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Recommendations on prevention and rehabilitation acknowledge that patient management should be based on an assessment of total risk. The various components addressed by CR programs will generally include attention to the following aspects:
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A primary principle of patient education is to facilitate necessary behavior change known to improve health outcomes. Changing health behavior requires assessment of a patients’ knowledge, attitudes, and beliefs as well as psychological health (especially anxiety and depression). The American Association of Cardiovascular and Pulmonary Rehabilitation acknowledges several guiding principles in effecting necessary change, as listed in Table 45–10. Support from the physician, program staff, and family contributes to the effective behavioral change. CR programs offer the opportunity for comprehensive, evidence-based, lifestyle modification.30
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Cigarette smoking, a major risk factor for the development of CHD, remains a leading cause of preventable death worldwide.35 It is expected that the number of smokers worldwide will increase to > 1.6 billion by 2025.36 The causal relationship between smoking and CV disease is well established. The effects of smoking on the CV system include stimulation of smooth muscle proliferation and cell migration to intima, increase in platelet adhesion to the endothelium, and an increase in fibrinogen levels (increased clotting).2 Smoking cessation will reduce the subsequent risk of death by up to 9% in absolute terms.36 Observational studies in post-MI patients suggest that this may be reflected as a halving of long-term mortality.37
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CR programs are the ideal setting in which to promote smoking cessation. Educating patients about the association between smoking and heart disease at this vulnerable period may be the trigger to motivate smoking cessation. Numerous nonpharmacologic and pharmacologic agents are available to aid the patient and health professional with this campaign. Both group therapy and individual counseling to instigate behavioral change are useful in helping the patient to quit smoking. Nicotine replacement therapy in the form of transdermal patches, chewing gum, nasal spray, oral inhalers, and sublingual tablets may augment the process of smoking cessation.2
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Obesity is a major public health problem throughout the developed world. Overweight, obesity, and excess abdominal fat are related to important CHD risk factors, including high levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, blood pressure, fibrinogen, and insulin and low levels of high-density lipoprotein cholesterol.38
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For overweight and obese patients with CHD, the combination of a reduced-energy diet and increased physical activity is recommended. An energy deficit is most readily achievable through choice of foods low in total fat content, with a reduction in saturated fat being more preferable. Further reductions in total energy intake can be achieved by reducing refined carbohydrate intake.2
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Nutrition plays a pivotal role in the etiology and development of CV disease. A range of dietary measures can make a favorable contribution to the secondary prevention of coronary artery disease.30 Changes in the quantity and quality of dietary fat improve the lipid profile. Blood pressure is lowered by reducing sodium intake and by adhering to the Dietary Approaches to Stop Hypertension (DASH) diet, a diet rich in vegetables, fruits, and low-fat dairy products and low in saturated and total fat. Consumption of a diet relatively low in fat, trans-fatty acids, saturated fatty acids, cholesterol, and sodium or relatively high in fruit, vegetables, polyunsaturated fatty acids, monounsaturated fatty acids, fish, fiber, and potassium is likely to reduce the risk of CV disease.39,40,41 Dietary therapy is additive to drug therapy and further reduces CV risk. Failure to adopt a cardioprotective diet may result in the need to use higher doses or combinations of medications.42,43 A cardioprotective diet pattern has been developed for easy incorporation into CR programs. The cumulative advantage accruing from all food and nutrients in an integrated dietary pattern offers the prospect of a substantial reduction in risk of CV disease for individuals and populations.44
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This dietary pattern (which is based on the Mediterranean diet) may be summarized as follows:
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Low in saturated fatty acids
Low in trans-fatty acids
Replace saturated fats with monounsaturated and polyunsaturated fats
Omega-3 fatty acids (eg, oily fish)
Replace some fat intake with soluble fiber
Reduce salt
Five or more portions of fruit and vegetables daily
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There is insufficient evidence to recommend nutrition supplements of antioxidant vitamins, minerals, or trace elements for the treatment of CV disease. There is evidence to support the effectiveness of nutritional education in generating positive and long-lasting changes in the dietary habits of patients involved in CR.45 Therefore, nutritional evaluation, counseling, and monitoring must occur as part of a comprehensive CR program.
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CR nutrition education is conducted over four phases to facilitate patient learning. Some patients may require more information/nutrition counseling than they can obtain in the context of a group program, such as patients with additional health needs (eg, diabetes mellitus, obesity, chronic heart failure) and patients from culturally and linguistically diverse backgrounds.2 A structure for nutritional education sessions is available in Appendix 45–1.
