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Comprehensive Cardiac Rehabilitation for Patients with Implanted Cardiac Defibrillators
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Results Thirty-four men and 16 women were interviewed, of whom 42% perceived cardiac rehabilitation as principally exercise based. In addition 52% thought exercise was most important, 16% dietetics and 14% stress management. 86% of patients said they had not been told about cardiac rehabilitation by the medical staff. 54% of patients were positive about attending for cardiac rehabilitation, 34% cited transport difficulties and 10% raised issues around caring as adversely affecting attendance. 54% of interviewees had negative or neutral views about group activities. Overall the interviews revealed patients had little knowledge of the process of coronary heart disease and perceived their surgery as the principal event.
Discussion It raises concern that patients had a limited understanding of cardiac rehabilitation, focusing almost exclusively on exercise. Patients conveyed that ‘education’ was not needed, though it is likely that many would need to review their risk factors. Difficulties in attendance suggest alternative methods of cardiac rehabilitation delivery should be considered. A majority perceived surgery as the principal event to which to respond, and not coronary heart disease. This has major implications for both patients and healthcare providers.
Comprehensive Cardiac Rehabilitation for Patients with Implanted Cardiac Defibrillators P Doherty, A Fitchet, C Bundy, W Bell, A Fitzpatrick, C Garratt Manchester Royal Infirmary Introduction Implantable cardioverter defibrillators are used for secondary and primary prevention of sudden cardiac death. However, 40% of patients fail to adapt to implantation, developing phobic anxiety states, depression and a fear of arrhythmia and defibrillator therapy (shock) during physical activity. Antecedent association between arrhythmia and physical activity contributes to a sedentary lifestyle and a concomitant reduction in functional capacity. There was insufficient evidence regarding the impact of cardiac rehabilitation within this population and accordingly a comprehensive programme was developed and evaluated. Method Sixteen patients out of 34 who agreed to attend cardiac rehabilitation were randomly selected and all consented to be included in the study. Mean age was 58 years (SD 10), range 34 to 74. The mean defibrillator implant period was 20.4 months (SD 13.8), range 7 to 53 and the mean left ventricular ejection fraction was 38% (SD 17), range 12 to 70. Functional capacity was defined by exercise test outcome using a sub-maximal incremental treadmill protocol with walking speeds from 1 to 4.5 mph on a constant 10% incline. The end point for the exercise test was influenced by a target heart rate of appropriately 75% of age-adjusted maximum, heart rate ten beats below defibrillator detection and the patient’s desire to stop. A pre-base exercise test ensured optimal medication and test familiarity. Patients attended cardiac rehabilitation sessions twice weekly for 12 weeks and performed predominantly aerobic exercise in a circuit emphasising warm-up, nine circuit exercises (four levels) and a cool-down exercise period. The monitoring and adjustment of exercise intensity was achieved by telemetry heart rate and ‘rate of perceived exertion’ with heart rate monitors being worn for all exercise sessions. Once-weekly home exercise and regular walks at intensities below cardiac rehabilitation Physiotherapy December 2002/vol 88/no 12
exercise were encouraged between sessions. Educational sessions on diet, medication, psychology and the benefits of an active lifestyle were provided. The outcome measures were exercise test results, anxiety and depression scale scores and body mass index. Repeated measures analysis of variance was used statistically. Results All 16 patients completed pre- and baseline exercise tests, 13 patients completed post cardiac rehabilitation exercise testing, the remaining three patients discontinued for social reasons. Eleven patients completed a further evaluation 12 weeks after cardiac rehabilitation; two were unable to attend due to exacerbation of co-morbidity. A baseline comparison between compliant and noncompliant patients found that the non-compliant patients were younger with greater functional capacity and less psychological distress. Functional capacity expressed as mean exercise test time (mm:ss) showed a mean difference of 01:16 (95% CI, 01:58 to 00:34 p = 0.001). Clinically significant anxiety and depression scores existed at baseline with mean anxiety scores of 13.4 (SD 3.6) reduced after cardiac rehabilitation to 8.1 (SD 3.6) (95% CI, 3.5 to 7.0, p = 0.001). Depression mean scores of 10.0 (SD 3.4) reduced to 6.7 (SD 3.0) (95% CI, 2.0 to 4.4, p = 0.002) after cardiac rehabilitation. There was a small yet significant mean decrease in body mass index of --0.4 (CI –0.72 to –0.08, p = 0.013) following rehabilitation. Improvements in exercise test time, anxiety and depression and body mass index were maintained following a 12-week maintenance phase. No defibrillator discharges occurred during exercise testing or the exercise circuit sessions. Conclusion Exercise testing and exercise training can be performed safely and without increasing the incidence of defibrillator therapy. Cardiac rehabilitation was found to be safe and effective for improving and maintaining functional capacity and psychosocial health within this pilot study. A multi-centred control trial is needed to establish the external validity of the intervention effect.
