking test will be sufficient.

Assessment before exercise training (2) High risk patients may be defined as those who have: experienced a MI complicated by heart failure, cardiogenic shock and/or complex ventricular arrhythmias angina or breathlessness occurring at low level of exercise, e.g. inability to complete the first 4 minutes of the walking test ST segment depression ≥1 mm on resting ECG undergone exercise testing with marked ST depression ≥2 mm or angina

Assessment before exercise training (3) Effort test and echocardiography are recommended to assess residual ischaemia and ventricular function respectively but are not a really necessary part of cardiac rehabilitation in all patients, except for high intensity exercise or in high risk patients. Anyway, in developed countries it is a normal practice for almost all patients.

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Location A number of randomised trials and large observational studies have found that low to moderate intensity exercise for low to moderate risk patients can be provided as safely and as effectively in the home or community as in the hospital setting. Patients at high risk and those undergoing high intensity training should only exercise at venues with full resuscitation facilities and staff trained in advance life support.

Exercise content (1) Cardio-respiratory fitness requires aerobic training of low to moderate intensity, long duration and with repetitive movement of large muscle groups. The frequency, intensity and duration of exercise can be varied to achieve the desired training effect. The individual’s preference best determines the appropriate mode of activity. All trials included aerobic exercise such as cycling, walking, jogging, rowing or calisthenics.

Exercise content (2) Exercise training should have: a 15-minute warm up period an aerobic conditioning phase (brisk walking for 20 to 45 minutes, preferably daily or at least 5 times per week) is adequate exercise for most post MI patients a 10-minute cool down period 5-10 minutes relaxation

Frequency and length of programme The experience suggests that incorporation of regular, sustained exercise into an individual’s lifestyle is likely to be more important than the frequency or length of formal exercise training.

Monitoring of exercise training Exercise intensity may be monitored by perceived exertion using Borg’s scale. A perceived exertion scale allows quantification of the subjective intensity of exercise. Ratings on Borg’s scale have been found to relate closely to other objective measures of exercise intensity, namely oxygen uptake and heart rate. The aim is to enable patients to achieve a level of “comfortable breathlessness” while exercising.

Correlation of training level with preceived exertion and heart rate

Resistance training Blood pressure may increase more during resistance training than during aerobic training. Hypertensive patients should not be enrolled in such a programme until their blood pressure is well controlled.

Chronic heart failure Systematic reviews of exercise-based cardiac rehabilitation in stable, chronic heart failure have found benefits to exercise capacity and possibly to symptoms. Benefit is probably derived from peripheral adaptations (vasodilation and improved muscle oxidative capacity) rather than improvements in ventricular function.

Older patients Systematic reviews indicate that older patients benefit at least as much as younger patients from exercise-based cardiac rehabilitation. A recent randomised trial of exercise-only cardiac rehabilitation in elderly patients with coronary disease reported not only greater exercise tolerance, but also improved physical activity, quality of life and well-being.

Women Systematic reviews indicate that women benefit from exercise-based cardiac rehabilitation in terms of functional capacity at least as much as men. A review of patients with heart failure undergoing exercise training found that women benefited as much as men in terms of increased exercise capacity and improved autonomic indices.

Long term follow up Once the process of short term recovery is complete, the emphasis of cardiac rehabilitation shifts to long term maintenance of physical activity and lifestyle change, with appropriate secondary prophylactic drug therapy.

Lifestyle modification and drug therapy for secondary prevention of CHD

Self-help groups (1) There is a long history of self-help groups for patients with cardiac disease, located in sports and community centres, schools and universities, hospitals anf church halls. All of them provide care following hospital-based programmes. There are many of these groups that are Affiliated Chapters of Heart Friends Around The World.

Self-help groups (2) The structure and content of programmes vary widely and include exercise sessions, relaxation sessions, invited speakers and group discussions. Many of the exercise programmes are professionally supervised by physiotherapists, nurses, or fitness instructors, but none are equipped with defibrillators.

Self-help groups (3) There is no direct evidence about the effectiveness of self-help groups in cardiac rehabilitation. An important aspect of self-help groups is the interaction between people and the opportunity to share experiences. This may be important to change behaviour in secondary prevention.

Long term exercise programmes Moderate physical activity should continue long term, but this proves difficult for most people with coronary disease once supervision is withdrawn. People with stable coronary disease should be encouraged to continue regular moderate intensity aerobic exercise.

The model of Healthy Farms Healthy farm: a model for cardiac rehabilitation outside hospital has been practiced on Saturday, May 22nd, 2010, at the Burgarella Farm. The following pictures are for example.

The Burgarella Farm

The life path (1)

The life path (2)

Healthy Farm

Healthy Farm

Healthy Farm

Healthy Farm

Healthy Farm