Long-term exercise training is important to ensure a return to health following a coronary event. Dr Alan Begg and Tom Brighton describe their area’s scheme

A project to provide a long-term, community-based exercise programme for patients with coronary heart disease is being set up in the Angus area. The programme is the result of a partnership between Angus Local Health Care Co-operative (LHCC), Angus Cardiac Group, for patients, and Angus Council and aims to help patients to make and maintain changes in lifestyle. It will complete local implementation of the SIGN guideline on cardiac rehabilitation.1,2

The SIGN guideline2 recommends exercise training in addition to psychological and educational programmes, to help patients with CHD recover and maintain physical and psychosocial health.

Regular exercise protects against cardiovascular disease, and physical training after a myocardial infarction (MI) helps address the deconditioning that occurs. One review of the evidence showed that exercise-only cardiac rehabilitation for patients of both sexes and all ages after an MI, revascularisation or angina reduced the total mortality by 27%, cardiac death by 31% and a combined end point of mortality, non-fatal MI and revascularisation by 19%.2

To maintain the benefits of a structured phase 3 cardiac rehabilitation exercise class, moderate physical activity should continue long term. Although some individuals may devise their own exercise regimen or use a home-based walking programme, most CHD patients find it difficult, once supervision is withdrawn, to continue taking regular exercise of an appropriate intensity.

Cardiac care in Angus

Exercise sessions are currently provided by Angus Cardiac Group, a patient group affiliated to Chest, Heart & Stroke Scotland. The group provides support for its members and maintains close contact with local healthcare professionals. It has played a key role in designing and developing local cardiac services, including providing funding.

However, there are several limitations to the present scheme:

  • It does not include all patients with CHD
  • It limits uptake to those attending Angus Cardiac Group meetings
  • It does not provide a service for all geographical areas
  • It provides exercise sessions only every two weeks
  • It has difficulty recruiting and retaining trained instructors
  • It does not meet national quality criteria.
  • There is a clear need to provide a structured, comprehensive long-term exercise programme in Angus.

Comprehensive care programme

Angus LHCC has developed a comprehensive programme of care for patients with CHD, covering the four phases of cardiac rehabilitation (Figure 1, below). The programme covers short-term recovery and goes on to ensure that long-term lifestyle changes and physical activity are maintained and that drug therapy for vascular protection is appropriate.

Figure 1: Cardiac care in Angus

A similar approach has been shown to help achieve National Service Framework targets for cardiac rehabilitation and secondary prevention relatively quickly.3 Nurse-led secondary prevention clinics improve medical and lifestyle aspects of secondary prevention.4

Managed clinical networks

The Coronary Heart Disease and Stroke Strategy for Scotland5 places managed clinical networks, which engage professionals and patients and coordinate care across organisational boundaries, at the heart of effective cardiac services in Scotland.

A managed clinical network for cardiac services is being set up in our local health board’s area, and the structures and processes developed in Angus are in line with this.

How will the new scheme work?

Patients will be identified and recruited to the new exercise programme through the existing cardiac rehabilitation programme and CHD network. Classes will be held weekly in local leisure centres in three locations. A nominal fee will be charged, but this will be subsidised initially, and help with travel will be available to those who need it. Information leaflets will keep everyone informed.

Fitness instructors will be trained to British Association for Cardiac Rehabilitation (BACR) standards, and the exercise class will reflect BACR recommendations.

The pre-training requirements for the fitness instructors are theoretical and practical training in the teaching of exercise to adults, previous community-based exercise experience, and active involvement in a phase 3 exercise programme. They must also have basic life support certification and personal liability insurance.

The training consists of 30 hours of teaching over 3 days, and 100 hours of independent study, followed by a formal assessment. They are also trained in first responder defibrillation.

Eligibility for the programme

  • be clinically stable
  • understand their symptoms
  • have completed a phase 3 exercise programme or successfully completed an appropriate functional capacity test.

Patients in the latter category, where some time may have elapsed since their coronary event and attendance at a hospital-run exercise programme, will be assessed by the cardiac rehabilitation staff. The Shuttle Walking Test, a low cost, ‘low-tech’ alternative to exercise testing is an appropriate test (Box 1, below).2

Box 1: The Shuttle Walking Test protocol from SIGN 57. Cardiac Rehabilitation2
Equipment required
  • Calibrated cassette player and shuttle walk test tape.

     

  • Two marker cones and non-slippery, flat walking surface at least 10 metres in length.
  • Heart rate monitor with record facility and adjustable upper alarm limits.
Protocol
  • Each subject should be screened by a member of the cardiac rehabilitation team for any exclusion criteria before proceeding.

