The Benefit Of Exercises In Cardiac Rehabilitation Essay
A study published in the Journal of Clinical Nurse in USA shows the importance of a lifestyle approach in the maintenance of secondary risk factors and especially physical activity, but unfortunately very little evidence exists, on the long-term adherence, to these programmes. An increase in physical activity and exercise is known to have an independent benefit, associated with reduced mortality and morbidity (Jolliffe et al. 2004) and is a primary objective of all cardiac rehabilitation programmes (USA, Department of Health 2000). The mechanisms underpinning the observed cardiac rehabilitation benefit could, theoretically, be attributed to an increase in physical activity status (Schairer et al. 1998, Thompson et al. 2003), however, further analysis suggests that this may not be as straightforward, as it first seems. Although each patient showed significant positive gains from rehabilitation, the effect was not evident, to the same extent, in all outcome measures, for each patient.The Benefit Of Exercises In Cardiac Rehabilitation Essay. For instance, the correlation between depression and MacNew Health-Related Quality of Life explained, 79% of the variance at 12 months, yet the same correlations with total energy expenditure only explained 5% of the variance, in the same time. The benefits gained from six-week cardiac rehabilitation, seen in the form of improved quality of life and reduced anxiety and depression, may not be explained by significant changes in physical activity.
• Heart Failure
After a Myocardial Infarction, the heart is so severally damaged that it is unable to generate sufficient force, to pump enough blood to keep the body alive, & as a result the patient goes into cardiogenetic shock. Whenever the left ventricle becomes dysfunctional, the heart becomes progressively weaker. Myocardial Infarction is by far, the most common cause of left ventricular dysfunction, & as a result the ejection fraction, is reduced to less than 50%. Other causes of this include: Chronic Hypertension, Valve diseases, school abuse and cardiomyopathy.
Following myocardial infarction, the reduction in stroke volume is due to impairment of both the filling and emptying phases of the left ventricle. Filling is reduced because damage to the left ventricle makes it less compliant and, consequently cannot accommodate the same volume of blood that a healthy heart can. This results in reduced preload and therefore, a reduction in stroke volume. Emptying is impaired because the loss of cardiac muscle mass (as a result of the infarction) reduces contractility and, consequently, a lower percentage of blood is ejected.
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If the infarct is extensive or the site of the myocardial infarction is anterior, then the left ventricle becomes bigger and thicker (a process known as remodelling) which initially helps to maintain cardiac output. Nevertheless, such compensatory mechanisms, although designed to support cardiac function, will over time, actually increase the work of the heart. For example, increased sympathetic activity raises blood pressure, which means the heart has to work harder in order to eject blood into the systemic circulation.
Once the compensatory mechanisms cease to be effective, left ventricle dysfunction typically progresses to a situation in which symptoms of heart failure becomes apparent.
Heart Failure occurs when the left ventricle is unable to maintain a cardiac output that is adequate to meet the oxygen demands of the body. Clinically heart failure is a syndrome in which patients have symptoms of breathlessness or fatigue, either at rest or during exertion. They may also experience ankle swelling. The right ventricle therefore ejects less blood causing blood to back up in the systemic circulation phase which in turn increases the pressure in the systemic capillaries. The result is, fluid leaks from the circulation into the tissues resulting in pitting oedema (swollen tissue in which indentation can be made, usually seen as swollen ankles).The Benefit Of Exercises In Cardiac Rehabilitation Essay. When the left-side fails, the reduced ejection fraction of the left ventricle causes blood to back up in the pulmonary capillaries. The result is, fluid leaks from the circulation into the tissues, hindering the gaseous exchange process, particularly on exertion.
Patients complain of fatigue, their exercise capacity is reduced and usually they notice deterioration, in quality of life. The degree of the left ventricular impairment has an effect on the survival rate; the worse the impairment, the lower the survival. The chances of heart failure, increase, with the average age being 75years. Half of all patients diagnosed with heart failure, will die within 4 years, and over 50% of those patients with severe heart failure will die within 1 year (ECS Guidelines, 2006).
Cardiac rehabilitation is a really important mechanisms to improve and prolong life for patients with Heart Failure, Endurance training improves symptoms and quality of life and decreases mortality rate and hospitalization, and also being recognised as a benefit for heart failure (HF) patients It has also been proven that endurance training benefits the cardiac and skeletal muscle oxidative metabolism and intracellular energy transfer in HF.
A studied published in the Cardiovascular Research Magazine, titled “Beneficial effects of endurance training on cardiac and skeletal muscle energy metabolism in heart failure” showed how the exercises can improve the life of patients diagnosed with heart failure.
The studied showed that heart failure induces a metabolic myopathy, affecting both heart and skeletal muscles. This manifests itself, mainly, by decreased oxidative capacity, shift in substrate utilization and altered energy transfer by phosphotransfer kinases. In skeletal muscle, endurance exercise capacity is mainly conditioned by increased oxidative capacity, increased lipid utilization, improvement of energy fluxes and a better relationship between energy production and utilization. Prolonged exercise is thus able to counteract these deteriorations, by improving oxygen and substrate delivery, as well as facilitating a metabolic remodelling of the cardiac and skeletal muscles. Although beneficial effects of endurance training in heart failure are indubitable, further work is needed to delineate the pleiotropic effects of physical activity on cardiac and skeletal muscle functions. This issue is of interest for clinical output, especially for rehabilitation of patients with heart failure. It is important one knows the beneficial effects of endurance training in CHF patients in terms of exercise capacity, quality of life and even morbi-mortality(Cardiovascular Research 73 – 2007)
There is increased evidence that no harm is done to the heart by endurance training, only benefits. If by further studies this proves to be true in human patients, training should be implemented in the care standards, together with β-blockers and medication antagonizing the renin–angiotensine–aldosterone system. Further research, examining the mechanisms of these beneficial effects, on the whole organ and cellular levels ,will be of vital importance, in order to identify potential advantageous effects of pharmacological and physical therapy . The Benefit Of Exercises In Cardiac Rehabilitation Essay.
