Rehabilitation and Cardiovascular Disease
by Ira Rashbaum, M.D.
| Geriatric Times |
 |
January/February 2002 |
|
Vol. III |
|
Issue 1 |
Cardiovascular diseases kill more Americans every year than any other
illness, including cancer and AIDS. Advances in medical and surgical
management, along with lifestyle modifications, have contributed to a greater
likelihood of survival into the senior years. Greater emphasis has been placed
on the roles of prevention and rehabilitation in the management of
cardiovascular disease. Despite this, cardiovascular rehabilitation is
generally felt to be an underutilized component in the total care of the
geriatric patient population.
Cardiovascular rehabilitation is not limited to patients who have sustained
myocardial infarction. Other rehabilitation candidates include patients who
have undergone coronary artery bypass grafting, heart valve repair or
replacement surgery, percutaneous transluminal coronary angioplasty, coronary
artery stenting, pacemaker insertion, implantable cardiac defibrillator
insertion, or insertion of a left ventricular assist device (LVAD). Also
patients with congestive heart failure can benefit.
One of the most significant developments in cardiac surgery in recent years
has been the introduction of minimally invasive direct coronary artery bypass.
Advantages of this technique include smaller incisions; less pain; a shorter
recovery time than with conventional bypass surgery; and decreased risk of
heart attack, stroke, memory loss, pulmonary complications, sternum infection
and post-operative anemia. This technique seems to be most applicable to
patients who have single-vessel coronary artery disease.
Stents are metallic scaffolds that can be placed inside a diseased segment
of a coronary artery to increase its diameter and improve blood flow to the
heart and decrease symptoms of angina. Coating and irradiating the stent have
been attempted to minimize the likelihood of arterial narrowing or clot
formation. Cardiologists initially recommended delaying or withholding
rehabilitation after stenting so as not to risk migration of the stent
elsewhere in the body. Fortunately, this approach has been shown generally to
be overly conservative.
Left ventricular assist devices are implantable pumps driven by pneumatic or
electrical systems that can provide necessary support to very ill patients with
congestive heart failure. Earmarked initially for patients awaiting cardiac
transplant, a recent study suggests LVADs can provide longer-term support for
failing hearts, possibly obviating the need for transplant. This may prove to
be especially valuable in the geriatric patient population, in whom
transplantation may be absolutely or relatively excluded. Rehabilitation of
patients with LVADs has been accomplished successfully.
Phases of Rehabilitation
The spectrum of cardiovascular rehabilitation has been described in terms of
phases. The delivery of these services is ordered and supervised by a physician
and administered by nurses, physical therapists, occupational therapists,
psychologists, social workers, exercise physiologists, vocational
rehabilitation counselors and nutritionists.
Phase I occurs in a hospital setting and can be divided further into two
phases. Phase IA, which occurs in an acute setting such as an intensive care
unit or other general hospital location, happens after an acute medical illness
or surgical procedure and involves low-level conditioning exercise and training
in functional activities. Phase IB refers to cardiovascular rehabilitation at a
specialized rehabilitation hospital or rehabilitation unit within a hospital
and takes place when the patient has successfully completed Phase IA. Both
aspects of Phase I utilize cardiac monitoring via telemetry. A primary goal of
Phase IB is the safe transition from the hospital setting to either a sub-acute
rehabilitation facility or home.
Phase II cardiovascular rehabilitation takes place in an outpatient setting
and includes exercise, smoking cessation, weight reduction, lipid management,
stress management and dietary changes. A focus of Phase II is secondary
prevention of additional cardiovascular events. Some Phase II programs include
telemetric monitoring.
Phase III usually is community-based, often without telemetric monitoring,
and lasts from three to 12 months after the initial cardiovascular event. Phase
IV is usually self-directed, begins approximately one year after the event, and
is directed toward long-term lifestyle and exercise adaptation.
Elements of Rehabilitation
Cardiac rehabilitation has two primary elements: exercise and education.