Results Thirty-four men and 16 women were interviewed, of whom 42% perceived cardiac rehabilitation as principally exercise based. In addition 52% thought exercise was most important, 16% dietetics and 14% stress management. 86% of patients said they had not been told about cardiac rehabilitation by the medical staff. 54% of patients were positive about attending for cardiac rehabilitation, 34% cited transport difficulties and 10% raised issues around caring as adversely affecting attendance. 54% of interviewees had negative or neutral views about group activities. Overall the interviews revealed patients had little knowledge of the process of coronary heart disease and perceived their surgery as the principal event.
Discussion It raises concern that patients had a limited understanding of cardiac rehabilitation, focusing almost exclusively on exercise. Patients conveyed that ‘education’ was not needed, though it is likely that many would need to review their risk factors. Difficulties in attendance suggest alternative methods of cardiac rehabilitation delivery should be considered. A majority perceived surgery as the principal event to which to respond, and not coronary heart disease. This has major implications for both patients and healthcare providers.
Comprehensive Cardiac Rehabilitation for Patients with Implanted Cardiac Defibrillators P Doherty, A Fitchet, C Bundy, W Bell, A Fitzpatrick, C Garratt Manchester Royal Infirmary Introduction Implantable cardioverter defibrillators are used for secondary and primary prevention of sudden cardiac death. However, 40% of patients fail to adapt to implantation, developing phobic anxiety states, depression and a fear of arrhythmia and defibrillator therapy (shock) during physical activity. Antecedent association between arrhythmia and physical activity contributes to a sedentary lifestyle and a concomitant reduction in functional capacity. There was insufficient evidence regarding the impact of cardiac rehabilitation within this population and accordingly a comprehensive programme was developed and evaluated. Method Sixteen patients out of 34 who agreed to attend cardiac rehabilitation were randomly selected and all consented to be included in the study. Mean age was 58 years (SD 10), range 34 to 74. The mean defibrillator implant period was 20.4 months (SD 13.8), range 7 to 53 and the mean left ventricular ejection fraction was 38% (SD 17), range 12 to 70. Functional capacity was defined by exercise test outcome using a sub-maximal incremental treadmill protocol with walking speeds from 1 to 4.5 mph on a constant 10% incline. The end point for the exercise test was influenced by a target heart rate of appropriately 75% of age-adjusted maximum, heart rate ten beats below defibrillator detection and the patient’s desire to stop. A pre-base exercise test ensured optimal medication and test familiarity. Patients attended cardiac rehabilitation sessions twice weekly for 12 weeks and performed predominantly aerobic exercise in a circuit emphasising warm-up, nine circuit exercises (four levels) and a cool-down exercise period. The monitoring and adjustment of exercise intensity was achieved by telemetry heart rate and ‘rate of perceived exertion’ with heart rate monitors being worn for all exercise sessions. Once-weekly home exercise and regular walks at intensities below cardiac rehabilitation Physiotherapy December 2002/vol 88/no 12
exercise were encouraged between sessions. Educational sessions on diet, medication, psychology and the benefits of an active lifestyle were provided. The outcome measures were exercise test results, anxiety and depression scale scores and body mass index. Repeated measures analysis of variance was used statistically. Results All 16 patients completed pre- and baseline exercise tests, 13 patients completed post cardiac rehabilitation exercise testing, the remaining three patients discontinued for social reasons. Eleven patients completed a further evaluation 12 weeks after cardiac rehabilitation; two were unable to attend due to exacerbation of co-morbidity. A baseline comparison between compliant and noncompliant patients found that the non-compliant patients were younger with greater functional capacity and less psychological distress. Functional capacity expressed as mean exercise test time (mm:ss) showed a mean difference of 01:16 (95% CI, 01:58 to 00:34 p = 0.001). Clinically significant anxiety and depression scores existed at baseline with mean anxiety scores of 13.4 (SD 3.6) reduced after cardiac rehabilitation to 8.1 (SD 3.6) (95% CI, 3.5 to 7.0, p = 0.001). Depression mean scores of 10.0 (SD 3.4) reduced to 6.7 (SD 3.0) (95% CI, 2.0 to 4.4, p = 0.002) after cardiac rehabilitation. There was a small yet significant mean decrease in body mass index of --0.4 (CI –0.72 to –0.08, p = 0.013) following rehabilitation. Improvements in exercise test time, anxiety and depression and body mass index were maintained following a 12-week maintenance phase. No defibrillator discharges occurred during exercise testing or the exercise circuit sessions. Conclusion Exercise testing and exercise training can be performed safely and without increasing the incidence of defibrillator therapy. Cardiac rehabilitation was found to be safe and effective for improving and maintaining functional capacity and psychosocial health within this pilot study. A multi-centred control trial is needed to establish the external validity of the intervention effect.