Dr Alan Begg explores updated SIGN recommendations on cardiac rehabilitation and strategies that encourage patient engagement in lifestyle risk factor management, psychosocial wellbeing, and behaviour change.
Read this article to learn more about:
- the definition of ‘cardiac rehabilitation’ and how to encourage uptake
- lifestyle interventions and preventive pharmacotherapy
- interventions for psychosocial wellbeing and vocational rehabilitation.
This is the second in our series of articles covering the recently published SIGN guideline 149 on Risk estimation and the prevention of cardiovascular disease1 and SIGN guideline 150 covering Cardiac rehabilitation.2 Although the process of cardiovascular disease is a continuum from the preclinical phase through to overt disease, the approach to prevention hinges on the point when a clinical event occurs. The first Guidelines in Practice article in this short series,‘Estimating cardiovascular risk is key to preventing disease’,3 concentrated on prevention prior to that cardiovascular event, whereas this article will concentrate on the approach that should be taken after the event.
Although there is a reluctance to define cardiovascular disease prevention in terms of primary and secondary prevention, there is also a blurring of the boundaries between cardiac rehabilitation and secondary prevention and what is normal medical care. With the imminent demise of the Quality and Outcomes Framework (QOF) across the devolved nations with its demarcation into specific disease categories, it seems reasonable at this juncture to redefine what is meant by cardiac rehabilitation.
The British Association for Cardiovascular Prevention and Rehabilitation has published a definition of cardiac rehabilitation (CR) (see Box 1).4 SIGN 150 states that the term CR may today be potentially misleading as patients with coronary heart disease (CHD) are mobilised quickly after a cardiac event and no longer require traditional rehabilitation to return them to normal activities.2 Patients, however, benefit from a holistic, person-centred approach to their care, which imparts knowledge and understanding of their condition and its implications, and lifelong skills to assist in self-managing this long-term condition. The guideline is based on this approach, utilising the literature on long-term conditions but without changing the term CR to something that would better reflect current practice.2 This contrasts with the previous SIGN guideline on CR published in 2002 (Clinical Guideline 57), which advocated a menu-driven approach to those with cardiac disease in which the exercise component tended to assume prevalence over the education and psychological aspects.5
Box 1: British Association for Cardiovascular Prevention and Rehabilitation definition of cardiac rehabilitation4
‘The coordinated sum of activities* required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease.’
*The BACPR’s six core components for cardiovascular disease prevention and rehabilitation constitute the coordinated sum of activities.
BACPR=British Association for Cardiovascular Prevention and Rehabilitation
Patients spend less time in hospital after an episode of acute coronary syndrome than previously so it is more challenging to ensure that all eligible patients are referred to and have access to CR. Uptake rates remain suboptimal and the guideline highlights a Cochrane Review on various strategies that were associated with increased uptake (see Box 2).2,6 Interventions to improve self-efficacy should be considered for inclusion in a CR programme as a possible means of maintaining patient engagement and behavioural change.2
Box 2: Strategies associated with increased uptake of cardiac rehabilitation2,6
Strategies found to be associated with increased uptake of CR in at least one trial are:
- structured telephone call/visit by a nurse/therapist after hospital discharge
- early appointments to CR
- motivational letters based on the theory of planned behaviour
- cardiac rehabilitation programmes tailored for women
- intermediate phase programmes (self-management, instruction, and exercise monitoring) for older patients.
Note that there is a lack of high-quality trials on improving CR uptake among hard to reach or under-represented groups, such as older women or people from ethnic minorities.7
Patients with cardiac disease increasingly also have other chronic diseases and it may be thought that a generic programme for patients with long-term conditions would be better than one focusing on one specific condition. However, no studies comparing outcomes for people with CHD enrolled in generic rehabilitation programmes with those in CR programmes only have been found. It is, however, important when assessing a patient attending CR to ensure that all long-term conditions which impact on their wellbeing are taken into account. Those attending CR should have an individualised assessment leading to a care plan and interventions specific to their needs.2
Lifestyle risk factor management
Cardiac rehabilitation programmes have traditionally consisted of an exercise and education component. Systematic reviews have highlighted that the reduction in cardiovascular mortality associated with attending CR programmes is attributed to the exercise component but often in highly selected cohorts.8,9 Data on the long-term outcomes in CR programmes of achieving lifestyle change is however lacking. The guideline does nevertheless make a series of recommendations and practice points in relation to lifestyle change (see Table 1).
|CR=cardiac rehabilitation; CHD=coronary heart disease|
Patients in a CR programme should be offered interventions that include contact for more than 4 weeks
Interventions should include a combination of telephone contact, behavioural support, and self-help materials
Smokers with CHD and comorbid clinical depression
Treatment should be offered to reduce depressive symptoms and to increase the likelihood of stopping smoking
Physical activity and reducing sedentary behaviour
An exercise component should be included to reduce cardiovascular mortality, reduce hospital admissions, and improve quality of life.