Chapter 3 – Methodology:
The long-term association between Cardiovascular Rehabilitation attendance and mortality has been rarely studied. A randomised controlled trial of 651 men, with AMI attending an exercise-only programme in the USA, found no difference, in all causes of mortality at 19 years (Cardiopulm Rehabil Prev 2000; 20:130). Conversely, a Swedish observational study of 305 men and women after Myocardial Infarction, found that attendance at Cardiovascular Rehabilitation was associated with a reduction in all-causes of mortality (37% vs. 48%) after 10 years, but not after 5 years (Eur Heart J 1993;14:831–5), These were earlier studies (in the 1970s) ,but since then outcomes might have been influenced by the changes in medical management that occurred during the 1980s and early 1990s, such as the introduction of β blockers in 1985 and of ACE inhibitors and statins in 1994–5. No contemporary studies have investigated the effects of Cardiac Rehabilitation, on the mortality rate in patients, with combined Myocardial Infarction, Coronary Artery Bypass Gravity Surgery and Percutanes Coronary Intervention, over a period of 10 years or more. However, an Australian Study done by the Heart Research Centre in Melbourne and published in the heart Magazine in December 2012, was the first study to do so ,and indicated that Cardiac Rehabilitation may have a sustained benefit on mortality.
The main finding from this study was that after a 14-year follow-up period, Cardiovascular Rehabilitation non-attendees had a higher risk of mortality, than those who did attend Cardiovascular Rehabilitation, even after taking into account baseline differences between groups. We also found a significant agenda sex-adjusted dose–response relationship between the proportion of sessions attended and all-cause mortality. This association became non-significant after further adjustment for baseline differences in those who smoked.
The study brings a crude all-cause mortality rates and attendance at Cardiac Rehabilitation, there were 199 deaths during a median follow up time of 14.2 years. Crude (unadjusted) all-cause mortality rates of attenders and non-attenders are shown in table 2. Among the total study population, nonattenders had a mortality rate per 10 000 person years which was nearly double that of attenders. A similar trend was seen for oth men and women, for those aged over 60 years at study baseline and for patients with Acute Myocardial Infarction or Coronary Artery Bypass Graft Surgery.
Crude all-cause death rates per 10000 person-years for attenders and non-attenders at a cardiac rehabilitation programme; overall and by subgroups:
Attenders* Non-attenders†
No of
deaths‡ Death rate per
10000 person-years
(95% CI)§ No of
deaths‡ Death rate per
10000 person-years
(95% CI)§
Total
(n=544)
76 210 (168 to 263) 123 429 (359 to 512)
Men
(n=397) 54 193 (148 to 252) 78 373 (299 to 465)
Women
(n=145)
22 270 (178 to 411) 45 579 (433 to 776)
Baseline age in years
≤49
(n=83) 5 76 (32 to 182) 4 84 (32 to 225)
50–59
(n=129)
8 84 (42 to 168) 10 127 (68 to 236)
60–69
(n=170)
29 208 (145 to 300) 29 388 (269 to 558)
≥70
(n=160)
34 558 (399 to 781) 80 930 (747 to 1158)
Coronary Artery Bypass Graft
(n=155)
25 182 (123 to 270) 24 410 (275 to 611)
Acute Myocardial Infarction
(n=295)
44 225 (168 to 303) 75 523 (417 to 655)
Percutaneous Coronary Intervention (n=92) 7 242 (115 to 507) 24 283 (190 to 422)
Chapter 4 – Analysis of Results/Findings:
The sample study done by The Heart Research Centre in Melbourne was drawn from 652 participants, recruited for an earlier study, investigating attendance patterns after referral to Cardiac Rehabilitation.The Benefit Of Exercises In Cardiac Rehabilitation Essay. Subjects for the original attendance patterns study were patients with Acute Myocardial Infarction, Coronary Artery Bypass Graft Surgery or Percutoneous coronary Intervention, who were consecutively admitted over an 11-month period, during 1996 and 1997 to one of two major teaching hospitals in Melbourne. In Victoria the prevailing policy of automatic referral to Cardiac Rehabilitation, was that, all patients were encouraged to attend a Cardiac Rehabilitation programme. at various hospitals. Participants were then tracked for 4 months after their acute event, to determine their Cardiac Rehabilitation attendance. This subsequent follow-up study used a retrospective cohort design, to examine long-term mortality outcomes on the participants that were enrolled, in the original attendance patterns study. That being, the 573 patients whose Cardiac Rehabilitation attendance was successfully determined. Allowing for disease severity and avoiding survival bias, 12 participants died within 1 year of their cardiac event and a further 17 had inadequate CR attendance records. This left 544 subjects (83.4% of the 652 patients in the original attendance patterns study) available for follow-up mortality study.
