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The following course content

Introduction   

Cardiovascular disease (CVD) is known to be one of the highest causes of morbidity and mortality globally. CVDs affect some 26 million people worldwide and the number is expected to rise 8 million more by 2030 (1). CVD is also the leading cause of disability in the world (7). In the U.S., the cost of CVD, including direct care, medications, loss of income, and disability is $219,000 per year.

As of 2019, 805,000 people in the U.S. had a heart attack and 659,041 deaths were from CVD (8). CVD is the highest healthcare cost in the world. Estimated losses can range from $20,000,000 to $30,000,000 in Vietnam and Ethiopia. Research in cardiac rehab has shown reduced morbidity and mortality, rehospitalizations, and cardiovascular events. This evidence shows that cardiac rehab is cost-effective with a savings of $12,000 per patient for a period of five years (7).

Some insurance companies and governments around the world pay for cardiac rehab, however, some patients have to pay out of pocket. In Europe, one research project showed a mere 36.5 % of cardiac patients had received rehab. In the U.S. only a small percentage (12.2%) of Medicare beneficiaries received cardiac rehab. This inadequacy may cause a person to not seek rehab. Statistics show around the world only a small percentage of patients enrolled in this important program (7).

Many patients are living with congestive heart failure (CHF), may have had a myocardial infarction (MI), or have had cardiac surgery. Those with high cholesterol, cardiac arrythmias, and failing heart valves may also be enrolled in cardiac rehab. Unfortunately, some of these patients may not understand the importance and seriousness of their conditions until it is too late (3).

Effective management of CVD will depend on the patient and team relationship. Good cardiac rehab can give the patient a better quality of life and may prolong their life. It is also important to keep the same age group in a program as learning and coping styles are different for different age groups (1).

Aside from bedside care on cardiac care floors, nurses should look at how they can assist in working with these patients post discharge. Nursing’s involvement in cardiac rehab is an ever-growing support for these patients. As we will see during this course, nurses play a very important role in this area of care.

This course will help you understand what cardiac rehab is as well as the role of the cardiac nurse in this important lifesaving program.

Cardiac Rehab: What is it?

“Cardiac rehab is a personalized program of education and exercise” for cardiac patients (4). It usually takes place in a specially designated unit. It includes educating patients on heart healthy lifestyles through supervision of exercise in a rehab unit and the importance of follow up with their providers. Its purpose is to keep those with heart conditions or cardiac surgery healthy and improve their quality of life (4). It also has been proven “to enhance the effect of acute treatment actions” (2). This program has demonstrated that patients who attend have better outcomes and less cardiac events in the future. They engage in more exercise, healthier eating, and changes (such as smoking cessation) to improve their quality of life. Physical functioning can improve as well as self-perception and mental health (1).

The research and follow up of cardiac rehab patients have been shown to reduce further MIs, risk of other cardiac complications, and prolong life for patients suffering from heart disease (4).

A team will review the patient’s history, interview the patient, and develop a plan of care that meets each individual patient’s needs (6). When developing the plan of care, it is imperative that a patient’s cultural and personal beliefs are incorporated so that there will be understanding and cooperation with the team. If necessary, an interpreter may need to be utilized to assist with translation (5). Rehab also includes emotional support for patients who require it.

The need for cardiac rehab worldwide is high, yet it is scarce in many countries. With regards to inpatient costs, provider visits and medications, cardiovascular disease has the highest economic burden in the world.

Patient Population 

As we have described in the last section, we now know what cardiac rehab is. We learned that it has many benefits, so let us now look at those who are the most eligible and/or at risk without it. 

To begin, “men and women of all ages with a variety of heart problems may join a program” (6). Any person who has had an MI, heart failure, arrythmias, angina or valve problems may be referred by a provider (most likely a cardiologist) to a cardiac rehab program. Also, patients who have undergone bypass surgery, angioplasty, pacemaker/defibrillator placement, and valve repair/replacement may be candidates for rehab (6). For patients who fall into the category of needing cardiac rehab, the team will also address lifestyle issues that cause heart disease (6). 

