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Heart Disease in Women
|What Is Cardiac Rehabilitation?
Cardiac rehabilitation (cardiac rehab) is a professionally supervised program that helps people recover after a heart attack or heart surgery like coronary angioplasty and coronary artery bypass surgery (CABG). Usually provided through community hospitals, the program provides education and counseling services with the aim of helping patients to improve their overall health and reduce the risk of future problems from heart disease. In cardiac rehab the patient works with a specialized team that includes cardiologists, nurses, occupational therapists, physical therapists, dietitians, psychiatrists, psychologists, social workers and counselors. These professionals can also communicate with the patient’s cardiologist or primary care doctor. Although many family doctors incorporate some of the fundamentals of cardiac rehab advice into their daily practice, a dedicated center can better reinforce the message of nutrition, risk factor reduction and exercise. Yet, despite this, cardiac rehab services are still under-used in the United States, even though the evidence suggests that structured programs improve quality of life and reduce the risk of death from CHD. Cost is not usually a factor because most insurance plans and Medicare cover rehab for up to 3 sessions per week for 3 months. Research shows that only 14 percent of eligible heart attack patients and 31 percent of CABG patients use the service in the United States. The statistics are similar in the UK. Reasons for lack of use cited by patients include:
• Distance to a center is too far.
• Lack of transportation.
• Low self-esteem.
• Lack of referral by their doctor.
• They did not perceive the benefits to be worth the effort.
Who Needs Cardiac Rehab?
The program will benefit men and women of all ages who have had any of the following:
1. Congestive heart failure.
2. Heart attack.
3. Percutaneous coronary intervention (PCI) such as angioplasty.
4. Stable angina.
5. Heart valve repair or replacement.
6. Lung or heart transplant.
7. Coronary artery bypass surgery (CABG).
8. Surgery to insert a pacemaker or implantable cardioverter defibrillator (ICD).
What Are The Benefits?
A cardiac rehab program will help you:
1. Gradually improve your physical fitness level to strengthen your heart. A personalized cardiac rehab exercise program will be created and you will be monitored by experts so that you can reach your targets safely.
2. Determine your ideal body weight and work out a balanced diet plan for you to achieve this.
3. Learn about new ways to cook and prepare food and how to incorporate low-cholesterol and low-fat options into your daily menu.
4. Learn about the impact of your job on your heart and how to take steps to protect yourself.
5. Quit smoking
6. Learn about stress management techniques such as meditation, yoga or massage. Why? Read about the dangers of stress.
7. Deal with any emotional and psychological issues you may have in relation to your condition - such as anger or depression. It is also an opportunity to discuss the effects of depression.
8. Talk to other men and women who are going through the same issues.
Rehab can help people live longer and it does reduce the chance of future heart attacks, chest pain and symptoms of angina. It may also lower a patient's need for heart medications and can slow the progression of atherosclerosis, which causes coronary heart disease. Over the long term patients feel stronger, fitter and emotionally healthier. Ideally their quality of life will be so improved that they can return to independent living.
What Are The Phases?
Typically cardiac rehab is divided into 3 phases:
Hospitalization and Early Recovery
This phase begins while the patient is still in hospital. It prepares her for day to day activities she will need to perform when she is discharged. If she is in intensive care after a heart attack a nurse will help her to exercise her legs, feet, arms and hands. This is known as full range of motion exercise. Next she will be helped to sit up, walk around and wash herself. After a few days she will be helped to climb stairs and walk down hallways. Some members of a rehab team may visit her in hospital to discuss the next stage of her recovery program.
This is an outpatient program which usually begins 2 to 6 weeks after being discharged from hospital. The patient visits her local cardiac rehab center 3 times a week for 2 to 6 months. Home based rehab is also an option for those with severe disabilities or who live too far away from a suitable center. Phase 2 begins with an extensive initial medical assessment (see below for details). An exercise stress test is carried out to determine how much exercise the patient can safely tolerate and an exercise program is designed around this. Over the months, she will gradually build up her activity level under the close supervision of a therapist. Constant supervision with electrocardiogram (ECG/EKG) is also included. A dietitian will talk about heart healthy foods and design a personalized food plan. Other coronary heart disease prevention techniques will be discussed and counseling is also offered to those suffering from depression, anxiety or stress because of their condition.
Late Outpatient or Maintenance Program
This is the maintenance phase which continues indefinitely. The patient is encouraged to maintain their lifestyle changes and to continue their exercise regime 3 times a week at a local gym, although some continue to use facilities at the rehab center. The aim is to reduce their overall long-term risk factors for heart disease by following a healthier lifestyle. During this phase there will be periodic assessments (not as frequent as phase 2) of the patient's symptoms, medications and risk factors.