Chapter 5 – Discussion of Results
The study showed really interesting results. First a total of 281 (52%) men and women attended at least one exercise session. There were no significant statistical differences seen between attendees and non-attenders. Comparing those who did not attend any sessions; attendees were more likely to be male, younger, and having undergone Coronary Artery Bypass Graft Surgery. Attenders were also more likely to be employed and have a family history of heart disease, but were less likely to report having diabetes, than non-attendees. It also examined the characteristics of the participants excluded. The 17 patients with inadequate CR records, were more likely to have had an AMI, (p=0.007), while the 12 participants who died within 12 months of their event ,were also more likely to have had an Acute Myocardial Infarction, but also be unemployed, live alone, have left school earlier (p=0.015) and have diabetes.
The most important findings of this Australian study were consistent with many meta-analyses and systematic reviews. All reporting significant reductions in all-cause mortality, following attendance at comprehensive Cardiac Rehabilitation programmes. This study showed a reduction in mortality, of between was 20% and 32% for Cardiovascular Rehabilitation attendees. These meta-analyses and systematic reviews were predominantly based on smaller trials (dating from the 1970s) and were confined to younger men after Acute Myocardial Infarction. They excluded women, older patients and other diagnostic groups, which were more reflective of a target group for Cardiovascular Rehabilitation. More recent studies, which have tended to include these patient subgroups, show that there is a 50% reduction in mortality as a result of Cardiac Rehabilitation. This is much more, consistent with the 58% reduction reported by the Australian Study. On the other hand a Canadian matched cohort study, using registry-based data, found a 50% reduction in mortality rates at 5 years after beginning Cardiac Rehabilitation attendance, while a study of 2396 Percutaneus Coronary Intervention patients, found a 47% reduction in mortality rates at 12 months, after starting Cardiac Rehabilitation attendance (Circulation 2011;123:2344–52) The Benefit Of Exercises In Cardiac Rehabilitation Essay.
All contemporary studies have demonstrated a beneficial effect of Cardiac Rehabilitation on mortality rates. However, two systematic reviews, comparing Cardiac Rehabilitation attendance and the reduction in mortality ,found no significant association in subgroup analyses of studies published ,after 1995 (Am J Med 2004;116:682–92) In both sub analyses, there was only a small amount of studies included, and the populations chosen were limited to younger male patients with Acute Myocardial Infarction, thus significantly reducing the results.. The recent Rehabilitation After Myocardial Infarction Trial (RAMIT) from the UK found no effect of Cardiovascular Rehabilitation attendance on all-cause mortality,19 although the study methodology has been criticised (Heart 2012;98:672–3).
Findings from RAMIT have led to suggestions that comprehensive CR may no longer be relevant, when you consider high effective treatments, such as β blockers, statins and early revascularisation (Heart 2011; 98:637–44). However, others suggest that the RAMIT findings demonstrate, that the type of CR performed in the late 1990s in the UK, was not as effective and was deemed as being ” not fit for purpose’(Heart 2012;98:605–6.). The UK model of Cardiovascular Rehabilitation is very similar to the Australian model described in our study. However, recent recommendations for CR in both countries, encourages a more comprehensive approach, by looking at funding, staffing, referral and attendance rate issues. All of these will continue to affect the optimal delivery of Cardiovascular Rehabilitation.
A further question remains about the continuing need for Cardiovascular Rehabilitation, in light of the reduction in Cardiac Heart Diseases related deaths, over the past few decades. Recent evidence shows, that this decline is slowing, especially among people aged <55 years (Heart 2008; 94:178–81). This pattern may be due to an increased risk of diabetes and obesity in this age group, both of which are major risk contributors to Cardiac Heart Diseases (Lancet 2004; 364:937–52). United Kindon studies exploring the changing clinical profile of Cardiac Rehabilitation attenders between the 1990s and 2006, found that, while there was a very large increase in statin use, as well as a subsequent improvement in lipid parameters, participants were now more commonly diagnosed with diabetes and were more likely to be obese (J Cardiopulm Rehabil Prev 2008;28:299–306). This trend suggests that there will be a continuing need for interventions such as Cardiac Rehabilitation.
Chapter 6 – Conclusion:
Although the short-term benefits of Cardiac Rehabilitation on risk factors are clear (with risk factor reductions accounting for about half the reduction in mortality, associated with CR), further research is required , as to what the long term benefits of Cardiac Rehabilitation has on risk factors. CHD progresses over several years, and therefore long-term follow-up of patients with CHD; will provide valuable evidence, for compiling strategies that will slow the progression of the disease. The beneficial effects of Cardiac Rehabilitation will be further substantiated by these findings
Evidence for the benefits of comprehensive Cardiac Rehabilitation programmes is strong and research should now focus on the ‘gaps’. There needs to be a system of referral, which will encourage patients to participate in Cardiac Rehabilitation, as well as developing strategies, to enhance patient retention, particularly among those population groups who do not attend CR, such as smokers, women and younger patients. Investigators should also continue to produce evidence for alternative models of cardiac secondary prevention, so that patients can choose from a range of options.
Observational studies need to be undertaken using larger samples, from a variety of populations and countries. Such studies might identify predictors of ‘successful’ Cardiac Rehabilitation programmes,
and they also might allow for subgroup analysis. An example of this would be, stratification of outcomes by socioeconomic status, in order to assess the potential impact of CR on health inequalities. Collection of appropriate baseline data would also allow for exploration of the mechanisms by which CR confers long-term benefit.
