Type: supervised CR exercise sessions usually consist of aerobic and muscular strength endurance training, which are normally alternated as part of a circuit class (Appendix A shows a typical CR exercise circuit). It should be noted that patients attending exercise-based CR should not present with any of the contra-indications to exercise and they should be risk stratified to predict cardiovascular events during exercise (Boxes 14.2 and 14.3).

Home-Based Exercise Programme

As discussed earlier, most CR programmes only offer between one-to-two supervised exercise sessions per week. Therefore, it is important for the patient to participate in a home based exercise programme to achieve the desired “dose” of exercise, which is at least 30 minutes of moderate intensity aerobic exercise performed on five days of the week (DH, 2004). To achieve this goal, walking is one of the easiest ways to exercise, it requires no skill or equipment, and it is socially acceptable with no age, gender or race barriers. Walking should be encouraged in most cardiac patients and the health professional should encourage the use of the RPE scale (Borg, 1998) to set the walking pace.

Psychosocial Wellbeing

Sexual Relationships

Sexual problems related to atherosclerosis, side effects of medical therapies, e.g. beta-blockers, or psychological factors (anxiety and depression) are common in patients with CHD. Therefore it is essential that the patient and partner are happy to discuss their sexual relationships before offering any advice. For those wishing to discuss such matters, advice can be given to help alleviate some of the fears surrounding sexual activity. One scenario might be the fear of provoking cardiovascular complications (angina, dyspnoea and palpitations) during sexual intercourse. This may lead to loss of libido and impotence for both the patient and partner. However, the patient and their partner can be reassured that if symptoms such as angina, dyspnoea or palpitations are absent during moderate exertion physical activity, they are unlikely to occur during sexual intercourse (Kostis et al., 2005). The reader is referred to Kostis et al. (2005) for a more detailed discussion in the area of sexual dysfunction and cardiac risk.

Return to Work

There are several limiting factors that might influence the patient’s ability to return to work following a cardiac event. Such limitations include low functional capacity, poor prognosis, reduced self-efficacy or inappropriate perceptions of actual job demands (ACSM, 2005). Exercise training may enhance the patient’s decision to return to work by improving self-efficacy (ACSM, 2005). In addition, aerobic and resistance training have been shown to improve the physiological (heart rate and blood pressure) response to a given workload, which might be advantageous for patients returning to a manual occupation (ACSM, 2005). The decision on the time frames for when a patient can return to work should be discussed in conjunction with the patient, employer, GP and CR team.

Travel

Travelling long distances should be avoided until the patient is medically stable. Planned travel should be discussed with the CR team, and high altitudes (>1500 m) and extreme temperatures should be avoided (Dickstein et al., 2008). In general, air travel is preferable to long journeys by other means of transportation (Dickstein et al., 2008).

Cardioprotective Medication

Drug therapy is an important part of CR secondary prevention programmes. This section discusses in brief the importance of some of the major drug therapies used in secondary prevention; further information can be found in more comprehensive cardiac books. The following recommendations are based on the recent NICE guidelines (NICE, 2007a), which advocate that all patients who have had an acute MI should be offered treatment with a combination of the following drugs:

• ACE (angiotensin-converting enzyme) inhibitor
  
• aspirin
  
• beta-blocker
  
• HMG-CoA reductase inhibitors (statins).

The effects of combination drug therapies in patients with CAD have been well documented. Hippisley-Cox and Coupland (2005) have demonstrated a 70–80% reduction in all-cause mortality with drug therapy combinations including ACE inhibitors, aspirin, beta-blockers and statins.

ACE Inhibitors

NICE recommends that ACE inhibitors should be offered to all patients following an acute MI (NICE, 2007a). In the past, ACE inhibitors were used in the treatment of left ventricular dysfunction and heart failure. However, mortality benefits have now been recognised in MI patients with preserved left ventricular function (Yusuf et al., 2000). ACE inhibitor therapy should be started as soon as possible, at an appropriate level and titrated upwards at short intervals until the maximum tolerated or target dose is reached (NICE, 2007a). ACE inhibitor therapy is also one of the first-line treatments for hypertension and should be used to achieve optimal blood pressure control (<130/80 mm Hg). However, if ACE inhibitor therapy is not well tolerated, angiotensin receptor blockers may be recommended as an alternative (NICE, 2007a).