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Evidence exists regarding the importance of hypertension as a risk factor for CV disease and the importance of lifestyle measures and appropriate medication to treat and control hypertension.14 (See Chap. 25 for medical therapy of hypertension.)
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Management of Hypertension
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It is well recognized that hypertensive vascular disease is a continuum. Genetic, environmental, and coexisting risk factors influence the rapidity and progression of vascular changes within the blood vessel walls. Ambulatory blood pressure monitoring is recommended to confirm diagnosis.46 Change in lifestyle behaviors may have important effects on BP control. Excessive alcohol consumption is associated with hypertension, and reduction or cessation of consumption of alcohol has been shown to improve blood pressure and reduce need for medication.46 A majority of people with hypertension are salt-sensitive, and reductions in dietary salt are effective. There is a direct link between increasing body weight and blood pressure levels, particularly if fat distribution is central.38 Obesity contributes to hypertension through its effect on the sympathetic and renin-angiotensin-aldosterone systems. Stress has a major effect on blood pressure, and recognition and elimination of this factor may have important effects. A weight loss of 5 kg has been shown to correspond to a blood pressure reduction of 10/5 mm Hg. Secondary causes of hypertension may be diagnosed if one of the following is noted: blood pressure of ≥ 180/110 mm Hg, uncontrolled hypertension despite three medications, or nondipping of blood pressure during 24-hour ambulatory blood pressure monitoring.
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Lifestyle changes and patient education are paramount in the management of hypertension. Such lifestyle measures include smoking cessation, regular exercise, weight reduction, and dietary changes. These measures will also enhance the effects of antihypertensive medication and demonstrate favorable influence on overall CV risk. The recommended DASH diet (low in salt and saturated fat and high in fiber, fruit, and vegetables) can lower blood pressure as effectively as nondietary measures using maximum monotherapy.47 Effective implementation of nonpharmacologic measures requires knowledge, time, and resources best undertaken by well-trained health professionals. CR provides an ideal setting to improve CV risk factors.
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Psychosocial factors may impact on the occurrence and recurrence of CHD and may affect rehabilitation. Psychosocial factors are numerous and include anxiety and/or depression, personality issues (eg, hostility, cynicism, mistrust), social isolation, anger and hostility, type D (or distressed) personality, lack of social support, chronic or subacute life stress (eg, stress at work, high demands, limited decision making, low rewards), or accumulation of painful and difficult situations during a relatively short period of time.2 Psychological stress can be as dangerous to the heart as physical stress for people with coronary artery disease. The link between depression, social isolation, and lack of quality social support and heart disease is strong and consistent. Depression, social isolation, and lack of quality social support are as risky to heart health as abnormal levels of blood fats, smoking, and high blood pressure. Prospective cohort studies provide strong evidence that psychosocial factors, particularly depression and social support, are independent etiologic and prognostic factors for CHD.2
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Pathophysiologic mechanisms with acute stress and intense emotion lead to sympathetic nervous system stimulation with an increase in heart rate and blood pressure, vasoconstriction, proarrhythmic potential, reduced endothelial dysfunction, endothelial injury, platelet activation, and/or hemostatic changes, all of which can result in the clinical consequences of myocardial ischemia, arrhythmias, and the potential for thrombosis. Positive psychological effects of CR have been demonstrated, although the variety of instruments used to assess health-related quality of life makes quantitative analysis difficult.48
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Anxiety and depression are prevalent in both cardiac patients and their families, and are associated with increased morbidity and mortality. Although they may be normal responses after a cardiac event and a natural part of recovery after any life-threatening or stressful event, in excess, they may seriously impede rehabilitation. Anxiety can affect both short- and long-term recovery after a cardiac event. It may relate more to how an individual responds to his or her condition than to its severity. Anxiety may trigger a variety of physiologic responses, such as increased levels of circulating lipids, platelet and macrophage cell activation, and increased heart rate, blood pressure, and myocardial oxygen demand, all of which have the potential to contribute to atherosclerosis and acute coronary syndromes. These responses have implications for the development of atherosclerosis, ischemia, MI, and sudden death.2
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CR programs provide a valuable chance to assess cardiac patients for anxiety and depression and provide interventions for those who need specialized care. Many instruments are available to CR professionals to assess anxiety and depression. The most practical method is the use of a self-report scale. Within psychology, psychometric robustness (which includes reliability and validity), sensitivity to change over time, brevity (which minimizes demands on patients), and a track record of having been used in past well-designed studies are some of the important hallmarks of good self-report measures for use in assessment, intervention, and evaluation studies with patients with chronic illness.49 A commentary on these instruments is included in Appendix 45–2. There is evidence that the use of active coping, rather than avoidant coping strategies, may lead to positive psychological adjustment and improved quality of life. The principles of self-management programs are outlined in Appendix 45–3.