Recent worldwide studies provide further support, for the long-term benefits of Cardiac Rehabilitation in a contemporary, heterogeneous population. We should continue to recognise, that comprehensive models of Cardiac Rehabilitation, have significant health benefits. When you look at the projected increase in obesity, diabetes and their impact on CHD, the need for Cardiac Rehabilitation, as an effective intervention, is crucial, if we are to keep the mortality rates down.
In conclusion the study highlighted some of the benefits patients receive through Cardiac Rehabilitation but also show how it is harder for patients with a Cardiac event to achieve the same level of results as their non cardiac event counterparts from the Rehabilitation programme.
All those points reinforce the importance of Cardiac rehabilitation. Studies carried out all over the world prove the benefits of these programmes but unfortunately a huge number of patients still drop out of the rehabilitation programme before the conclusion. The Benefit Of Exercises In Cardiac Rehabilitation Essay. Sadly there are an even greater percentage of patients that do not make physical exercise a lifestyle habit and relapse into another Cardiac Event.
Governments are spending millions on rehabilitation programmes but Health and Fitness professionals should also develop a better understand of the principles and of Cardiac Rehabilitation as in this area where they can literally save lives.
Purpose: Cardiac rehabilitation aims to improve quality of life and reduce mortality of cardiovascular disease. In order to obtain this cardiac rehabilitation programmes aim to help patients make the necessary health related behaviour changes and as a result improve quality of life. This study was done evaluate if health changes occur in a short term cardiac programme and what effect this has on quality of life.
Method: To address these issues. We assessed health behaviour changes in relation to exercise and diet and effects of these on quality of life using 27 patients during a 6-8 week phase 3 cardiac rehabilitation programme. Instrument used to measure was a self-designed questionnaire based on SF-36 questionnaire.
Results : Among the 27 patients 24 (89%) were male and 3 (11%) were female. The mean age was 60.17 (±12.645). 40% had Myocardial infarction, 37% had coronary bypass surgery and 22% had Angioplasty. 44% had a family history of coronary artery disease. The Sturwood questionnaire scale detected behaviour changes in relation to diet and exercise and quality of life and outlook on life scores. Quality of life scores was significantly influenced by changes in exercise and diet scores, such that patients reporting high exercise changes and diets changes displayed higher quality of life scores (p<0.05)
Conclusion: Quality of life is improved with physical and mental changes to improve health. Taking a multi-disciplinary approach to cardiac rehabilitation by using as exercise, dietary education, risk factor education and access to psychologists quality of life can be increased over a short period of time of 6 to 8 weeks. Therefore is it suggested to all cardiac rehabilitation programmes to take a multi-disciplinary approach for increased results of quality of life.
Introduction
It is estimated by the British Heart Foundation that 2.6 million are affected by heart disease in the UK. In England, Wales and Northern Ireland there are 395 cardiac rehabilitation programmes. Cardiac rehabilitation is defined by the 1964 World Health Organisation as providing an optimal physical, mental and social environment for the cardiac patient that allows them to regain to maximal functional capacity in society.
Cardiac rehabilitation is a secondary prevention of cardiovascular events. Around 46% of people that have MI, angioplasty (PCI) and coronary artery bypass attend CR in the England PROBLEM OF CARDIAC REHAB.
In the 1930′-s those that survived an acute coronary event their cardiac rehabilitation was comprised of at least 6 weeks of bed rest which could be extended upto 12 weeks. This continued into the 1940’s however the patient was able to alternate between bed rest and chair sitting. In the 1950’s patients were allowed to walk 3-4 minutes at a slow pace after 4 weeks of bed to chair rest. The Benefit Of Exercises In Cardiac Rehabilitation Essay. During this time Dr Herman Hellerstein (Evans, Probert and Shuldham, 2009) discovered that during this time of bed rest that the patients were rapidly deconditioning and a large number of patients suffered pulmonary embolism after bed rest. As a consequence of these observations Dr Hellerstein introduced a multidisciplinary approach to the cardiac rehabilitation programme. Since the 1950’s cardiac rehabilitation has not changed appreciably apart from the exercise programme has been combined with dietary education, risk factor assessments and psychosocial support for patients in order to obtain the greatest benefit from cardiac rehabilitation. (Evans, Probert and Shuldham, 2009)
According to the British Heart Foundation cardiac rehabilitation now consists of a structured programme that involves exercise, education on diet and the use of appropriate medication in order to reverse the progression or slow down the rate of coronary heart disease. The main aims of cardiac rehabilitation is to educate the need for a change in lifestyle and to help patients overcome the fear of returning to everyday life activities and becoming part of society again.
A programme includes a medical, psychological, social assessment to discover the needs of the patient. It provides education pertaining to the causes of the illness and provides appropriate information describing the necessary lifestyle changes to enable the patient to have the best possible future health. It helps the patients to set up goals for lifestyle change and ensures they maintain them by reviewing and providing support for these goals.