In my own family, my husband who has type 2 diabetes and was 70 at the time, came home one evening stating he had chest pain which radiated across his chest and left arm. I asked him if it was pain on a scale of 1-10 and he said 10. We went to the ER to discover he had a right coronary artery blockage. After three days on heparin and IV medications, he went to the cardiac catheter lab in a town 45 mins away.   

He had a stent placement and was told his cardiac catheterization showed that only one vessel was blocked enough for angioplasty and stenting. Three months later while on vacation in Florida he again presented with chest pain that was different from his first MI. He took one nitroglycerin tablet with relief, but because we were away from home, I wanted him to be checked out to be certain. To my disbelief, his left anterior artery was 99% blocked. We were told by the cardiologist that a piece of plaque must have broken off and occluded the artery.  Another stenting was done and thankfully he has been fine since. 

When we arrived home and he followed up with his cardiologist, cardiac rehab was suggested. The nurses were wonderful. He went three times per week for six weeks and has done very well.  His A1C is down. His echocardiogram showed an ejection fraction of 60% and his cholesterol and lipids are within normal limits. 

Fortunately, there was little to no damage to his cardiac muscle, but the cardiac rehab taught him much about the importance of a healthy diet and losing weight (he lost 12 lbs.), walking for exercise and how to prevent any further events. Rehab also taught him about cardiac health and how to prevent any further issues. Even though I am a nurse and tried to teach him all I could about diabetes and heart disease, cardiac rehab made much more of an impact. 

For people without a person who is savvy enough to intervene and get a patient to the hospital, the outcome may not have been as positive, but I feel strongly that cardiac rehab did more for him than I ever could to keep his heart healthy.

Interventions and Treatment in Cardiac Rehab  

Let us discuss the interventions and treatments of cardiac rehab. First a cardiologist will prescribe cardiac rehab for patients they feel could benefit from it. Some tests may be performed to ascertain if the patient is appropriate for the program. In most cases there will be a team assigned to the patient, including a cardiac rehab nurse, physical and occupational therapists, dieticians, and a social worker or mental health provider (6).  

An interview will take place and a thorough history including diet, exercise, smoking history, and cardiac history will be queried. An individualized program will be developed specifically for the patient being interviewed (6). Goals for rehab will be set and frequent checkups with the cardiologist may occur (4). 

A major part of cardiac rehab is doing exercises to strengthen the heart. The exercise is typically low impact such as walking, jogging, or rowing. Also included will be weightlifting and resistance training to help with muscular fitness (4).  

Lifestyle education is also included. This education includes educating the patient on eating a heart-healthy diet and maintaining or losing weight.  Seven to nine hours of sleep is recommended as well since the body and heart need to rest to heal. Rehab will also include cardiac rehab nurses/educators who will instruct on ways to lower cholesterol, keep diabetes in check, and lower blood pressure and obesity (1,4). We will discuss the other duties of cardiac rehab nurses in the following section. 

At my husband’s rehab, a social worker interviewed him to see how he was coping with his heart attacks. This may be very important for some who are emotionally upset by their diagnosis (1).

Average Length of Stay  

In some facilities, rehab may be scheduled for three times per week for about six to 12 weeks. It can be longer if the physician prescribes, and the patient may also continue longer if they feel they would like the guidance and support. 

There are four phases of cardiac rehab. These include: (12) 

1. The Acute Phase 
2. The Subacute Phase 
3. Intensive Outpatient Therapy 
4. Independent Ongoing Conditioning 

Phase 1: Acute Phase 

Phase one usually starts in the hospital after any cardiac procedure when a physical therapist (PT) meets with the patient and evaluates them for mobility, safety, and physical fitness abilities (12). The PT works with the team for discharge planning and adds exercises to the patient’s plan that will ensure safety as well as increase the health of the heart. The PT also teaches the patient sternal precautions if open heart surgery was performed. Once the patient is discharged home, the second phase or subacute phase of rehab can begin.   