The assessment should be individualised and the component should be tailored to individual choice
Exercise should be delivered in a range of settings
Consider including aerobic and resistance exercises as part of the exercise prescription
Consider using a range of technology-based interventions to encourage exercise (see Box 3)
Consider psychoeducation such as goal-setting and self-monitoring to facilitate adherence
Delivery of dietary advice
To enhance adherence, a range of strategies such as telephone follow up, educational tools, contracts, nutritional tools, and feedback should be considered
Weight loss programmes
Consider referral to programmes delivered by experts if weight management assistance is required.
Box 3: Technology-based exercise interventions that could be considered for patients participating in cardiac rehabilitation programmes2
- Telephone-call follow up
- Behavioural support by internet or text messages
- ’Exergames’ or active video games
- Online tutorial websites
- ‘Cardiofit’ internet-based expert programme
- Virtual CR programmes.
Prescribed drugs are an important aspect of reducing cardiovascular risk and future events in patients with cardiovascular disease (see Table 2). Involvement within a CR programme offers the ideal opportunity in what was historically seen as the secondary prevention clinic to monitor risk factors (blood pressure and cholesterol levels), titrate medication, and encourage concordance.2 Ideally, this would take place within the context of comprehensive long-term conditions management and monitoring.
|SBP=systolic blood pressure; DBP=diastolic blood pressure; CVD=cardiovascular disease; ACE=angiotensin-converting enzyme|
Aspirin 75 mg daily
Should be offered to individuals with established atherosclerotic disease
Consider clopidogrel 75 mg daily or a combination of low-dose aspirin (75–300 mg daily) and dipyridamole 200 mg twice daily
If there is a history of stroke or transient ischaemic attack and the person is in sinus rhythm, to prevent stroke and other vascular events
Offer intensive statin therapy with atorvastatin 80 mg per day.
A lower dose could be considered in those at increased risk of adverse effects or drug interactions.
In all patients with established atherosclerotic cardiovascular disease following an informed discussion of the risks and benefits.
Blood pressure-lowering drug therapy
If sustained clinic SBP is >140 mmHg and/or DBP >90 mmHg
Offer drug therapy
In patients who have had an ischaemic or haemorrhagic stroke or TIA, even if the baseline blood pressure is at a level considered conventionally normotensive
Offer drug therapy to reduce the risk of recurrence
Aim to achieve a blood pressure target of <140/90 mmHg
In individuals with established uncomplicated CVD or who are at high risk of CVD
The following drug-based therapy is based on the recommendations in SIGN 148.10
|Beta blockers||Maintain long-term therapy||For those patients with acute coronary syndrome|
|ACE inhibitors||Commence on long-term therapy||In patients with myocardial infarction in first 36 hours and in those with unstable angina|
|Angiotensin receptor blockers||Commence on long-term therapy if intolerant of ACE inhibitors||In those with myocardial infarction but only if complicated by left ventricular dysfunction or heart failure|
Patients with CHD can have difficulty adjusting to their diagnosis, living with a new condition, and coping with the impact on their social role and functioning. The psychological consequences of CHD can affect recovery, morbidity, mortality, and quality of life.2 It is important to ensure that CR incorporates a stepped-care pathway to meet these psychological needs.
SIGN Guideline 149 highlights how depression, anxiety, and social isolation or lack of quality social support are risk factors not only for the development of cardiovascular disease but also for its prognosis and need to be taken into account when assessing a patient’s individual risk.1 Measuring psychological wellbeing with recognised assessment tools is important as part of the clinical pathway. Using these tools to assess anxiety and depression should be repeated over the course of the rehabilitation programme.2
Interventions and therapies
Psychological treatments are effective in treating psychological symptoms in patients with CHD although there are uncertainties regarding which subgroups of patients benefit the most from treatment, with no evident direct link between psychological therapies and total or cardiac mortality.2
The guideline recommends that all patients with clinical depression or anxiety should be offered a package of psychological care based on a cognitive behavioural model as an integral part of CR. This includes stress management, cognitive restructuring, and communication skills.2 For those with clinical depression or anxiety, cognitive behavioural therapy (CBT) should be the first-choice psychological therapy and it should be considered for patients assessed as having specific psychological needs such as support with symptom control. It is good practice that this CBT should only be delivered by health practitioners with accredited relevant competencies and approved clinical supervision.2
A meta-analysis showed that an intensive supervised relaxation course with a mean time of 9 hours can enhance recovery from a myocardial ischaemic event and contribute additionally to secondary prevention.11 On this basis a supervised course of full relaxation therapy should be considered as part of CR.2
Pharmacological treatment with selective serotonin reuptake inhibitors (SSRIs) should be considered in patients with depression and CHD. Caution however is required in patients receiving polypharmacy where the bleeding risk may be increased.1
Age, gender, type of employment, and other factors have an impact on return to work. Younger, married males in office employment are more likely to return to work. Health beliefs can delay return to work but those with more control over their work roles are more likely to return to work. Vocational rehabilitation interventions to address illness perceptions should be considered as part of CR if the person has the potential to continue in employment. Similarly, physical activities designed to simulate those in the workplace should be considered as part of CR. The CR programme should enable the person’s continued participation in the programme after they have returned to work.2
Cardiac rehabilitation in the context of the future of general practice
Reducing the workload burden is an important aim for the future of general practice. Cardiac rehabilitation offers the opportunity to build and support the wider practice team and to offer rehabilitation and monitoring for other long-term conditions. The use of non-medical prescribing within this context is important although appropriate training and evaluation of non-medical prescribers is required to ensure safe and effective care.2 This approach will ensure that patients continue to have access to a range of professional services, allowing GPs to focus their time on patients with undiagnosed problems and the most complex care needs.