Cardiac rehabilitation has four phases in total. Phase 1 is when the medical condition of the patient is stable but is still an inpatient at hospital. In this phase the person is likely to be visited by a nurse that will educate the patient about the event and the reasons why it occurred, they will also provide information about lifestyle changes such as physical activity, smoking and diet. The nurse will also ensure that the secondary prevention medication has been implemented. This is usually done by a nurse that is a member of staff on the cardiac rehabilitation team and will refer the patient to the programme. (Bethell, Lewin and Dalal, 2009)
Phase 2 is early discharge and the period when the patient is at home waiting to start the 6-12 week exercise programme. Those that have been treated with angioplasty have to wait 2 weeks, Myocardial infarction (MI) patients have to wait 4 weeks and coronary bypass patients have to wait 6 weeks to begin the programme. Over this period the patient receives on-going education and encouraged to take healthy lifestyle choices by telephone calls, or visits from staff from the cardiac rehabilitation programme or by a primary care team. (Bethell, Lewin and Dalal, 2009)The Benefit Of Exercises In Cardiac Rehabilitation Essay.
Phase 3 is an out-patient 6-12 week program me. The main method of phase 3 cardiac rehabilitation is the use of a supervised group class that usually takes place in a local community centre such as a leisure centre. The patient is assessed before they join the programme. This involves a review of their medical history, the results of any examinations such as electrocardiograms, echocardiograms, blood lipid levels and blood sugar levels. The patient has a physical examination such as weight, height and blood pressure (Bethell, Lewin and Dalal, 2009). The patient is then asked to take part in a physical function test which is either a 6 minute walk test, treadmill test or a shuttle test to identify the exercise level at which the patient can perform and therefore how long they need to be enrolled on the programme. The patient also has a psychological and quality of life test to determine if the patient requires any psychosocial help. All the assessment findings are analysed and are used to classify the patient into one of three risk categories (high, intermediate and low). Those at high and intermediate risk will need additional supervision throughout the programme.
The Phase 3 of cardiac rehabilitation mainly involves a progressive exercise training programme and is supported by risk factor monitoring, relaxation training and education (involving the understanding of the causes and risk factor in heart attacks, diet and the use of medication to control the illness and how exercise is important after heart failure).
Phase 4 is the long term maintenance of behaviour change to continue to improve health and to carry on with lifestyle changes that were undertaken in phase 3. This is supported by cardiac rehabilitation centres providing exercise classes and annual check-ups of symptoms, exercise, diet, smoking, blood lipids, blood sugar levels and medication.
Referral to cardiac rehabilitation is restricted to one of three diagnostic groups, these are MI, elective angioplasty (PCI) or coronary artery bypass surgery (CABG). The majority of patients admitted have one or more risk factors that are significant on impacting health such as obesity, high systolic blood pressure (>140 mmHg) or diastolic blood pressure (>90 mmHg), smokers and those that did not meet the national exercise recommendations. Patients that have suffered myocardial infarctions represent the greatest proportion admitted to the programme from the three diagnostic groups followed by CABG group and PCI. Other patient groups are referred such as those with angina or heart failure but this is only a small minority of patients. Men outnumber women 2:1 this may be explained by the fact that there is a greater prevalence in heart disease in men, however women live longer than men so the prevalence of heart disease catches up in women. This is proved by the fact that women are on average 6 years older than men when attending the cardiac rehabilitation. However it may also represent the poor uptake of cardiac rehabilitation in women.
Development.
Most cardiac rehabilitation programmes over the past years have been through nurses and physiotherapists that have noticed a gap in the service of patients that have experienced a coronary event and through this have provided professional care through little or no budget.
Multi-disciplinary
It has been recognied by the British Heart Foundation that the quality of care in the England is variable they have acknowledged a large gap between the quality of care given as opposed to the quality that should be provided.
Cardiac rehabilitation is a multidisciplinary programme. The British Association for Cardiac Rehabilitation Minimum clinical standards recommend that for each team there should be at least one nurse, physiotherapist, dietician, pharmacist, a clinical psychologist and have administrative support . However from the National Audit for 2010 there is a great variance in the professionals involved with programme. Nearly all programmes have a nurse available (95%) and many of the programmes have a physiotherapist (70%) or an exercise specialist 56%. The Benefit Of Exercises In Cardiac Rehabilitation Essay. However very worryingly just over half of the programmes have access to a dietician (56%) and worse only 11% have access to a psychologist. 12% of patients have borderline depression and 8% have depression when admitted to the programme.
There are many benefits of cardiac rehabilitation in the literature : one of the main findings in heart failure patients is a reduction in resting heart rate and systolic blood pressure which increases the ability of the muscles to extract oxygen for energy at a given work intensity. Patients with heart failure often experience myocardial ischaemia during low physical exertion but with exercise training the patient is able to perform the same work at a higher intensity and therefore the threshold at which myocardial ischemia or angina occurs increases. (Leon 2005). Wenger et al (1995) found that performing aerobic exercise three times a week over a three month period increased maximal oxygen consumption by 15% to 20% when working at an intensity of between 70% to 85% of maximum heart rate. Taylor et al (2004) produced a systematic review and a meta-analysis which included 8940 patients, the discovered that all-cause mortality and cardiac mortality was reduced with cardiac rehabilitation. They also found a decrease in systolic blood pressure, total cholesterol levels, and triglyceride levels. However they did not find any reductions in diastolic pressure, non-fatal MI or improved quality of life due to increased health.