Aspirin

Aspirin should be offered to all patients after an acute MI, and should be continued indefinitely (NICE, 2007a). Generally, aspirin and other anti-platelet therapies are recommended for all patients with established atherosclerotic disease (Wood et al., 2005). Anti-platelet therapy has been shown in meta-analyses to significantly reduce the risk in all-cause mortality, vascular mortality, non-fatal re-infarction of the myocardium, and non-fatal stroke in unstable angina, acute MI, stroke, transient ischaemic attacks or other evidence of vascular disease (Antithrombotic Trialists’ Collaboration, 2002; Antiplatelet Trialists’ Collaboration, 1994).

Other anti-platelet therapies include a combination of clopidogrel and low-dose aspirin, which is reserved for high-risk patients who have suffered a non-ST segment elevation MI or have undergone percutaneous coronary interventions (NICE, 2007a). In general, such patients can be offered combination therapy for at least 12 months. In addition, clopidogrel can be offered as an alternative to patients who are intolerant to aspirin (NICE, 2007a).

Beta-Blockers

Beta-blockers are used in the treatment of myocardial ischaemia, heart failure and cardiovascular disease protection following an MI, and are also used as a second-line treatment in hypertension (Wood et al., 2005). The benefits of beta-blockers have been well documented in a recent meta-analysis by Freemantle et al. (1999), which showed evidence of significant reductions in all-cause mortality, cardiovascular death and in particular sudden cardiac death, as well as non-fatal re-infarction. Beta-blockers should be offered soon after an acute MI when the patient is clinically stable, and continued indefinitely (NICE, 2007a).

HMG-CoA Reductase Inhibitors

HMG-CoA reductase inhibitors (statin therapy) are hypolipidemic drugs, which are recommended for adults with clinical evidence of cardiovascular disease (NICE, 2007a). Statin therapy has been shown to reduce the relative risk of death by 30% (Scandinavian Simvastatin Survival Study Group, 1994) and should be the first-line treatment for reducing total and LDL cholesterol (NICE, 2007a). These findings have been supported by a meta-analysis of statin trials, which comprised of more than 90,000 patients (Baigent et al., 2005). In this meta-analysis a reduction of 1 mmol/l in LDL cholesterol resulted in a 12% proportional reduction in all-cause mortality, a 19% reduction in coronary mortality and a 24% reduction in the need for coronary revascularisation (Baigent et al., 2005). Statin therapy should be offered as soon as possible following a cardiovascular event regardless of the initial cholesterol value (NICE, 2007a). This has been supported by three clinical trials, which have assessed the short-term impact of the immediate use of statin therapy. The three trials concluded that early statin therapy reduces early mortality following an acute coronary syndrome (Cannon et al., 2004; de Lemos et al., 2004; Schwartz et al., 2001). Statin therapy should be continued indefinitely and gradually titrated upwards to meet the recommended lipid targets. The safety of statin therapy has been well documented (Talbert, 2006); however, fibrates, nicotinic acid, anion exchange resins or ezetimbe can also be offered as an alternative to patients who are insensitive to statin therapy (NICE, 2008).

Summary

Cardiac rehabilitation is an evidence-based approach that focuses on managing patients with CHD through lifestyle interventions and cardioprotective medication. Lifestyle interventions in a CR setting include a supervised, or at home, exercise programme, advice on the Mediterranean diet and in some instances counselling on smoking cessation. In addition, CHD patients should be assessed and, where necessary, treated for anxiety and/or depression. The overall evidence for promoting and implementing the various lifestyle interventions and prescribing cardioprotective medication has been well documented in reducing several CHD risk factors along with reducing cardiac mortality and morbidity. However, when delivering lifestyle interventions social, cultural and financial considerations must always be considered in tailoring treatment to the individual needs of each patient.

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