Chapter 7: CARDIAC REHABILITATION IN WOMEN

INTRODUCTION

Although death rates from cardiovascular disease (CVD) have declined in recent years, CVD continues to be the leading cause of death for women in the United States. In the years between 1997 and 2007, the overall death rate from CVD declined 26.3%; however, the rate of death has been increasing by an average of 1.3% annually between 1997 and 2002, which is statistically significant.¹

Cardiac rehabilitation (CR) involves exercise training, education, counseling regarding risk reduction and lifestyle modification, and, frequently, behavior interventions in patients with cardiac events or chronic cardiac disease. For many women who experience a cardiac event, a structured CR is their first opportunity to become physically active. CR is an important component of multidisciplinary approach for management of the patients with various presentations of coronary heart disease. CR improves functional capacity, recovery, and psychological well-being. It is a class I recommendation endorsed by American Heart Association and American College of Cardiology in treatment of patients with CVD. Moreover, it is a cost-effective intervention following an acute coronary event and chronic heart failure (CHF)^2,3,4 as it improves prognosis by reducing recurrent hospitalization and health-care expenditures, while prolonging life.

In addition to a structured exercise program, components of a CR program often include medical history and physical examination; nutrition counseling; weight, blood pressure, and lipid management; diabetes education; psychosocial evaluation and treatment; and tobacco cessation programs.⁵ The benefits of participation in CR program include improved exercise capacity, improvement in lipid profile, reduction of obesity, prevention or reduction of Type 2 diabetes mellitus, improvement in depression and anxiety, and improvement in overall quality of life.⁶

Despite the role of cardiac rehabilitation having been extensively documented, endorsed, and promoted by a number of health-care organizations for the comprehensive secondary prevention of cardiovascular events, it continues to remain vastly underutilized; much more so in women. They are less likely to be referred for rehabilitation program, and even when referred, are less likely to attend.⁷ The Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women strongly endorse cardiac rehabilitation after a coronary event.⁸ Barriers to participation for women include the lack of financial resources, transportation difficulties, and lack of social and emotional support.

HISTORICAL PERSPECTIVE

Following the clinical description of myocardial infarction by Herrick in 1912, prolonged bed rest up to 2 months was advocated for fear of infarct expansion, aneurysm formation, congestive heart failure, cardiac rupture, and sudden death. Strenuous activities were restricted for prolonged periods, and sometimes indefinitely. Resumption of normal life style was rare.⁹

By late 1940s, Levine and Lown advocated the use of chair therapy as an alternative to prolonged bed rest.¹⁰ It was erroneously believed that the dependent lower extremities resulted in reduced venous return, thereby decreasing the stroke work and cardiac output.¹¹ Early ambulation was defined ...