Benefits of diet
Although most research concentrates on improved physical health there have been relatively few studies reporting how short term cardiac rehabilitation programmes impacts on quality of life and outlook on life and health especially in those patient who have had coronary revascularisation surgery (Hung et al, 2004). Belardinelli et al (1999) showed that quality of life improved in cardiac patients improved with exercise however this was measured over a longitudinal period with out-patients in long term rehabilitation care. Stahle et al (1999) used the Karolinska questionnaire with older cardiac patients which evaluated the efficacy of impact of a one year exercise only rehabilitation on quality of life. More recently Yohannes et al (2004) and Freitas et al (2011) looked at 6 and 4 week intense exercise rehabilitation using SF-36 questionnaire they evaluated that the short term effects of rehabilitation improved quality of life scores and also found decreased levels of depression and anxiety evaluated by the HAD scale. A follow up study (Yohannes et al, 2010) after 12 months reported that the benefits of the programme were maintained. The Benefit Of Exercises In Cardiac Rehabilitation Essay. However, the Freitas et al (2011) study was conducted in France and therefore the main objective of this study was to determine if the phase 3 cardiac rehabilitation programmes in England could produce a positive impact on quality of life and outlook on life, as well as a quantitative analysis to discover if there are behavioural changes relating to exercise and diet. If changes have occurred and are initiated in the programme we will need to determine if there are factors that influence these changes such as age, gender, coronary event, weight and family support rather than the aspect of the benefits of the programme. This study will also investigate three cardiac events including MI, CABG and PCI the latter two of which are the least studied in assessing exercise and its impact on quality of life. The study will also include the impact of diet on quality of life……
It is predicted that patients that have made behavioural changes in relation to exercise and diet will have an improved quality of life than those that do not make behavioural changes. The null hypothesis is that cardiac rehabilitation has no effect on behavioural changes and therefore no effect on quality of life.
Diet improvement and quality of life – more on multidisciplinary how should be looking at diet as well.
Method
The population of interest were adults that had recently undergone a coronary event and as a result had been referred to a cardiac rehabilitation programme. The population that was accessible to this study consisted of people that were patients at cardiac rehabilitation centres that met the following criteria: had undergone a recent coronary event (e.g. myocardial infarction, coronary by-pass surgery or angioplasty); currently at phase 3 of the rehabilitation programme; must be over the age of 18 years. Permission was asked at five cardiac rehabilitation centres that included phase 3 patients, all 32 patients met the criteria throughout the centres. Out of the 32 patients that were asked to participate in the study 27 returned a response.
The sample composed of 24 males and 3 females (88.9% and 11.1% respectively). The age of the sample ranged from 24 to 79, the average age 60.17 ± 12.645 years. From a diagnosis point of view the sample was comprised of 11 myocardial infarction (40.7%), 10 coronary by-pass surgery (37%) and 6 percutaneous coronary angioplasty (22.2%).
Although the sample cannot be considered to be representative of all cardiac rehabilitation programmes in England and the type of coronary event, this was not the main goal of this study. The main purpose of this study was to determine if cardiac rehabilitation could improve quality of life. Any results reported in this study could be generalised to local cardiac rehabilitation programmes in Yorkshire and Nottingham and also to programmes that have similar patients and implement a similar programme. The Benefit Of Exercises In Cardiac Rehabilitation Essay.
Measures
The measure used was developed specifically for this study and was administrated through the use of a questionnaire. The questionnaire was divided into five sections. First section includes 13-item questions that are composed of open and closed type questions and aims to collect basic information such as age, type of coronary event, smoking habits and lifestyle choices prior to the coronary event. Sections two, three, four and five were 10-item Likert-type response scale questions where 1 = ‘strongly disagree’ and 9 = ‘strongly agree’ and the scale scores was the sum of the 10 items. Scores from 1 to 4 were considered minus scores (for example: 1 = -1, 2 = -2), 5 = neutral and was scored 0 and scores from 6 to 9 were plus scores (for example 6 = 1, 7 = 2). The total scale score was the sum of the four scale sections of 40 items. Each scale section measures behaviour change, changes in perception and awareness and physical changes in relation to exercise, diet, quality of life and outlook on life and health due to cardiac rehabilitation programme. The entire questionnaire is provided in Appendix A.
Procedure
The patients were recruited at five separate programmes; three of the programmes were based in Yorkshire, and two programmes Nottingham. All patients were attending a phase 3 of the cardiac rehabilitation programme referred by a hospital cardiac nurse to attend.
The Yorkshire rehabilitation programmes all took place in local community leisure centres. It was an 8 week programme in which the patients had an exercise session and an education session twice a week. Patients participated in an exercise class for one hour with a warm up, circuit exercises and then a cool down. The level of exercise that the patient preformed at was determined by a bleep test before the exercise programme. After the exercise the patients attended an education class. Throughout the programme the patients had two education sessions with the dietician, one with the fitness instructor on the importance of exercise and the rest of the sessions with the cardiac nurse on the education of cardiovascular disease, managing stress, medicine management and two sessions on basic life support.
At the Nottingham cardiac programmes the phase 3 programme was carried out in a hospital. It was a 6 week programme and comprised of an exercise session and education session twice a week. A physiotherapist took the exercise classes and a nurse that took the education classes. The exercise lasted for 50 minutes with a warm up, circuit exercise and a cool down and had a 15 minute relaxation period. The Benefit Of Exercises In Cardiac Rehabilitation Essay. The patients in the cardiac rehabilitation also had other members of a multidisciplinary team to raise any issues with such as an occupational therapist, a pharmacist, dietician and an administrator. If requested the patient also has access to a psychologist.
