The SIGN cardiac rehabilitation guideline aims to improve CHD patients' physical and psychological wellbeing, as Dr Alan Begg explains
The Scottish standardised death rates from coronary heart disease in both men and women are falling; however, the prevalence of heart disease is increasing because people are living longer. As a result, the numbers of patients potentially requiring rehabilitation following myocardial infarction, revascularisation or with stable angina or heart failure will increase.
The Scottish Intercollegiate Guidelines Network (SIGN) has recently developed a national clinical guideline on cardiac rehabilitation.1 This evidence-based guidance is supported and endorsed by the British Association of Cardiac Rehabilitation and is likely to be as widely used in England as in Scotland.
The new guideline complements the existing guidelines on secondary prevention following MI,2 stable angina3 and heart failure.4
SIGN was established in 1993 by the medical Royal Colleges in Scotland to develop evidence-based clinical guidelines. It is funded by the Clinical Resource Audit Group (CRAG) of the Scottish Executive.
Development of the cardiac rehabilitation guideline was based on a systematic review and critical appraisal of the current literature, with the evidence base identified, selected and evaluated according to the defined SIGN methodology.5 Guideline recommendations are graded according to the strength of the supporting evidence (Table 1, below).
|Table 1: Key to levels of evidence and grades of recommendation|
|LEVELs of evidence|
|1++||High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias|
|1+||Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias|
|1-||Meta-analyses, systematic reviews, or RCTs with a high risk of bias|
High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
|2+||Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal|
|2-||Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal|
|3||Non-analytic studies, e.g. case reports, case series|
|Grades of recommendation|
At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
The cardiac rehabilitation guideline development group was truly multi-disciplinary. It included physicians, cardiologists, GPs, physiotherapists, specialist nurses, a clinical psychologist, a patient representative, a public health specialist and a health economist.
The group was chaired by Dr Chris Isles, a consultant physician from Dumfries and Galloway Royal Infirmary who has an interest in cardiac rehabilitation.
What is cardiac rehabilitation?
The aim in all patients with heart disease is comprehensive cardiac care which, in addition to cardiac rehabilitation, includes secondary prevention and normal medical care.
The definition of cardiac rehabilitation used in the guideline and which contains all the key elements is:
'Cardiac rehabilitation is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health.Í
It is important that patientsÍ partners, other family members and carers are involved in this process.
Cardiac rehabilitation can be thought of as facilitating recovery whereas secondary prevention prevents further illness.
The interventions used in cardiac rehabilitation can be grouped into three main categories:
- exercise training
- educational support
- psychological support.
Together they are referred to as comprehensive cardiac rehabilitation (CCR); cardiac rehabilitation programmes should contain all three categories (Grade A). Patients for whom CCR is recommended and the grades of evidence are given in Box 1 below.
Box 1: Patients who should receive comprehensive cardiac rehabilitation (CCR)
|CCR is recommended:|
|CCR should be considered:|
Phases of cardiac rehabilitation
There are four phases of cardiac rehabilitation:
- Phase 1: Inpatient stage or after a ïstep changeÍ in the patientÍs cardiac condition. A step change is defined as any myocardial infarction, onset of angina, emergency hospital admission for CHD, cardiac surgery or angioplasty, or first diagnosis of heart failure.
- Phase 2: Early post-discharge period; the Heart Manual self-help programme can reduce anxiety, depression and hospital readmission rates.
- Phase 3: A structured programme of exercise, education and psychological support as well as advice on risk factors. The setting can be hospital or the community and the service provided should meet the individual patientÍs needs.
- Phase 4: Long-term maintenance of physical activity and lifestyle change.
Women and patients over the age of 75 years were excluded from many early cardiac rehabilitation trials, but all the evidence suggests that older patients and women do as well as men (both Grade B), and should be included in CCR programmes. The lower grades reflect only that there is less evidence in these groups.
The available evidence in cardiac transplant, valve surgery and congenital heart disease patients or in those with an implantable cardioverter defibrillator did not allow specific graded recommendations to be made.
A Cochrane review of men and women of all ages with previous MI, revascularisation or angina found that with exercise-only cardiac rehabilitation there was:6
- 27% reduction in all-cause mortality
- 31% reduction in cardiac death
- 19% reduction in the combined end-point of mortality, non-fatal MI and revascularisation.