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Cardiopulmonary Resuscitation Training for Relatives of Cardiac Patients
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Sudden cardiac death is defined as follows: “An unexpected death due to cardiac causes that occurs within one hour of symptom onset. Cardiac arrest, usually due to cardiac arrhythmias, is the term used to describe the sudden collapse, loss of consciousness and loss of effective circulation that precedes biologic death.”50
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Recognition and treatment of potentially lethal arrhythmias in the coronary care unit has reduced mortality; however, up to 75% of fatalities occur out of hospital. Of these out-of-hospital cardiac arrests, it is estimated that a majority occur in the home with the spouse or family member being a witness.51
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An important need identified by spouses of recovering cardiac patients is the need to learn what to do if their spouse has a cardiac arrest at home.52 Various professional associations have made recommendations regarding cardiopulmonary resuscitation (CPR) training for the relatives of cardiac patients. The AHA endorsed CPR training of the lay public in 1971, and from 1992, the AHA guidelines recommend targeting courses to relatives and close friends of persons at risk. The AHA International Guidelines starting in 2000 strongly recommend targeting family members of high-risk adult and pediatric patients, stating that: “Healthcare professionals should recommend CPR training for family members as part of the discharge teaching plan for high-risk patients. Persons caring for high-risk populations must be educated to recognize airway or CV emergencies and must be taught how to intervene appropriately and to contact the emergency medical system.”53
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Barriers to Utilization of Traditional Cardiac Rehabilitation Programs and the Future
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The most common barrier to CR is lack of physician referral. Despite national guidelines in the United States designating CR as a Class IA recommendation, Menezes et al54 report that up to 80% are not referred. In particular, women, those of lower socioeconomic status, and patients aged > 65 years have lower rates of referral.11,55,56 Additionally, patients who have limitations due to geographic location or insurance coverage issues are less likely to be referred and to participate.15 Of those who are referred, patient factors for nonparticipation include financial burden, transportation difficulties, and competing priorities.15,54,57 Importantly, once referred to CR, reasons for nonattendance were more likely due to personal factors, such as perceptions of heart disease and family influence, versus physical issues.58 In Europe, the EuroAspire survey analyzed records and interviews of 9000 patients in 22 countries in Europe and reported that only one-third of patients with CHD received any form of CR.59 Even among those referred to CR, the dropout rate is high among post-MI patients (29% dropout at 1 month).60 Patient-related factors include affordability, including insurance coverage, transportation difficulties, and competing priorities. From a systems perspective, lack of personnel and resources have been cited as having a significant impact on utilization.
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CR is a Class 1 recommendation from the AHA, the ACC, and the European Society of Cardiology.61,62 In European CR programs, patients who are referred are more likely to enroll and complete CR due to both national health insurance coverage and employer support.63 Although most of the literature regarding CR originates from higher income countries, CR has been evaluated in low- and middle-income countries (LMICs) and has demonstrated improved clinical results, but lower enrollment rates.64 Worldwide, only 39% of countries offer CR, with a breakdown of 68% of high-income countries versus 23% of LMICs.65 Although fewer randomized trials of SP programs have been undertaken in LMICs, improvement in clinical outcomes should be expected with CR programs, given the particularly poor rates of control of CV disease risk factors. Due to both financial constraints and geographic challenges, the use of home- or community-based programs warrants investigation in LMICs. Strategies to improve CR availability are necessary and include supportive public health policies as well as novel models of delivery.65
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In light of the known barriers to care, innovative strategies to bring CR to more patients necessitates newer delivery models. In addition to telemedicine models, Internet-based, home-based, and community-based programs may complement the current facility-based programs.66 A systematic review and meta-analysis of home-based versus facility-based CR concluded that for low-risk patients after MI and revascularization, home-based CR improved health-related quality of life and clinical outcomes including death, revascularization, or hospital admission equally as well as center-based CR.67 The out-of-facility delivery models should augment the various needs of individuals based on their individual CV risk, age, and social support. Recently, investigators from Toronto, Canada, compared health behaviors and outcomes of women randomly assigned to women-only CR programs with women assigned to participation in traditional programs and found both physical activity and quality of life improved in both groups.68 Other alternatives for providing comprehensive CV risk reduction include electronic media programs.69 Mobile health technologies such as the Circle of Health app provide education, motivation, and instruction for all individuals interested in maintaining CV health.70 Mobile technologies may be used in connection with at-home or facility-based programs with the potential to improve outcomes.