1. Cardiac Rehabilitation Paula O’Neill CHD Nurse Specialist Hammersmith/Charing Cross Hospitals 24 th September 2008

2. Learning Objectives Components of cardiac rehabilitation Components of cardiac rehabilitation What is cardiac rehabilitation? What is cardiac rehabilitation? Structure of cardiac rehabilitation Structure of cardiac rehabilitation Ways of delivering cardiac rehabilitation Ways of delivering cardiac rehabilitation The future of cardiac rehabilitation The future of cardiac rehabilitation

3. Definition of Cardiac Rehabilitation “The sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community”. World Health Organisation

4. The Evidence Comprehensive help with lifestyle modification involving education and psychological input as well as exercise training can reduce mortality by 20-25% over 3 years. Oldridge et al 1988; O’Connor et al 1989

5. Target Groups Coronary heart disease (CHD) –Exertional angina. –ACS (unstable angina or NSTEMI or STEMI) following medical/surgical management. –Revascularisation –Stable heart failure and cardiomyopathy Those at high risk of developing CVD: total CVD risk > 20% over 10 years or diabetes mellitus.

6. Who should be involved? Patient Pharmacist Nurse Consultant GP Physiotherapy Dietician Exercise instructor Smoking cessation advisor Social Services Psychologist District Nurses Practice nurses Health Visitor Secondary care

7. Components of CR. Lifestyle: Lifestyle: –Diet and weight management –Smoking cessation –Physical activity and exercise – Secondary prevention – Education Psychosocial care Psychosocial care Long-term management strategy Long-term management strategy

8. Physical Activity Assess and risk stratify Assess and risk stratify Develop individual exercise plan Develop individual exercise plan Teach FITT principle Teach FITT principle Regain/develop physical fitness Regain/develop physical fitness Regain confidence in physical activity Regain confidence in physical activity Develop long-term activity plan Develop long-term activity plan Self monitoring Self monitoring

9. Secondary Prevention Cholesterol management Cholesterol management BP management BP management Blood sugar management Blood sugar management Cardio-protective drug therapy Cardio-protective drug therapy

10. Education CHD as a disease CHD as a disease Treatment including medication Treatment including medication Recovery process Recovery process CHD risk factors CHD risk factors Symptom management Symptom management Living with CHD Living with CHD

11. Psychosocial Care Reduce fear and anxiety Reduce fear and anxiety Assist with adjustment Assist with adjustment Promote positive attitude Promote positive attitude Facilitate behaviour change Facilitate behaviour change Identify need for further support Identify need for further support

12. Structure of Cardiac Rehabilitation Phase 1:In-patient (1 st contact) Phase 1:In-patient (1 st contact) Phase 2:Immediate post discharge Phase 2:Immediate post discharge Phase 3:2-4 weeks post discharge Phase 3:2-4 weeks post discharge Phase 4:Long-term, on-going Phase 4:Long-term, on-going

13. Phase 1 Understanding of condition Understanding of condition Information & education Information & education Risk factor assessment Risk factor assessment Personalised health plan Personalised health plan Psychological assessment/support Psychological assessment/support Referral Referral Drug therapy Drug therapy

14. Phase 2 Home visits. Home visits. Telephone support. Telephone support. Clinics Clinics

15. Phase 3 Reassess health & risk factors first. Health Education Health Education Exercise Exercise Relaxation Relaxation

16. Phase 4 Maintenance of exercise/activity Maintenance of exercise/activity On-going lifestyle support On-going lifestyle support

17. Challenges for the Pt and Family

18. Frightening, life threatening event (MI, major surgery) A chronic illness, reduced life expectancy, symptoms Altered identity - an invalid, walking time bomb Fears for family and partner being left alone Threat to employment and financial status Medication side effects (lethargy, impotence) Being treated differently by other people Neurological impairement (esp. cardiac arrest pats.) Making lifestyle changes, smoking, diet, activity

19. Delivering CR Can be done individually or in a group Venue:Home CommunityClinics Menu: Mixing up of all 4 phases too provide an individualised package of care.

20. Other services / Professions 1.Sexual medicine clinic 2.Welfare rights bureau 3.Social worker 4.Marriage guidance services 5.Specialist heart failure nurse Sample Cardiac Rehabilitation Menu Activity / Fitness hosp exercise grouphosp exercise group home exercise programmehome exercise programme advice on resumption of active lifeadvice on resumption of active life Age Concern Health MentorAge Concern Health Mentor Walk for HealthWalk for Health Phase 4 exercise programmePhase 4 exercise programme Tai Chi classesTai Chi classes Smoking Willpower aloneWillpower alone smoking cessation clinicsmoking cessation clinic Nicotine replacementNicotine replacement Referral for medicationReferral for medication Internet programmeInternet programme Diet / Weight loss Self-management of diet / medicationSelf-management of diet / medication dietetics referraldietetics referral Weight WatchersWeight Watchers Internet programmeInternet programme Coach ProgrammeCoach Programme Education Hospital educational programmeHospital educational programme Home educational programmeHome educational programme Mentor / volunteer / lay-workerMentor / volunteer / lay-worker InternetInternet Psychological adjustment Self help advice materialsSelf help advice materials Stress management classStress management class Stress management on tapeStress management on tape Counselling psychologistCounselling psychologist Clinical Psychology / PsychiatryClinical Psychology / Psychiatry Social support Buddy systemBuddy system Patient support groupPatient support group Mentoring schemeMentoring scheme

