Up and At 'em! (Part Two)

Part two of our four-part After A Heart Attack series focuses on cardiac rehabilitation



Dwight Eisenhower had a heart attack in April 1955. Of course, he got the best care, including care directed by Paul Dudley White, a leading cardiologist of the time and a founder of the American Heart Association. Not a minute of exercise was included anywhere in his recovery plan. Twelve weeks of bed rest was the standard of care. The controversy of the day was whether he should sit up in a chair or remain in bed. After he had an episode of chest pain while sitting up, Eisenhower was returned to bed.

It was only after he was released from the doctors’ care that the president took up his own plan: regular exercise, stress reduction — he had a legendary temper, a low-cholesterol diet and weight control. Clearly, Eisenhower was way ahead of his doctors.

The experts of the time feared that any activity could trigger another heart attack, but now healthcare professionals view the situation differently. “Your heart is a muscle,” said Patrick Dunn, Ph.D., manager of Connected Health for the American Heart Association’s Center for Health Technology and Innovation, who worked as a certified exercise physiologist in cardiac rehab for more than 30 years. “Consider this, if you just go to bed for 12 weeks, any muscle is going to get weaker. And second consider this, if you’re just lying around in bed for 12 weeks, you’re at increased risk for developing a blood clot.” A third thing to consider is that even if you had another heart attack, your rehab is strengthening your heart. A stronger heart can better compensate for the damage, so you are more likely to survive.

The 4 phases of Cardiac Rehab

Phase 1 begins in the hospital and involves getting the patient up and moving as soon as possible, primarily to prevent blood clots and begin the education process. Today’s patients may not even get 12 hours before they’re out of bed, a far cry from Eisenhower’s 12 weeks of bedrest.

Phase 2 begins after a patient has been discharged from the hospital. It’s usually done in a gym at a hospital or rehab hospital. These facilities are overseen by a cardiologist. Certified preventive and rehabilitative exercise specialists are on staff as well as nurses. Phase 2 typically starts with an exercise physiologist creating a personalized exercise prescription and then training in groups with other patients. All patients’ heart rates, blood pressure and EKGs are constantly monitored by nurses experienced in caring for patients with heart disease. “Phase 2 usually consists of one-hour sessions three times a week for 12 weeks,” Dunn said. “During those 36 sessions, basically every move the patient makes is monitored.” Nonetheless, patients learn how to check their heart rate and judge the intensity of their workout. As the weeks pass, patients work up to more intense and longer aerobic activity on a treadmill or exercise bike; the goal is to train the patient back to health. Counseling and educational sessions are included to help patients understand the nutritional and other lifestyle adjustments they need to commit to for their best health. These are usually held before or after the exercise period.

Cardiac rehab is covered by Medicare and most other insurers for the following:

  • Heart attack (myocardial infarction (MI)) in the last 12 months
  • Heart condition, such as stable angina or stable chronic heart failure.
  • Heart procedure or surgery, including CABG, coronary angioplasty, stenting or heart valve repair or replacement, or heart or heart-lung transplant.

Check with your medical team and insurer to be sure you’re covered.

Phase 3 is more of a transitional phase, some of the monitoring is removed. “So maybe not monitoring the EKG, but still monitoring heart rate and blood pressure. Phase 3 is in a supervised setting, like a rehab center,” Dunn said. The length of Phase 3 depends on the patient. “It can be as short as a couple of weeks. For a heart transplant patient or someone with a very acute disease, they may stay in Phase 3 for the rest of their lives.”

In Phase 4, the patient is unsupervised and unmonitored, typically still in a rehab center, but sometimes it may be in a community center or YMCA. “Phase 4 does not have an endpoint. Once you get there, you basically stay there forever,” Dunn said. This is the way to maintain the gains, as well as continuing to practice all that’s been learned through the CR process.