Exercise likely exerts its beneficial effects through a variety of direct and
indirect mechanisms, including improvement in the relationship between cardiac
oxygen supply and demand, increase in high density lipoprotein cholesterol
levels, decrease in serum triglyceride levels, decrease in blood pressure,
decrease in the aggregation of platelets and improvement in coronary arterial
dilatation.
Exercise associated with cardiovascular rehabilitation has been
traditionally aerobic. The referring physician should prescribe a submaximal
exercise stress test in order to provide the patient and the rehabilitation
provider with an exercise prescription, including target heart rate and blood
pressure parameters.
Strength training is especially important for older adults in improving
strength, balance, functional capacity and bone density (Verrill, 2001).
Resistive exercise training has been shown to be beneficial for older adults
who have cardiovascular disease or for those who are at risk for developing
metabolic or cardiovascular complications.
Some cardiovascular surgeons, however, advise against strength training when
the sternum is incised. A standard one-hour rehabilitation session comprises
two aerobic exercise sessions and one session of strength training, emphasizing
isotonic exercise rather than isometric exercise. Isometric exercise, performed
by exertion against an immovable object, has been associated with a
particularly large increase in blood pressure. Isotonic exercise, movement of a
constant weight through a range of motion, is felt to be safer.
It is extremely important to ascertain the psychological status of geriatric
patients with cardiovascular disease. Fear, depression and isolation due to a
lack of social support may have an untoward effect on morbidity and mortality
in this patient population. Assistance from rehabilitation team members or
other mental health care professionals may be necessary. Support from friends
and family and from groups can be critical.
The education element of rehabilitation of the geriatric patient with
cardiovascular disease is the "secret weapon" of the entire process. Compared
with patients whose rehabilitation consists solely of exercise, patients who
have sustained heart attacks have decreased morbidity and mortality when
education is infused into their rehabilitation. Patients should learn about
cardiac anatomy and physiology, the pharmacology of cardiac medications, proper
nutrition, smoking cessation, diabetes management, and stress reduction.
Since a greater number of senior citizens are deferring retirement or are
semi-retired, the services of a vocational rehabilitation counselor should be
offered. This professional can address return-to-work issues such as date of
work resumption, ergonomic adaptation or job retraining.
Cardiovascular disease and an active sexual life do not have to be mutually
exclusive. The traditional advice concerning return to sexual activity is the
ability to climb two flights of stairs. The newer guideline, assuming sexual
activity will be with the patient's usual partner, is the ability to perform
approximately five metabolic equivalents of physical activity. A physician,
physical therapist, occupational therapist or exercise physiologist can educate
patients and their often equally anxious partners on understanding whether they
meet this benchmark and provide other tips on how to safely and successfully
resume sexual activity.
In terms of prevention of cardiovascular disease progression, the Lifestyle
Heart Trial used a low-fat vegetarian diet, smoking cessation, stress
management and moderate exercise in symptomatic patients with coronary artery
disease (Ornish et al., 1990). Patients reported a 91% reduction in angina
frequency, a 42% reduction in angina duration, and a 28% reduction in angina
severity. After the yearlong study, average coronary artery narrowing decreased
from 40.0% to 37.8%. The control group showed an increase in average coronary
artery narrowing from 42.7% to 46.1%.
The evolving field of rehabilitation of cardiovascular disease definitely
includes the geriatric patient population. In a variety of diseases, quality of
life and mortality statistics can be improved when rehabilitation is an
integral part of the health care equation.
Dr. Rashbaum is clinical associate professor of rehabilitation
medicine at New York University School of Medicine.
References
Ornish D, Brown SE, Scherwitz LW et al. (1990), Can lifestyle changes
reverse coronary heart disease? The Lifestyle Heart Trial. Lancet
336(8708):129-133.
Verrill DE (2001), Strength training for older adults. Geriatric Times
2(4):26-27.