Cardiac rehab grows as population ages and treatment options expand
Exercise and medication can improve recovery
The prevailing school of thought on how to best treat heart-failure patients has changed considerably in recent years. While it was once believed that ACE inhibitors and beta-blockers were taboo, now they are a first line of treatment for the disease. The same is true with regard to exercise, which once was not recommended, but now is known to be safe and therapeutic.
"There still are people at good treatment centers who have old ideas of not referring patients to cardiac rehab because of concerns that exercise is deleterious for them, but it is known that exercise can help the heart," says Ira G. Rashbaum, MD, clinical associate professor of rehabilitation medicine at the New York University School of Medicine and an attending physiatrist at Rusk Institute of Rehabilitation Medicine in New York City. Rashbaum spoke about cardiac rehab at the 63rd Annual Assembly & Technical Exhibition of the Chicago-based American Academy of Physical Medicine & Rehabilitation, held Nov. 21-24 in Orlando.
"Cardiac rehab in general is an underutilized phenomenon in our country, and congestive heart failure patients are underutilized for this," Rashbaum says. "Hopefully, in the next 10 to 20 years you’ll see more people referred to rehab for heart failure."
Rehab therapy is going to be an important political and economic issue, he points out, especially with Medicare, because heart failure patients are considered advisable for admission to inpatient units, but are not covered for outpatient treatment, he says.
"I think this will change," he adds. Eventually the federal government will realize that there are enough data on cardiac rehab’s efficacy, as well as a growing population of cardiac patients, to warrant Medicare’s coverage of these cardiac rehab services, Rashbaum adds.
With this in mind, it’s probably a good idea for rehab facilities interested in cardiac rehab to establish some best-practices guidelines. Rashbaum offers these suggestions:
• Pharmacological management: Rehab professionals, including nurse practitioners and even physiatrists, should review cardiac rehab patients’ medications with a cardiologist to make certain pharmacological management is individualized, Rashbaum suggests.
"Make sure there are enough eyes looking at the list of medications so that it’s done the best way possible," Rashbaum says. "Keep the cardiologist involved."
It’s also advisable for rehab professionals to keep up with the latest in cardiac pharmacological management. Not so long ago, the use of beta-blockers and ACE inhibitors was considered contraindicated in treatment of heart failure. Now they are front-line drugs, Rashbaum notes.
"There is a variety of medications that can be used to treat congestive heart failure," Rashbaum says. "Generally, rehab professionals and cardiologists are looking at using a combination of medications to get the best therapeutic effect."
While some medications previously shunned now are part of the treatment plan, other medications, such as diuretics and digoxin, are now used more judiciously, Rashbaum notes.
Diuretics, for example, can help rid the body of excess fluid and decrease the load on the heart; however, they could deplete the blood’s potassium, which would make supplementation necessary. They also may worsen heart failure when used on a long-term basis, Rashbaum says.
"Digoxin is a medication that helps the heart to contract and pump somewhat better," Rashbaum explains. "While this also is a medication that is appropriate to use, you generally don’t want to use it in a vacuum, but instead use it in concert with other drugs."
• Phases of cardiac rehab: Phase one occurs in an inpatient hospital setting and can be further broken down into phase 1-A at the acute care hospital and phase 1-B at the inpatient rehab hospital or department.
"So if someone has a heart attack and is in the coronary care unit, that’s the medical hospital, and after the person is stable, they can be moved to the rehab hospital," Rashbaum says.
Phase two is the immediate cardiac rehab that occurs in an outpatient setting. It generally consists of about 36 outpatient sessions, Rashbaum says.
A patient typically stays in the cardiac rehab hospital for 10 to 14 days and then would be transferred to outpatient cardiac rehab.
Phase three is when a patient is referred to a community-based heart program, such as those held at a YMCA. This generally lasts from three to 12 months after the initial cardiac event or diagnosis, Rashbaum explains.
The fourth phase begins one year after the cardiac disease was diagnosed, and is directed at long-term lifestyle changes.
Unfortunately for heart failure patients, Medicare and many insurers will not cover phases two through four, Rashbaum says.
• Exercise therapy: "Exercise for heart failure patients is a combination of a whole variety of exercise modalities," Rashbaum says.
Inpatient cardiac rehab programs will have patients attached to portable cardiac monitors, called telemetry, to monitor their vital signs while they are assisted in exercise therapies. Some outpatient settings will also use these devices, Rashbaum says.
"Patients involved in exercise programs as inpatients or outpatients should be under the care of a physician who is familiar with cardiovascular diseases," Rashbaum says. "And they should have exercise stress tests to assess the safety of their being involved."
Stress tests will give physicians, nurses, therapists, and physiologists the parameters of how high or low the patient’s blood pressure and heart rate should go, Rashbaum adds.
Need More Information?
- Ira G. Rashbaum, MD, Clinical Associate Professor of Rehabilitation Medicine, New York University School of Medicine; Attending Physiatrist, Rusk Institute of Rehabilitation Medicine, 400 East 34th St., New York, NY 10016. Telephone: (212) 263-6328. E-mail: [email protected].
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