It’s not unusual for patients who are at risk but haven’t experienced an event such as heart attack, a procedure or surgery to be directed to participate in Phases 3 and 4. “If a person does poorly on a stress test, has high cholesterol and a bad family history, they don’t actually meet the criteria for Phase 2,” Dunn said. “The doctor might put them into a Phase 3 or 4 program directly. Again the point is to strengthen the heart muscle and improve their quality of life.” Although they are not monitored, patients have access to cardiac rehab specialists. The patient generally covers the cost of these programs, usually a monthly membership fee, like at a health club. (See Choosing a Cardiac Rehab Facility below.)

Benefits of Cardiac Rehab

Dr. Patrick Dunn

In addition to what is learned in specific counseling and education sessions, much can be learned during the exercise portion as patients connect with each other, either one-on-one or in small groups. Ad hoc conversations with nurses and exercise physiologists also play an important role in education. “Today a lot of the patients are using digital tools recommended by the rehab center or apps and systems they found on their own to learn more,” Dunn said. “They can provide education, monitoring, and even social support. However, they lack the direct supervision.” Digital tools may be helpful for those for whom cost or proximity to a facility are obstacles to participating in Phases 3 and 4. (See Breaking Down Barriers below.)

“We put people in cardiac rehab because if we can increase the strength of that muscle, it will help them have a much higher quality of life,” said Dunn. The short-term goal of cardiac rehab is restoring normal function, getting back to the same functional levels that one had prior to their event. Long-term goals are to reduce their risk of another heart attack and improve the quality of their life.

Clear benefits … being missed

“The research on cardiac rehab shows a tremendous benefit for going to rehab versus not going to rehab,” Dunn said. “The patients who go to rehab are much less likely to have another heart attack and there is as much as a 25-50 percent increase in survival if they do — if they participate in all 36 sessions. Other benefits may include reduced hospital readmission, improved quality of life and better control of blood pressure and cholesterol.”

While exercise training and lifestyle education are crucial parts of all cardiac rehab programs, Dunn emphasized that social support plays an important part. “For one thing, it can reduce the anxiety level of patients when they connect with others,” he said. “The more they can connect with other patients, the better they may feel about themselves. They don’t feel isolated, like ‘I’m the only one experiencing this kind of problem.’ In my 30 years of experience, I have found that modeling other patients is an effective way for adult patients to learn how to change their behaviors for a more heart-healthy lifestyle.” The American Heart Association’s Support Network is also available 24/7 for those who would like to connect and share with other patients.

Despite all that, fewer than 20 percent who are eligible for cardiac rehab are ever referred to a program. If you’ve had a cardiac event, procedure or surgery and didn’t get a cardiac rehab prescription afterwards, talk with your doctor about whether you should have one. You may use our downloadable cardiac rehab referral card in English or Spanish to help start the conversation with your healthcare provider.

“The medical care someone receives following a heart attack, open-heart surgery, or stent is a lifesaving experience,” Dunn said. “Cardiac rehabilitation can be a life-changing experience. Becoming more active, learning to eat better, deal with stress, and manage risk factors, such as blood pressure and cholesterol, can result in a better quality of life.”

Visit the American Heart Association website for more information about cardiac rehab. You can also order a copy of our popular cardiac rehab workbook and DVD, An Active Partnership for the Health of Your Heart. It offers encouragement, knowledge and resources to help you make lasting lifestyle changes.

Cardiac rehab supervisor, David Cowan, talks about some of the benefits of CR.

Though cardiac rehab can be a vital resource on the road to recovery, just 12 percent of eligible Medicare beneficiaries ever participate. One reason participation rates have historically been low is a Medicare rule that requires a physician to directly supervise these programs, which can limit access and add on unnecessary costs.

The American Heart Association supports H.R. 3355 and S. 488 that would allow physician assistants, nurse practitioners and clinical nurse specialists to supervise cardiac rehabilitation services on a day-to-day basis under Medicare. The legislation will not alter the requirement for medical direction of these programs, but rather would allow non-physician practitioners to meet the direct supervision requirement.

Urge your congressional representative today to co-sponsor bipartisan legislation that would allow non-physician providers to supervise cardiac rehab programs and make cardiac rehab accessible to more Medicare patients.

Julie O’Leary shares how cardiac rehab helped her establish a “new normal” after her heart attack.

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