Phase 2: Subacute Phase 

As discussed above, the subacute phase begins once the patient is discharged home and is healing. This phase usually lasts three to six weeks (12). Continued monitoring from the team occurs to assess the plan and how the patient is progressing. The patient will learn how to perform appropriately and monitor their own heart rate. This phase will also assess how much exertion the patient is experiencing.  This phase allows for more patient education and promotes independence with rehab and life in general. 

Phase 3: Intensive Outpatient Therapy 

Phase three includes more intensive exercise and may occur in a group setting (12). At this point the patient should be able to self-monitor their heart rate and any symptoms occurring during exercise.  The PT will be available to help increase tolerance of exercise, while monitoring any untoward changes. As the patient finishes this phase of rehab, the PT may work with the patient to tailor an exercise program which includes stretching for flexibility, strengthening, and cardiovascular exercise. 

Phase 4: Independent Ongoing Conditioning 

Phase four begins when the patient can be independent with their exercise plan (12).  The PT may be available to help with changes to the exercise program and increases the patient’s ability to return to optimal health.

The Nurse’s role in Cardiac Rehab 

Up until now, we have discussed what cardiac rehab is, what staff is part of the team, burden of cost, who is eligible, and the four phases of cardiac rehab. There are multiple roles for the nurse in this important part of cardiac care, so let us take a look. 

A cardiac rehab nurse “must be prepared to educate, advise, guide, and support patients and treat them” (3). A rehab nurse needs excellent communication and must be passionate about assisting patients for healthy living (3). The rehab nurse needs to stay up to date with new techniques and the latest trends to ensure the best outcomes for patients (3). These nurses work closely with cardiologists and the rest of the rehab team and may even be with patients during stress tests.  

In rehab, complete vital signs will be monitored by the nurse while the patient is exercising and under their care. A cardiac monitor will be placed on the patient to watch for untoward events and the patient will be watched closely by the nurse while continuously monitoring vital signs, assessing how the patient looks and changing the plan where necessary. Nurses will also educate on lifestyle changes as we previously discussed, such as proper cardiac and diabetic diets as many of these patients may be diabetic.   

Cardiac nurses also educate on maintaining exercise at home, quitting smoking if needed, and answering questions related to medication, dietary changes, and dealing with the stress and anxiety of the disease and prognosis (10). Information on the patient’s visit will be documented in the medical record each time the patient visits rehab. Nurses working on cardiology units also have a degree of responsibility to encourage cardiac rehab for their patients (9). 

To become a cardiac rehab nurse, one must have at least a bachelor’s degree (master’s degree preferred). A specialization in cardiology is ideal. A minimum of 2,000 hours of cardiovascular nursing practice may be required to become certified. A cardiac rehab nurse also must be certified in basic life support (CPR) and proficient in the use of an automated external defibrillator (AED). At least one member of the cardiac team should be certified in advanced cardiac life support (ACLS).

Patient Education 

The team in cardiac rehab will all have something to teach the patient. PTs work with each patient to instruct individual-specific exercises to the patient that will strengthen the heart and entire body. They will teach the patient warm-up and cool down exercises, how to hold the body while using weights or resistance training for muscle strength, and how often exercises should be performed (4). 

The rehab nurse will discuss healthy eating, such as increasing fruits, vegetables, lean meats, and fish, and cutting out or reducing caffeine intake. Rehab nurses will also teach patients about eliminating processed foods, especially those with high salt and fat content. Reading food labels for nutritional value will also be part of dietary education. The nurse will explain and teach how to take and monitor blood pressure. Keeping a diary of these numbers to bring to the cardiology appointments will also help the patient understand the importance of keeping their blood pressure at safe levels and following the rehab instructions. 

There are six principles that are common to teaching adults (5): 

• “Need to know”: It is important that the patient understands what and why it is being taught. 

• “Self-directed approach”: The patient should be involved in planning of their rehab program. 

• “Prior experience”: Any existing knowledge, attitude, and beliefs will help to individualize the plan. 

• “Readiness to learn”: What does the patient already know and what do they need to know? 

