The level of involvement of each member of the multidisciplinary team varies, but in general the medical practitioners prescribe cardioprotective medication and the allied health professionals empower lifestyle and behaviour change through education and counselling, along with providing a suitable environment in which to exercise. Once these behaviours have been addressed and the patient is medically stable, the usual path of care is a referral to a long-term community-based phase IV CR programme, which is usually led by an exercise professional (BACR, 2006).

Phase I Cardiac Rehabilitation

Phase I should start immediately after the patient has been admitted to the hospital following an acute coronary syndrome (ST segment elevation MI or non-ST segment elevation MI), or a step change in their cardiac condition, e.g. known angina requiring revascularisation, or an exacerbation in their condition, e.g. heart failure (BACR, 2006). The hospital setting is usually a coronary care unit, medical ward, tertiary centre or a cardiothoracic centre. All patients are eligible for phase I CR. The first component of phase I CR includes an assessment of the patient’s physical, psychological and social needs. Relevant information is usually given verbally or written in the form of a booklet on the following areas (BACR, 2006):

• diagnosis and treatment
  
• risk factor modification
  
• lifestyle modification
  
• medication
  
• management of chest pain and shortness of breath
  
• physical activity
  
• anxiety and depression
  
• returning home, work and travel.

The length of stay in hospital varies from hospital to hospital but generally patients are discharged between two and five days after admission, depending on their condition. The time frames to achieve all the above objectives are limited by the short stay in hospital and they are usually continued into phase II.

Phase II Cardiac Rehabilitation

Phase II CR takes place in an outpatient setting following discharge from hospital. The care of the patient is transferred back to the GP and CR is usually delivered by the primary care trust or the referring hospital. Phase II lasts between two and six weeks, but is dependent on local provision and the patient’s cardiac condition. During phase II the patient should be continually assessed in the following areas (DH, 2000):

• cardiac risk
  
• physical, psychological and social needs for CR
  
• provision of lifestyle advice and psychological interventions
  
• provision of resuscitation training to family members.

The above objectives are normally achieved through follow-up phone calls, risk factor management clinics and home visits. Phase II can be a worrying time for many patients and their family members, as they may feel vulnerable after discharge from hospital. However, phase II is paramount to enhance risk factor and lifestyle changes. Many CR programmes enrol the patient in the Heart Manual, Angioplasty Plan or Angina Plan; these are home-based self-supervised programmes with medical support (Lewin et al., 1992, 2002). These programmes can be used as a sole CR programme or in conjunction with a formal CR programme. The beneficial effects of home-based CR are comparable to centre-based CR. This has been demonstrated in a recent meta-analysis, which showed that home- and centre-based forms of CR are equally effective in reducing mortality and cardiac events, risk factor reduction and improving health-related quality of life in patients following an MI or revascularisation (Dalal et al., 2010).

During phase II, patients may also be invited to attend educational talks on various topics such as:

• CHD
  
• medication
  
• diet
  
• physical activity
  
• stress management
  
• relaxation techniques.

Phase III Cardiac Rehabilitation

Phase III CR can start at any time and is usually dependent on local provision and the cardiac status of the patient. In general, patients start phase III two weeks following planned percutaneous coronary intervention, four to six weeks post uncomplicated MI and six to eight weeks post cardiac surgery (BACR, 2006). During phase III, patients start a formal rehabilitation programme with individualised and group exercise sessions.

The first step in the assessment of the patient during phase III includes a clinical history, the results of any investigations to rule out contra-indications to exercise (coronary angiography, echocardiograms, stress ECG, etc.), a physical examination (resting heart rate, blood pressure, body mass index and waist circumference), and physical and psychological tests. Physical tests usually take the form of an exercise test, which might include a treadmill test, incremental shuttle walk test (Singh et al., 1992), Chester step test (Sykes, 2003) or the six-minute walk test (Butland et al., 1982). The purpose of these tests is to help determine functional capacity, risk stratification, to set appropriate exercise intensities and to measure the effects of the CR programme. Furthermore, simple psychological tests can be used to measure depression and quality of life before and after the programme. Such psychological tests include the hospital anxiety and depression scale (Zigmond and Snaith, 1983) and Short-Form 36 (SF-36v2) functional limitation questionnaire (Ware and Sherbourne, 1992).

Following the assessment, a medically based supervised exercise programme and home programme can be started. The benefits of regular exercise in lowering total and cardiac mortality in patients with established CHD have been well documented (Clarke et al., 2005; Taylor et al., 2004). A recent meta-analysis of 8,940 men and women showed that exercise-based CR programmes reduce all cause mortality by 27% and cardiac mortality by 31% compared with patients receiving usual care (Taylor et al., 2004). These findings have been echoed in a much larger meta-analysis of 21,295 patients, which showed that secondary prevention programmes, including risk factor counselling or education along with regular exercise sessions, reduced mortality and recurrent MI rates (Clarke et al., 2005). This meta-analysis demonstrated that CR programmes with exercise had a non-significant 12% effect on reducing mortality and a significant 38% positive effect on reducing recurrent MIs. Furthermore, CR programmes without exercise had a 23% positive effect on lowering mortality (which was significant) and a non-significant 14% benefit on reducing recurrent MIs.

Phase IV Cardiac Rehabilitation

Phase IV CR usually follows phase III and is normally delivered in the community. The community setting is the preferred choice as it promotes independence. The purpose of phase IV is to promote the long-term maintenance of health behaviours that were achieved during phases I, II and III. Phase IV is usually led by a BACR exercise instructor and involves the patient attending regular exercise sessions, which are similar in nature to the exercise class in the phase III setting. The limited number of studies that have investigated the long-term benefits of phase IV CR have shown that it continues to improve quality of life, promotes smoking cessation adherence and offers social support (Willmer and Waite 2009; Thow et al., 2008).

Summary

Every healthcare professional involved in the care of patients with CHD should actively promote cardiac rehabilitation. Rehabilitation consists of four phases, which aim to promote lifestyle advice, education, risk factor management, psychosocial advice, nutrition advice, cardioprotective drug therapy, supervised exercise sessions and long-term management strategies. CR has been shown to reduce total and cardiac mortality when compared with usual care. However, the uptake of this specific and focused rehabilitation is low and each aspect of the rehabilitation pathway should take into account social, cultural and financial considerations, and all lifestyle inventions must be tailored to the individual.

References

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