21. Angina Plan WHAT? Self help package Self help package A CBT programme A CBT programmeWHO? Recent angina Recent angina 1 year since diagnosis 1 year since diagnosis www.anginaplan.org.uk

22. Using the Angina Plan Advice tape & information sheet Advice tape & information sheet 30 minute appointment 30 minute appointment 4 phone calls over 3 months (5-10 mins) 4 phone calls over 3 months (5-10 mins)

23. Pro & Cons of the Angina Plan Restrictions Must be literate Must be literate Must be motivated Must be motivated Cost Cost Time commitment Time commitment Advantages (RCT) Less medication Less medication Less GP/hospital visits Less GP/hospital visits  anxiety/depression  anxiety/depression MI treated quickly MI treated quickly  incidence of CHD  incidence of CHD Lewin R et al (2002) A Randomised controlled trial of a self management plan for patients with newly diagnosed angina. British Journal of General Practice 52: 476, 194- 201

24. The Heart Manual (1) 6 week, home based post MI rehab programme 6 week, home based post MI rehab programme A work book, diaries, record sheets and information A work book, diaries, record sheets and information 2 audio tapes, advice for family, a stress management course on tape 2 audio tapes, advice for family, a stress management course on tape A specially trained ‘Facilitator’ A specially trained ‘Facilitator’

25. The Heart Manual (2) Exercise programme – walking Exercise programme – walking Secondary prevention – written advice Secondary prevention – written advice Cognitive behavioural techniques Cognitive behavioural techniques Change patients beliefs and attributions (cardiac misconceptions) Self help for psychological problems Relaxation and stress management Initial face-to-face session, then phone calls or home/clinic visits at week 1, 4, 6 after discharge. Initial face-to-face session, then phone calls or home/clinic visits at week 1, 4, 6 after discharge.

26. Multi-centred RCT of HM vs. Hospital based. Equal gain on all measures including 2 Met gain in fitness, HM fewer readmissions. Andrew Coats, Jenny Bell Initial RCT - less anxiety & depression: better quality of life: fewer readmissions to hospital: less contact with GP. Lewin B, Lancet, 1992. The Heart Manual: Evidence Base The Heart Manual: Evidence Base Recommended by - WHO: BHF: Department of Health: Scottish Office

27. CHD NSF By 2009 85% of MI and revasc patients will be offered cardiac rehabilitation After that all except unstable angina patients should receive CR.

28. The Reality 25-30% of patients getting cardiac rehab in 2006-7.

29. Problems Inequalities – women, poor, ethnic minorities, depressed, smokers, elderly, all believed to be under-represented, postcode lottery Inequalities – women, poor, ethnic minorities, depressed, smokers, elderly, all believed to be under-represented, postcode lottery Failure to invite all indicated in NSF – angina, heart failure, ICD, arrhythmia Failure to invite all indicated in NSF – angina, heart failure, ICD, arrhythmia Dropout – varies widely from programme to programme Dropout – varies widely from programme to programme Staffing – from single-handed, part-time, coordinator for 600 patients to a full multi- disciplinary team. Only 50% of programmes have an identifiable budget. Staffing – from single-handed, part-time, coordinator for 600 patients to a full multi- disciplinary team. Only 50% of programmes have an identifiable budget.

30. Cost of Cardiac Rehabilitation The average cost per patient in 2006-7 was £413 The average cost per patient in 2006-7 was £413 Single day in a CCU costs £1,400 Single day in a CCU costs £1,400 Angioplasty (does not reduce mortality) costs £3,000 Angioplasty (does not reduce mortality) costs £3,000 Bypass surgery costs £8,000. Bypass surgery costs £8,000.

31. Remember the Evidence! Comprehensive help with lifestyle modification involving education and psychological input as well as exercise training can reduce mortality by 20-25% over 3 years. Oldridge et al 1988; O’Connor et al 1989 Oldridge et al 1988; O’Connor et al 1989

32. Cardiac Rehabilitation Saves Lives! No treatment in cardiac disease has stronger scientific evidence or a significantly greater impact on survival. No treatment in cardiac disease has stronger scientific evidence or a significantly greater impact on survival. The scientific evidence has been reviewed by many scientific and expert bodies over the last 30 years. The scientific evidence has been reviewed by many scientific and expert bodies over the last 30 years. Every review has come to the same conclusion that cardiac rehabilitation is an essential treatment. CR is only form of chronic disease management with an evidence base. CR is only form of chronic disease management with an evidence base.

33. The Solutions NACR NACR National Campaign National Campaign NICE Guidelines NICE Guidelines CR QoF CR QoF Tariffs Tariffs CDM Agenda CDM Agenda