For those patients that agreed to participate the purpose of the study was fully explained. Participants were ensured confidentiality and had the opportunity to withdraw participation from the study at any time. The questionnaire was handed out to the patients directly after rehabilitation session, most of the patients filled out the questionnaire at the session however there were some patients that preferred to take the questionnaires home and sent the questionnaire back in the mail. For those that completed the questionnaire at the session if they had any questions regarding the questionnaire they could be answered.
The Sturwood questionnaire in this study was based on a health related quality of life questionnaire designed by Ware (1998). The Short Form (SF-36) Health questionnaire is composed of 36 items and measures the following eight health aspects: physical functioning, role-physical, bodily pain, general health which assesses the physical component score and vitality, social functioning, role-emotional, and mental health compose the mental component score. It is a generic measure that does not focus specifically on age, gender, disease or treatment group. It can assess general and specific populations and has been used by over 5000 publications. The SF-36 has high internal consistency Bohannon and DePasquale (2010) found the questionnaire in elderly was supported by a Cronbach alpha of .82 between its items. The reason for designing a questionnaire based on the SF- 36 was that we wanted to make the questions specific to cardiac rehabilitation and also health behaviour changes associated with exercise and diet.
Ethics
The patients used in the cardiac rehabilitation programmes were patients of the NHS. Cardiac exercise and education session were taken by professional cardiac nurses physiotherapists and exercise specialist employed by the NHS. Ethical Permission for this study was granted by University of Leeds that produced an ethics proposal form. This ethics proposal, along with the questionnaire was shown to the head cardiac nurse in each of the two areas for permission to be used with their patients. Ethics Proposal form and Risk Assessment form is provided in Appendix B and C. The Benefit Of Exercises In Cardiac Rehabilitation Essay.
Analysis
The results were analysed using a SPSS statistical programme (Version 17.0.1) Non-parametric testing was used for categorical variables. Preliminary analysis of the data were performed to assess the normality of the data in terms of skewness and kurtosis to ensure there was no violation of the assumptions of normality. Continuous variables were assumed to be normal and therefore parametric statistical testing can be used. Categorical variables were compared using Spearman’s Rank Order Correlation. A paired t-test was used to analyse the effects of the rehabilitation programme on the amount of physical activity done a week, physical activity was reported before entering the programme and physical activity reported after completing the programme. Continuous variables were compared using Persons Product-Moment Correlations between average scale scores from the Sturwood Questionnaire An independent t-test was used to analyse difference between groups such as gender, those with family history and those that smoked prior to the programme against scale scores for each section on the on the questionnaire. A one-way ANOVA test was used to analyse difference between more than two groups such as age groups, attendance to the programme, the different cardiac centres, type of coronary event and weight group between average scale scores from the questionnaire.
Results
Twenty seven cardiac patients participated in this study after an acute coronary event.
Table 2. Means, standard deviations, minimum, maximum, skewness and kurtosis for scale scores in each section of the Sturwood questionnaire.
The relationship between average scale scores was investigated using Pearson product-moment correlation coeffiecient. The direction of the relationship between all variables is positive which suggest that with high exercise score patients are likely to score highly in the diet and quality of life categories of the questionnaire. This is also the same for high scores for quality of life are associated with high scores on diet and overall outlook on life and health. The strength of the relationships is medium strength according to Cohen (1988, pp79-81) guidelines for all relationships apart from the correlation of average quality of life score and average outlook on life score which has a large positive relationship.
Exercise
A paired-samples t-test was conducted to evaluate the impact of a cardiac programme intervention on amount of physical activity a week. There was a statistically significant increase in the number of times a week the patient performed physical activity from prior to the event (M=2.38, SD=1.267) to after the event (M= 3.5, SD, 0.99), t (25) = 6.257, p<. 0005 (two-tailed). The mean increase in physical activity was 1.115 with a 95% confidence interval ranging from 0.748 to 1.483. The eta squared statistic (0.50) indicates a large effect size.
An independent samples t-test was conducted to compare the exercise scores for those that had a family history of a similar cardiovascular event. There was a statistically significant finding in exercise scores for those with a family history of cardiovascular disease (M = 23.92, SD = 6.694) and those without a family history of cardiovascular disease M = 15.67, SD = 8.304; t (25) = 2.858, p= 0.05 (two-tailed). The magnitude of the differences in the means (mean difference = 8.250, 95% Confidence interval: -2.305 to 14.195) was large (eta squared = 0.25). This significance in the data suggests that those patient that had a history of cardiovascular disease in their family had overall higher scores on the exercise category than those that did not have a family history of the disease.
Quality of life
A one-way between-groups analysis of variance was conducted to explore the impact of type of cardiovascular event the patient suffered on the average quality of life score as measured by the Sturwood questionnaire. The Benefit Of Exercises In Cardiac Rehabilitation Essay. Subjects were divided into three groups according to the type of cardiovascular event they were referred to the rehabilitation programme for (Group 1: Myocardial infarction; Group 2: Coronary bypass surgery; Group 3: Percutaneous coronary angioplasty. There was a statistically significant difference in mean scores at the p< 0.005 level in quality of life scores for the three groups: F (2, 27) = 3.934 p=0.05. The effect size, calculated using the eta squared was 0.25. Post-hoc comparisons using Tukey HSD test indicated that the mean score for Group 1 (M = 9.09, SD = 10.625) was significantly different from Group 3 (M = 22.5, SD = 6.091). Group 2 (M = 16.4, SD = 10.233) did not differ significantly from either Group 1 or 3. The PCI group had a greater quality of life mean score than the MI group.