- Patients with coronary heart disease generally spend less time in hospital than previously so do not need traditional rehabilitation; however they do benefit from continuing holistic, person-centred care
- Practitioners should use evidence-based strategies to increase uptake of CR and encourage self-efficacy
- People attending CR should receive an individualised assessment, care plan, and interventions tailored to their needs; all long-term conditions impacting on their wellbeing should be taken into account.
- Lifestyle interventions should include:
- smoking cessation—contact should continue for more than 4 weeks and treatment offered where there is comorbid depression
- exercise—consider individualised aerobic and resistance exercises delivered in a range of settings; and technology-based interventions and psychoeducation to promote adherence, goal-setting, and self-monitoring
- dietary advice—use strategies to encourage adherence and consider referral to weight-loss services delivered by experts for some patients
- Drugs should be offered for evidence-based secondary prevention, as recommended
- Monitor risk factors (e.g. blood pressure, cholesterol levels), titrate medication, and encourage concordance
- Psychosocial health: incorporate a stepped-care pathway to address psychological consequences of CHD, which can affect recovery, morbidity, mortality, and quality of life; continue to assess anxiety and depression over the course of the CR programme:
- offer patients with clinical anxiety, depression, or specific psychological needs a package of CBT-based care, delivered as an integral part of the CR programme by accredited professionals
- a supervised course of full relaxation therapy should be considered
- Consider vocational rehabilitation interventions to address illness perceptions and tailored physical activities in patients who could return to work.
written by Dr David Jenner, GP, Cullompton, Devon
- SIGN 150 moves the focus of cardiac rehabilitation from an exercise-based rehabilitation regimen to a comprehensive, multi-disciplinary approach
- Commissioners should consider how they wish this service to be provided to offer a seamless service for people following a coronary vascular event
- Due to the uncertain future for QOF and workload issues in general practice, a specialist nurse-led service with clear pathways for accessing further professional help (e.g. CBT) could be commissioned, with a clear service specification based on this guidance:
- if commissioned, such a service should be initiated in secondary care on discharge and capable of integrating closely with general practice, ideally with access to the patient’s care record
- With the uncertainty over the future of QOF, clear outcome targets relating to blood pressure and pharmacotherapy should be built into the specification and be audited and reported to ensure the effectiveness of any new service.
- Scottish Intercollegiate Guidelines Network. Risk estimation and the prevention of cardiovascular disease. SIGN 149, 2017. Available at: www.sign.ac.uk/sign-149-risk-estimation-and-the-prevention-of-cardiovascular-disease.html
- Scottish Intercollegiate Guidelines Network. Cardiac rehabilitation. SIGN 150, 2017. Available at: www.sign.ac.uk/sign-150-cardiac-rehabilitation.html
- Begg A. Estimating cardiovascular risk is key to preventing disease. Guidelines in Practice, October 2017. Available at: www.ginp.co.uk/oct17-cvd
- British Association for Cardiovascular Prevention and Rehabilitation (BACPR). The BACPR standards and core components for cardiovascular disease prevention and rehabilitation (3rd edition). London: British Cardiovascular Society, 2017. Available at: www.bacpr.com/resources/BACPR_Standards_and_Core_Components_2017.pdf
- Scottish Intercollegiate Guidelines Network. Cardiac rehabilitation. SIGN 57, 2002. Available at: www.scotphn.net/wp-content/uploads/2015/11/Cardiac_Rehabilitation.pdf
- Karmali K, Davies P, Taylor F et al. Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database of Syst Rev 2014; (6): CD007131.
- Dressler C, Pattenden J, Atkin K, Lewin R. Interventions to increase the uptake of cardiac rehabilitation: Systematic review. Br J Cardiac Nurs 2012; 7 (7): 338–345.
- Anderson L, Thompson D, Oldridge N et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016; (1): CD1001800.
- Rauch B, Davos C, Doherty P et al. The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: a systematic review and meta-analysis of randomized and non-randomized studies—the Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol 2016; 23 (18): 1914–1939.
- Scottish Intercollegiate Guidelines Network. Acute coronary syndrome. SIGN 148, 2017. Available at: www.sign.ac.uk/sign-148-acute-coronary-syndrome.html
- van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2005; 12 (3): 193–202.