There was no effect on fatal MI and no apparent additional benefit from CCR. It is suggested that the latter finding may be due to the fact that it would be very difficult to exclude the provision of psychological and educational support even if it was not offered in exercise-only trials.
Also, unlike the exercise only trials most of the CCR trials were done after the advent of thrombolysis and prophylactic medication with the benefits being in addition to the benefits from these treatments.
On the basis of the trial evidence it is recommended (Grade A) that exercise training should form a core element of cardiac rehabilitation programmes and that the formal exercise component should be offered at least twice a week for a minimum of 8 weeks.
However, incorporating regular sustained exercise into an individualÍs lifestyle is likely to be more important than the frequency or length of formal exercise training.
Safety of exercising
The evidence shows that the incidence of serious adverse events during supervised exercise is low. Most patients will benefit from and should be encouraged to undertake at least low-to-moderate intensity exercise unless they have clinically unstable cardiac disease or limiting co-morbidity.
Exercise testing and echocardiography are recommended to assess residual ischaemia and ventricular function, but for most patients at low risk, clinical risk stratification based on history, examination and resting ECG, along with a functional capacity test such as the shuttle walking test, will be sufficient before exercising.
Patients at high risk are defined in the guideline, along with details of functional capacity tests which should be evaluated before and on completion of exercise training (Grade D).
The evidence is clear that low-to-moderate exercise training can be undertaken as safely and as effectively in the home or community as in a hospital setting for low-to-moderate risk patients (Grade B).
Other aspects of exercise training covered in the guideline include:
- Intensity of exercise
- Patient monitoring during exercise
- Resistance training
- Long-term exercise programmes.
A targeted approach
Psychological and educational support can facilitate a return to normal living as well as encourage patients to make lifestyle changes and to deal with psychological distress. The aim is to give patients back their confidence, make them feel better and improve their quality of life.
Patients should be screened for anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) at discharge, at 6-12 weeks post-MI or following a decision on surgical intervention. Screening should be repeated at 3-month intervals if appropriate.
Figure 1 (below) outlines how anxiety and depression can be identified and managed in patients undergoing cardiac rehabilitation.
|Figure 1: Algorithm for targeting therapy and interventions in patients undergoing cardiac rehabilitation|
The Heart Manual
Community-based staff can take a greater role in cardiac rehabilitation by providing patients with the Heart Manual,* which is recommended to facilitate CCR (Grade A).
The Heart Manual is a 6-week cognitive behavioural rehabilitation tool for use in the immediate post-MI period. Developed from the Health Belief model, the programme is designed to correct misconceptions about the cause of heart attack and to help patients develop strategies for dealing with stress, to neutralise enduring misconceptions.
The Heart Manual emphasises self-management, but must be recommended by a doctor and facilitated by specially trained nurses. It is one way of providing educational and psychological support for post-MI patients, although it will not meet the needs of a minority who require additional help.
The Heart Manual can lead to significantly lower re-admission rates. It can also improve patientsÍ emotional state and sense of control.
Ensuring ongoing benefit
It is recommended (Grade A) that structured care and follow up should be provided by primary care teams for patients with coronary heart disease.
The evidence for this recommendation comes from two UK primary care trials, which suggest that a structured approach benefits health-related quality of life and uptake of secondary prevention. The findings of one trial suggest that the intervention needs to be continued long term for the benefits to be maintained.7
Nurse-led secondary prevention clinics in Grampian not only improved patientsÍ wellbeing but resulted in fewer hospital admissions.8
Putting the guideline into practice
Managed clinical networks9,Audit data should ïfall outÍ of routinely collected clinical data which link all involved professionals and organisations in a co-ordinated way, not constrained by existing boundaries, may be an effective way to provide comprehensive cardiac care, especially across the primary and secondary care interface.
Routine data collection on a ïcollect once, use oftenÍ basis, using appropriate information and management systems, should be part of everyday clinical care.