• “Problem centered approach to learning”: It is important to provide a supportive environment and teach practical “how to” information. May use a variety of media. 

• “Motivation to learn”: Watch the patient’s ability to apply the information and update the plan as needed.

Advocacy 

In any illness, it is important to have support whether from family, friends, or outside help. Individuals with cardiac disease are at a high level of needing an advocate. Some patients may feel anxious or depressed. If the patient is worried about losing their job, there is support for vocational training. If they must retire or become disabled, there may be a big transition or adjustment period for them (4). Counseling is always available and cardiac rehab nurses can assist in finding the patient a therapist.    

Advocacy also includes supporting a cause, such as getting funding for cardiac rehab from the government and private donors. Advocates in this situation “influence public policy, laws and budgets by using facts, personal stories, their relationships, the media, and messaging to educate government officials, policy makers and the general public” (7). 

Despite all the evidence that cardiac rehab works, it has been a challenge to secure funding around the world for this important program (7). Rehab professionals from around the globe have been advocating for their patients to shape policies in healthcare that support the ever-increasing need for cardiac rehab.  Methods of communication are vital to identify the needs of the government, insurance companies, and most importantly the patient (7). 

A successful advocacy program will include evidence of need, media coverage, and pamphlets or peer reviewed journals discussing the need (7). An organized plan with strategies and goals to “address scientific, policy, financial, and communication needs” (7).

Discharge Follow Up 

Once discharged home, the patient will be expected to follow the regimen designed for them at rehab.   They should have excellent knowledge of what they have learned and put it into practice. In some instances, rehab can be done at home through a visiting nurse agency with nurses, and physical and occupational therapists. Exercises that were taught should be continued. Family members will need education about healthy diets, including how to cook and what kind of food needs to be consumed. Low fat and low salt will be at the top of the list.    

As patients progress, the home team can assess and reevaluate needs for amending the plan, making those changes as necessary to continue recovery (12). Ongoing visits with the cardiologist will be important. Follow up electrocardiograms (EKGs), medication changes, and echocardiograms may be ongoing. Following the plan at home can contribute to a longer and improved quality of life (4).

Patient Resources 

If your facility does not have cardiac rehab, as a nurse you may need to know what is available and where the patient can find what they need. The American Heart Association (AHA) has a resource page (American Heart Association) for patients, families and caregivers called “Support Network” (13). On this site, patients can find a whole host of assistance and resources. They can share their stories and be in contact with others who have the same issues and become a member. 

Other resources may be found at your local senior center, councils for the aging, and other community agencies. There are also many resources through the American Association of Retired Persons (AARP).   

The U.S. Centers for Disease Control and Prevention (CDC) has a webpage (Centers for Disease Control & Prevention) with information and printable handouts. Below are a few of the topics available (14).  

• Managing My Blood Pressure: Patients can use this printable list of questions to ask their health care team to help them manage their blood pressure.  

• My Blood Pressure Log: People can use this printable log to keep track of their blood pressure measurements at home.  

• My First Blood Pressure Visit: Encourage patients to record important blood pressure–related information on this page before their appointments.  

• The Correct Way to Measure Blood Pressure: Share this graphic with patients, family, and friends to show them the correct way to measure blood pressure.

Conclusion

We know that cardiac disease is the highest cause of deaths in the world. This is due to many factors, such as diet and exercise, lack of education on healthy lifestyles and the full lives people have today, especially in rural areas and poorer countries who have little or no resources. As nurses it is extremely important that we take time out of our busy days to educate and enlighten our patients about the risks of heart disease and what changes they can make to remain healthy. 

As stated above, heart disease brings with it the highest health care costs for the government, healthcare facilities and physicians.  Many facilities have initiated policies and procedures in the attempt to mitigate outbreaks of heart disease and to lower costs. 

Nurses play a major role in cardiac rehab by assisting patients who are either at risk or already have a diagnosis. Cardiac rehab has increased the quality of life for many individuals and extended life for many patients.  Many studies have shown promise in cardiac rehab, but prevention is always the key.

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