Cardiac rehab's benefit too often unrealized
Most people who are hospitalized after a coronary event have a better outcome if cardiac rehabilitation is part of their recovery. So why is it that, nationally, physicians prescribe the care for only about 20 percent of patients who could benefit?
The question vexes Dr. Margaret Hall, chief of cardiology at Northwest Hospital & Medical Center.
“Doctors either don’t think of it or they think it’s not available. Maybe they don’t recognizethe range of services that come with cardiac rehab. Whatever the case, doctors ought to have their order sets arranged so the prescription is generated automatically in appropriate cases.”
Compounding Hall’s frustration is the fact that insurance routinely covers the first phase of rehabilitation.
“Physicians who routinely treat people with cardiac conditions know that exercise helps control weight, cholesterol and blood pressure – the main factors that raise risk for a subsequent event,” Hall said.
Cardiac rehab differs from other exercise regimens in one basic respect: staff members’ experience with heart-ailing patients. At Northwest Hospital, two cardiac-trained nurses and two master’s level exercise physiologists review the medical history and then meet with the patient.
To generate a baseline physical fitness, the patient is connected to a heart monitor and carefully tested for stamina, strength and coordination. Rehab specialists note physical limitations and probe for details about detrimental habits such as smoking.
Patients also are asked to fill out a scale for depression, which “can enormously impact their follow-through,” Hall said. With each patient, the team presents its findings to Hall and collaboratively establishes a personal exercise plan. Resulting sessions typically run thrice weekly for 12 weeks, with the nurses and physiologists monitoring for abnormal heart rhythms and other adverse signs.
“You can take someone who has not been an exerciser and show them the benefits, through the difference of pretest and post-test levels. Virtually everyone has a significant improvement in their capacity over the course of the therapy, so people are compelled to keep it up,” Hall said.
Rehab patients and their families also are invited to a series of 20 classes during the span, about topics such as medications, stress, smoking-cessation and vitamin supplements.
Over the course of three months, some patients grow comfortable enough to confide a detail like falling off the diet bandwagon or not being able to afford their medication – feedback equally as valuable as exercise data in refining the course of care, Hall said.
Some cardiac conditions are outliers to the rationale, she cautioned: Immediate rehab is not appropriate for people, for example, with an active congestive heart failure or infection or unstable rhythm. Vigorous exercise should be avoided in the early weeks after stent implantation. But for most patients in the aftermath of a coronary event or surgery, a medically considered exercise prescription is far preferable to the alternative, she said.
“If left to their own devices, patients overdo or underdo. We have families who push grandpa into the chair and don’t want him to get up again because they’re worried he’ll have another heart attack. That’s often the worst thing you can do for somebody with any of the heart conditions that we treat with rehab.”
Northwest Hospital’s cardiac-rehab clinic has a counterpart to the south, at Valley Medical Center in Renton. Both programs are affiliates of UW Medicine Regional Heart Center.