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Rehabilitation and Cardiovascular Disease
by Ira Rashbaum, M.D.
Geriatric Times January/February 2002 Vol. III Issue 1
Cardiovascular diseases kill more Americans every year than any other illness, including cancer and AIDS. Advances in medical and surgical management, along with lifestyle modifications, have contributed to a greater likelihood of survival into the senior years. Greater emphasis has been placed on the roles of prevention and rehabilitation in the management of cardiovascular disease. Despite this, cardiovascular rehabilitation is generally felt to be an underutilized component in the total care of the geriatric patient population.
Cardiovascular rehabilitation is not limited to patients who have sustained myocardial infarction. Other rehabilitation candidates include patients who have undergone coronary artery bypass grafting, heart valve repair or replacement surgery, percutaneous transluminal coronary angioplasty, coronary artery stenting, pacemaker insertion, implantable cardiac defibrillator insertion, or insertion of a left ventricular assist device (LVAD). Also patients with congestive heart failure can benefit.
One of the most significant developments in cardiac surgery in recent years has been the introduction of minimally invasive direct coronary artery bypass. Advantages of this technique include smaller incisions; less pain; a shorter recovery time than with conventional bypass surgery; and decreased risk of heart attack, stroke, memory loss, pulmonary complications, sternum infection and post-operative anemia. This technique seems to be most applicable to patients who have single-vessel coronary artery disease.
Stents are metallic scaffolds that can be placed inside a diseased segment of a coronary artery to increase its diameter and improve blood flow to the heart and decrease symptoms of angina. Coating and irradiating the stent have been attempted to minimize the likelihood of arterial narrowing or clot formation. Cardiologists initially recommended delaying or withholding rehabilitation after stenting so as not to risk migration of the stent elsewhere in the body. Fortunately, this approach has been shown generally to be overly conservative.
Left ventricular assist devices are implantable pumps driven by pneumatic or electrical systems that can provide necessary support to very ill patients with congestive heart failure. Earmarked initially for patients awaiting cardiac transplant, a recent study suggests LVADs can provide longer-term support for failing hearts, possibly obviating the need for transplant. This may prove to be especially valuable in the geriatric patient population, in whom transplantation may be absolutely or relatively excluded. Rehabilitation of patients with LVADs has been accomplished successfully.
Phases of Rehabilitation
The spectrum of cardiovascular rehabilitation has been described in terms of phases. The delivery of these services is ordered and supervised by a physician and administered by nurses, physical therapists, occupational therapists, psychologists, social workers, exercise physiologists, vocational rehabilitation counselors and nutritionists.
Phase I occurs in a hospital setting and can be divided further into two phases. Phase IA, which occurs in an acute setting such as an intensive care unit or other general hospital location, happens after an acute medical illness or surgical procedure and involves low-level conditioning exercise and training in functional activities. Phase IB refers to cardiovascular rehabilitation at a specialized rehabilitation hospital or rehabilitation unit within a hospital and takes place when the patient has successfully completed Phase IA. Both aspects of Phase I utilize cardiac monitoring via telemetry. A primary goal of Phase IB is the safe transition from the hospital setting to either a sub-acute rehabilitation facility or home.
Phase II cardiovascular rehabilitation takes place in an outpatient setting and includes exercise, smoking cessation, weight reduction, lipid management, stress management and dietary changes. A focus of Phase II is secondary prevention of additional cardiovascular events. Some Phase II programs include telemetric monitoring.
Phase III usually is community-based, often without telemetric monitoring, and lasts from three to 12 months after the initial cardiovascular event. Phase IV is usually self-directed, begins approximately one year after the event, and is directed toward long-term lifestyle and exercise adaptation.
Elements of Rehabilitation
Cardiac rehabilitation has two primary elements: exercise and education. Exercise likely exerts its beneficial effects through a variety of direct and indirect mechanisms, including improvement in the relationship between cardiac oxygen supply and demand, increase in high density lipoprotein cholesterol levels, decrease in serum triglyceride levels, decrease in blood pressure, decrease in the aggregation of platelets and improvement in coronary arterial dilatation.
Exercise associated with cardiovascular rehabilitation has been traditionally aerobic. The referring physician should prescribe a submaximal exercise stress test in order to provide the patient and the rehabilitation provider with an exercise prescription, including target heart rate and blood pressure parameters.
Strength training is especially important for older adults in improving strength, balance, functional capacity and bone density (Verrill, 2001). Resistive exercise training has been shown to be beneficial for older adults who have cardiovascular disease or for those who are at risk for developing metabolic or cardiovascular complications.
Some cardiovascular surgeons, however, advise against strength training when the sternum is incised. A standard one-hour rehabilitation session comprises two aerobic exercise sessions and one session of strength training, emphasizing isotonic exercise rather than isometric exercise. Isometric exercise, performed by exertion against an immovable object, has been associated with a particularly large increase in blood pressure. Isotonic exercise, movement of a constant weight through a range of motion, is felt to be safer.
It is extremely important to ascertain the psychological status of geriatric patients with cardiovascular disease. Fear, depression and isolation due to a lack of social support may have an untoward effect on morbidity and mortality in this patient population. Assistance from rehabilitation team members or other mental health care professionals may be necessary. Support from friends and family and from groups can be critical.
The education element of rehabilitation of the geriatric patient with cardiovascular disease is the "secret weapon" of the entire process. Compared with patients whose rehabilitation consists solely of exercise, patients who have sustained heart attacks have decreased morbidity and mortality when education is infused into their rehabilitation. Patients should learn about cardiac anatomy and physiology, the pharmacology of cardiac medications, proper nutrition, smoking cessation, diabetes management, and stress reduction.
Since a greater number of senior citizens are deferring retirement or are semi-retired, the services of a vocational rehabilitation counselor should be offered. This professional can address return-to-work issues such as date of work resumption, ergonomic adaptation or job retraining.
Cardiovascular disease and an active sexual life do not have to be mutually exclusive. The traditional advice concerning return to sexual activity is the ability to climb two flights of stairs. The newer guideline, assuming sexual activity will be with the patient's usual partner, is the ability to perform approximately five metabolic equivalents of physical activity. A physician, physical therapist, occupational therapist or exercise physiologist can educate patients and their often equally anxious partners on understanding whether they meet this benchmark and provide other tips on how to safely and successfully resume sexual activity.
In terms of prevention of cardiovascular disease progression, the Lifestyle Heart Trial used a low-fat vegetarian diet, smoking cessation, stress management and moderate exercise in symptomatic patients with coronary artery disease (Ornish et al., 1990). Patients reported a 91% reduction in angina frequency, a 42% reduction in angina duration, and a 28% reduction in angina severity. After the yearlong study, average coronary artery narrowing decreased from 40.0% to 37.8%. The control group showed an increase in average coronary artery narrowing from 42.7% to 46.1%.
The evolving field of rehabilitation of cardiovascular disease definitely includes the geriatric patient population. In a variety of diseases, quality of life and mortality statistics can be improved when rehabilitation is an integral part of the health care equation.
Dr. Rashbaum is clinical associate professor of rehabilitation medicine at New York University School of Medicine.
References
Ornish D, Brown SE, Scherwitz LW et al. (1990), Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 336(8708):129-133.
Verrill DE (2001), Strength training for older adults. Geriatric Times 2(4):26-27.