Initial Medical Assessment
When you arrive for your first rehab consultation your medical team will want to carry out a full medical assessment. It will focus on any previous heart disease diagnosis you were given as well as which types of coronary heart disease treatment you received. They will also discuss any prior symptoms of coronary heart disease and which medications you are currently taking. They will also assess your risk factors for future problems. A physical examination will be carried out which may include an ECG (such as a treadmill stress test), blood pressure, blood sugar and blood cholesterol tests. Based on this assessment the doctor will recommend a treatment plan with both short-term and long-term goals with the aim of controlling your overall risk factors.
The doctor will measure your blood pressure in both arms during the initial assessment and in subsequent weeks. This is to check for the presence of high blood pressure (hypertension). The following readings will prompt different actions:
120-139 mmHg systolic blood pressure/80-89 mm Hg diastolic pressure: Lifestyle changes will be recommended to lower blood pressure.
140 mmHg or over/90 mm Hg or over: Blood pressure drugs will be prescribed.
130 mmHG or over/80 mm Hg or over WITH diabetes, heart failure or chronic kidney disease: Blood pressure meds may be prescribed.
Blood will be taken to check for cholesterol levels both in the initial assessment and 2 months or so after starting cholesterol lowering drugs. Dietary counseling on how to adopt a heart-healthy diet plan will also be discussed. The aim with intervention is to the keep your LDL (low-density lipoprotein, the 'bad' fats) lower than 70 mg/dl.
Obesity in women: Your body mass index (BMI) will be calculated, based on your height, weight and waist circumference. If you are overweight (BMI of 25 or more, obesity measures as BMI of 30 or more) then short-term and long-term goals will be set to help you lose weight. A patient may, for example, be set a target of losing 5 to 10 percent of their body weight over 6 months. This will be achieved by following a healthy diet plan and exercising several times a week. A dietician will determine the overall necessary calorie allowance to achieve this.
If you smoke your doctor will ask if you are ready to quit. If you are not (and it is worth being honest) he will discuss the implications of your decision. If you are ready to stop smoking, the doctor will help you set a date for quitting. They may also prescribe nicotine patches or gum to help the process, or the drug Zyban (an antidepressant which helps with smoking cessation). You may also be referred to a smoking cessation group or recommended alternative measures such as hypnotherapy.
Those with diabetes will have their diet reviewed and their blood sugar levels (HbA1c test) will be monitored. They will be taught how to recognize the signs of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and a dietician will discuss a diabetic diet with them. A doctor will review the patient's medications and dosage. Studies shows that many drugs such as aspirin therapy, statins, beta blockers and ACE inhibitors lower the risk of heart disease, but have even greater benefits for those with diabetes.
How Do I Find A Program?
Your cardiologist will give you details about a program near you. If he or your primary care doctor does not mention rehabilitation, ask them about it. As mentioned in the introduction above, one of the main reasons for under use of the rehab services is the lack of physician recommendation. If you are not happy with the response, contact your local hospital who will be able to give your details of the nearest cardiac rehab center. Alternatively the American Heart Association has a complete list of cardiac rehabilitation programs in the United States. See: www.heart.org
10 Questions To Ask When Choosing A Program
1. Do you need a doctor’s referral to enter the program?
2. Will the program provide my referring doctor with progress reports?
3. Do I need to take an exercise stress test before entering the program?
Some programs organize this for you.
4. What counseling and educational facilities are provided and can they include my family?
Ideally a good program will provide support services to the whole family.
5. Will I have a personalized exercise plan designed for me?
You should do.
6. Will I be supervised by a doctor while exercising?
A doctor should be immediately available.
7. Who is providing the service and are they certified by the American Association of Cardiovascular & Pulmonary Rehabilitation (CPR)?
8. Are all the staff CPR certified?
They should be.
9. Does the center have emergency equipment in case of a problem?
It should do.
10. Do they discuss fees and insurance coverage up front?
They should do.
Question: I had a heart attack 5 month ago. Is it too late now to join a cardiac rehab program?
No, it is not. Sometimes it is even recommended to rest after a major illness. Joining a program now means you can still benefit by having personal exercise program designed for you and you will learn how to eat healthy and introduce heart friendly prevention techniques into your life. You will also learn about medication compliance and have the opportunity to meet others in the same situation.
For those not in a cardiac program, they should discuss with their doctor about starting a home cardiac exercise program. Also read about living with heart disease.