Other Results
A one-way ANOVA test was used to assess the difference between the five cardiac rehabilitation programmes and scores on the Sturwood questionnaire. There were no significant findings between the programmes and exercise, diet, quality of life, outlook on life and health and overall score.
The relationship between the amount of family support given to the patient and the amount of change in healthy lifestyle in family was investigated using Spearman Rank Order Correlation. Preliminary analyses were performed and found violation of the assumption of normality. There was a medium strength positive correlation between the two variables, rho = 0.466, n = 27, p < 0.05, which high amount of family support associated with high family change in healthy lifestyle.
A Chi square test for independence (with Pearson Chi square) indicated a significant association between gender and family support, X² (1, n = 27) = 14.9, p = 0.001, phi = 0.742. Females are offered less support by their family than males.
Figure. 1.
Discussion
Exercise and diet.
The present study showed that even over a short period of time cardiac rehabilitation can increase exercise and diet habits. One of the findings in this study was that the cardiac rehabilitation did increase the number of times physical activity done a week. Patients were asked the number of times they participated in physical activity prior and after the rehabilitation programme. The mean increase in physical activity participated in a week was 1 exercise session a week. This is not a large increase however it does suggest that the programme has encouraged behaviour change. This small increase in physical activity may be due to the fact that that programme was only 6-8 weeks long and patients may feel they have not built up the stamina to take part in more physical activity.
The exercise score in the Sturwood questionnaire was the highest out of the other sections on the questionnaire. This suggests that cardiac rehabilitation has the greatest effect on behaviour and awareness change in exercise. Those patients that increased the amount of exercise undertaken and had more awareness of the health benefits of exercise also had greater levels of quality of life. The National Audit for Cardiac rehabilitation found the greatest improvement in quality of life scores was in the perceived fitness and activity section. Patients’ perceptions on overall health and problems with social activities improved. This was also seen in patients that had improved their diet and awareness of the benefits of a healthy diet had higher levels of quality of life. Those patients with little behaviour and awareness change reported lower levels of quality of life……
An interesting finding in this study was those with a family history reported a greater improvement in exercise change compared with those that had no family history. The Benefit Of Exercises In Cardiac Rehabilitation Essay.
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Quality of Life
The results of this study show two important findings. First cardiac rehabilitation resulted in an improvement in behaviour change and awareness of health. Second, an increase in health changes resulted in an improved quality of life. In fact analysing the scores obtained on the Sturwood questionnaire revealed an improvement of physical and awareness health lifestyle in exercise and diet in all types of coronary events. These data matches the results from Stahle et al and Yohannes et al that reported long term benefits of exercise cardiac rehabilitation with improved quality of life. These data also confirm with the data of Hung et al that showed physical exercise (weight lifting for 8 weeks, three times a week) to improve quality of life in patients with coronary heart disease measured with a MacNew heart disease health related quality of life questionnaire in elderly patients. Lastly the results show similarity to Freitas et al study that showed using a multi-disciplinary cardiac rehabilitation programme for 4 weeks that there was improved quality of life and found physical and mental improvements in health measured by the SF-36 questionnaire. In this study it was found that health changes had been implicated for the lowest attendance in the programme which was three weeks. A possible explanation for improved quality of life over such a short period of time could possibly be a result of using a multi-disciplinary approach in the rehabilitation programme. Both in this study and in Freitas et al study there was the use of relaxation sessions, and supplemented dietary education sessions and necessary information for changing health lifestyles by a nutritionist and cardiac nurse. Also in this study some of the patients had access to a psychologist and occupational therapists. Based on this finding it therefore shows the importance of cardiac rehabilitation taking a multi-disciplinary approach to increase health related changes that reduce cardiovascular risk factors such as exercise, diet and cessation of smoking to reduce the risk of repeating coronary events.(Chow et al 2010)
One interesting finding was that there was no significant difference between improved health behaviour and quality of life between different cardiac rehabilitations centres. Two of the centres were based in a hospital and three in community leisure centres. These findings present a number of clinical interventions in relation to the use of health services. Based on these data, cardiac rehabilitation could be accessed by a greater number of people after a coronary event provided that there is an increase in leisure centres implementing a phase three cardiac rehabilitation programme. In many centres, especially hospital cardiac rehabilitation there is a high demand and limited amount of spaces on a cardiac programme. Not only will there be more availability for patients to be admitted to the programme but it will allow for more high risk patients to be closely monitored at hospital based cardiac centres.
One finding from this study was found when comparing between coronary event groups of each of the scale sections. There were no significant findings between groups in terms of exercise, diet, outlook on life health and overall score of the questionnaire apart from in quality of life score. There was a significant finding between PCI treated patients and MI patients in quality of life scores with PCI patients reporting higher scores. A study by Cohen et al 2011 found a significant difference in quality of life scores between PCI patients and CABG patients measured by SF-36 questionnaire. The study also used a Seattle Angina Questionnaire (SAQ) to measure frequency of angina; higher scores on this measure indicated a better health status. CABG patients reported higher quality of lif. The Benefit Of Exercises In Cardiac Rehabilitation Essay.
