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Understanding the need for Cardiac Rehabilitation
Non-communicable diseases (NCDs), also known as
chronic diseases are the result of a combination
of genetic, physiological, environmental and
behavioral factors. They are responsible for
almost 71 of the total deaths globally today,
with Cardiovascular Diseases (CVDs) accounting
for the most NCD deaths followed by cancer,
respiratory diseases and diabetes (WHO 2018). Any
cardiac event caused due to a CVD is life
changing and making heathy changes to ones life
can be difficult. It is therefore essential that
support is extended beyond patients hospital
admission to ensure optimization of physical,
social and emotional recovery and Cardiac
Rehabilitation is the important key to
this. Cardiac Rehabilitation dates back to the
early 1900s, where the concept evolved from
observing simple bed rest for 6 weeks after acute
coronary events to becoming a multidisciplinary
approach (1950 by Hellerstein), to help cardiac
patients recover faster and return to their
optimal fitness level over a period of time.
Today, it involves pre-operative education and
counselling, post-operative patient care,
optimization of medical treatment, lifestyle risk
factor modification, nutritional counselling,
smoking cessation, behavioral change and
education, stress management, management of
blood pressure, diabetes or dyslipidemia,
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individually tailored exercises protocol,
cardio-protective therapies and long-term
management with timely audit and
evaluation. Cardiovascular diseases (CVDs) have
become the leading cause of mortality in India
and a quarter of all mortality is attributable to
CVD, with ischemic heart disease and stroke
accounting for more than 80 of CVD deaths. These
statistics point to the fact that Cardiac
Rehabilitation is the need of the hour, to help
survivors lead an optimally fit life. The aim is
to reduce the risk of a future cardiac event by
stabilizing, slowing, or even reversing the
progression of cardiovascular disease or cardiac
insult.
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Patients with cardiovascular disease events such
as myocardial infarction, percutaneous coronary
intervention (PCI), bypass surgery (CABG,
Coronary Artery Bypass Graft), stable angina,
heart transplant, heart valve surgery and heart
failures (with exceptions) are the ones requiring
Cardiac Rehabilitation. Occasionally,
contraindications to this program only concern
the exercise aspect while all other components
can be pursued. Traditionally Cardiac
Rehabilitation is divided into 3 phases (some
programmes may have 4 phases with phase 2 being
considered as a subacute phase with light
activity at home before beginning a formal
supervised outpatient program) which aims to
facilitate recovery and prevent future events.
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Phase 1 or the in-patient phase is initiated
right in the hospital after a Myocardial
Infarction, cardiac event or surgery and extends
as long as the patient stays in the hospitals.
It involves the physiotherapist helping patient
with monitored early progressive mobilization
including bedside exercises to make self-care
possible by discharge, with brief counselling
about the nature of illness, treatment, risk
factor management and follow up planning. Phase 2
or the subacute phase starts immediately post
discharge and usually extends for 2-4 weeks
after percutaneous coronary intervention or
Myocardial Infarction and 4 to 6 weeks after
cardiac surgery. It focuses on health education
and resumption of physical activity (light
activity) at home and vary in format from center
to center. Contact with the individual either
through telephone follow up, home visits or
individual /group education sessions are
maintained facilitating ongoing education and
exchange of information.
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Phase 3 or the supervised outpatient program
consists of a supervised program usually 2-4
weeks after percutaneous coronary intervention or
Myocardial Infarction and 4 to 6 weeks after
cardiac surgery in an outpatient setup and
extends for 12 to 36 weeks. It aims to help
patients return back to work or hobbies and
lifestyle. During this period, the patient visits
the outpatient clinic 2-3 times a week and
exercises for 15 to 60 minutes depending on his
condition under the supervision of the
therapist. This exercise regime usually includes
aerobic training, stretching/flexibility
exercises and an introduction to strength
training. At this stage, the physiotherapist
works with the individual to monitor his/ her
response to exercise with parameters such as the
heart rate, blood pressure, oxygen saturation,
breathing rate, rate of perceived exertion and
his ECG and also trains the individual to
monitor his own heart rate and activity level.
Certain outcome measures such as simple walk
tests may be used pre and post phase 3 to
evaluate the progress in the exercise capacity of
the individual. Phase 4, aims to move the
individual towards more intense independent
physical activity and lifetime maintenance with
prime focus on physical fitness and additional
risk factor reduction. Here, the physiotherapist
expects the individual to monitor his own
response to exercise including heart rate and
perceived exertion. Home or gymnasium exercise
program are encouraged with the aim of
continuing risk factor modification and exercise
program learned during phase 3. Cardiac
Rehabilitation has numerous benefits such as
mortality and morbidity reduction from
exercise-based program, improvement in life
quality by improving symptoms such as lessening
of chest pain, dyspnea, fatigue, stress and
enhancement of overall sense of psycho-social
well-being. It is not only clinically effective
but also cost effective when compared to lipid
lowering medications, thrombolytic and bypass
surgery.