     

  • Place two cones exactly 9 metres apart, thus allowing the subjects to walk 10 metres when they go round the cone at the end of each shuttle.
  • Subjects then listen to the instructions on the audio cassette. These should be repeated verbally to ensure that they understand what is expected during the test.
  • Subjects walk around the 10 metre course aiming to be turning at the first marker cone when the first audio signal is given, and turning at the second cone at the next audio signal.
  • Subjects should be accompanied around the first level of the test to help them keep pace with the audio signals. Thereafter the operator stands mid-way between the two marker cones offering advice on completion of a level: ‘Walk a bit faster now if you can’.
  • Progression to the next level of difficulty is indicated by a triple bleep which lets the subject know that an increase in walking speed is required.
  • The full test comprises 12 levels each of one minute duration with walking speeds that rise incrementally from 1.2 miles per hour (1.9 km per hour) to 5.3 miles per hour (8.5 km per hour).
  • The test is completed at 12 minutes or if one of the termination criteria are met.
Termination criteria
  • Any anginal symptoms or feeling too breathless to continue.

     

  • Feeling dizzy or faint.
  • Leg pain limiting further exercise.
  • Achieved level of perceived exertion ?s15 (Borg Scale).
  • Achieved heart rate ?85% predicted (detected by audible upper alarm limit).
  • Failure to meet the speed requirements of the test – subject more than half a metre from the cone when the bleep sounds.
Following the test
  • Subjects should continue to walk slowly around the course a further four times to avoid any syncopal attacks associated with abrupt cessation of exercise.

     

  • Subjects are then seated and asked to confirm their limiting symptom.
  • Record total distance walked, heart rate and perceived exertion for each level completed, peak heart rate and reason for test termination.
  • If subjects have fully recovered after 10 minutes then no further action is required. If they report continuing breathlessness or angina then a further rest period should follow during which they may receive sublingual nitrates, have an ECG or be seen by a doctor as appropriate.
Adapted from SIGN 57. Cardiac Rehabilitation, with permission

Quality outcome indicators

The following quality outcome indicators have been agreed and data will be recorded on an ongoing basis:

  • Initiating event for attendance at classes
  • Prior attendance at a phase 3 programme
  • Source of recruitment
  • Length and frequency of attendance
  • Reasons for discontinuing
  • Risk factor changes.

Benefits for all

We have created an effective partnership between a patient group and the health and local authorities, and involved the users at all stages of planning and implementation. The benefits are:

  • Patients are more involved in their own programmes of cardiac rehabilitation
  • Long-term moderate intensity aerobic activity is available for all patients with CHD
  • Patients’ families are encouraged to increase their daily activity, with resulting health improvement
  • The SIGN guideline on cardiac rehabilitation is now fully implemented locally
  • Trained fitness instructors’ skills can be used in other patient groups
  • Automated defibrillators are available in local leisure centres
  • Ongoing project monitoring, user evaluation and feedback enables the scheme to be modified as necessary
  • Quality indicators are in line with those of the Clinical Standards Board for Scotland
  • Provision of a key component of the planned local managed clinical network for cardiac services.

Expert patients

Although the purpose of the project was to provide a phase 4 exercise programme, it provides the perfect opportunity to develop the concept of the expert patient locally.6

The basis of our phase 2 rehabilitation programme, the Heart Manual, provides a user-led, self-management programme which reduces anxiety, depression and hospital readmission rate in patients recovering from an MI. Using a group of expert patients, other aspects of lifestyle change and risk factors can be addressed in a way that is fully integrated with existing secondary prevention efforts, using advanced information technology systems already in place.7

Funding and development of the scheme

The scheme will commence on 1 October 2003. Staff will be provided by the three project partners and additional initial funding will be provided by the New Opportunities Fund (NOF).8 This lottery fund provides money for health, education and environment initiatives throughout the UK. In Scotland, NOF supported schemes include those that reduce the risk of CHD through effective evidence-based prevention programmes.

Conclusion

The long-term sustainability of the scheme will be guaranteed by funding from Angus Cardiac Group, Angus LHCC and Angus Council.

We envisage that the main obstacle to success, in this rural area, may be a reluctance to travel to the nearest participating leisure centre. Encouraging good uptake of this service and ensuring full compliance, which should lead to improved patient outcomes, poses a challenge for us all.

References

  1. Begg A. New SIGN guideline underlines importance of cardiac rehabilitation. Guidelines in Practice 2002; 5(4): 25-34.
  2. SIGN 57: Cardiac Rehabilitation. Edinburgh: Scottish Intercollegiate Guidelines Network, 2002.
  3. Dalal HM, Evans PH. Achieving National Service Framework standards for cardiac rehabilitation and secondary prevention. Br Med J 2003; 326: 481-4.
  4. Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four-year follow up of a randomised controlled trial in primary care. Br Med J 2003; 326: 84.
  5. Coronary Heart Disease and Stroke: Strategy for Scotland. Scottish Executive. www.scotland.gov.uk/library5/health/chds-oo.asp
  6. The Expert Patient A New approach to chronic disease management for the 21st century. London: Department of Health, 2001. www.doh.gov.uk/cmo/ep-report.pdf.
  7. Begg A, Griffith JM. The electronic health record and the management of cardiovascular disease. Br J Cardiol 2002; 9(10): 630-3.
  8. The New Opportunities Fund www.nof.org.uk/index.cfm?loc=hea&inc=chdscot

We would like to thank Karen Fletcher and the project steering group for their assistance in setting up this project, and Karen Dunn for her work on the manuscript.

 

Guidelines in Practice, July 2003, Volume 6(7)
© 2003 MGP Ltd
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