Table 2 (below) gives the recommended minimum data fields, to be used in addition to the minimum data set recommended by the CHD Task Force,10 for the implementation of the guideline and to meet audit requirements.
|Table 2: Additional minimum data fields for cardiac rehabilitation|
|Initiating event for cardiac rehabilitation|
|Myocardial infarction||Y/N/NR||Heart failure||Y/N/NR|
|Bypass surgery||Y/N/NR||Internal cardiac defibrillator||Y/N/NR|
|Seen by rehabilitation nurse||Y/N/NR|
|Rehab programme||Exercise only||Education only||Comprehensive CR|
|Heart Manual issued||Y/N/NR|
|Heart Manual completed||Y/N/NR|
|Entry to programme Day/Month/Year||Exit from programme Day/Month/Year|
|Reasons for not completing at least one form of rehabilitation|
|Patient not interested||Undergoing investigations|
|No transport||Return to work|
|Too far to travel||Physical incapacity|
|HAD score before discharge||A=/D=/Refused/NR|
|Follow up HAD score (for values 8 or more)||A=/D=/NI/Refused/NR|
|Functional capacity before training programme||Y/N/NR|
|Functional capacity after training programme||Y/N/NR|
|Misconceptions about cardiac condition||Y/N/NR|
|Written information given||Y/N/NR|
|Carers seen||Y/N/No carer/NR|
|Basic life support discussed with carer||Y/N/NR|
|Secondary prevention clinic||Y/N/NI/NR|
|BACR Phase 4 exercise||Y/N/NI/NR|
|A, anxiety; D, depression; NI, not indicated; NR, not recorded; BACR, British Association for Cardiac Rehabilitation|
Cardiac rehabilitation is as cost effective as other interventions such as treatment of hypertension, hyperlipidaemia, thrombolytics for inferior MI and angioplasty for severe angina and single vessel disease.
Community-based and practice staff have an important role to play in comprehensive cardiac rehabilitation. The key points they should consider for patients undergoing cardiac rehabilitation are listed in Box 2.
* Health professionals can obtain copies of the Heart Manual from: Administration Building, Astley Ainslie Hospital, Grange Loan, Edinburgh EH9 2HLS. Tel: 0131 537 9127; email: firstname.lastname@example.org
The Heart Manual Project is a nonprofit-making NHS organisation that supports the use of the Heart Manual within the health service. To maintain quality, as well as for safety reasons, the Heart Manual is not supplied directly to the public, or to untrained staff. The project maintains a register of ïqualifiedÍ facilitators and organises facilitator training.
- SIGN 57: Cardiac Rehabilitation. Edinburgh: Scottish Intercollegiate Guidelines Network, 2002.
- SIGN 41: Secondary Prevention of Coronary Heart Disease following Myocardial Infarction. Edinburgh: Scottish Intercollegiate Guidelines Network, 2000.
- SIGN 51: Stable Angina. Edinburgh: Scottish Intercollegiate Guidelines Network, 2001.
- SIGN 35: Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction. Edinburgh: Scottish Intercollegiate Guidelines Network, 1999.
- SIGN 50: A Guideline DeveloperÍs Handbook. Scottish Intercollegiate Guidelines Network, 2001. www.sign.ac.uk
- Jolliffe JA. Rees LK, Taylor RS et al. Exercise-based rehabilitation for coronary heart disease (Cochrane Review) In: Cochrane Library, Issue 4, 2000. Update software.
- Cupples ME, McKnight A. Five year follow up of patients at high cardiovascular risk who took part in a randomised controlled trial of health promotion. Br Med J 1999; 319: 687-8.
- Campbell NC, Thain J, Deans HG et al. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. Br Med J 1998; 316: 1434-7.
- Baker CD, Lorimer AR. Cardiology: the development of a managed clinical network. Br Med J 2000; 321: 1152-3.
- Coronary Heart Disease/Stroke Task Force Report. Scottish Executive, September 2001. www.show.scot.nhs.uk/sehd/publications/cdtf/cdtf.pdf
- The Scottish Office Department of Health. Towards a Healthier Scotland. Edinburgh: The Stationery Office, February 1999.
SIgn 57: Cardiac Rehabilitation was launched on 29 January 2002 at the Royal Alexander Hospital, Paisley at a clinical meeting held in conjunction with opening of the Health at Heart Centre - a pupose-built cardiac rehabilitation centre - as part of the have a heart Paisley demonstrator Project11