II. Background
- Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 14-31% participation)
- Cardiac Rehabilitation has great efficacy as a secondary prevention tool
III. Indications
-
Medicare reimbursed indications (3 sesssions per week for 3 months)
- Following acute Myocardial Infarction (STEMI or non-STEMI) in the last 12 months
- Status-post Coronary Artery Bypass Graft (CABG)
- Status-post Percutaneous Coronary Intervention (PCI)
- Stable Angina Pectoris
- Status-post Vascular Surgery
- Status-post Heart Transplantation
- Status-post Heart Valve Repair or Replacement
- Recent CVA (women only)
- Other indications
- Stable Congestive Heart Failure with reduced left-ventricular ejection fraction
- Peripheral Arterial Disease
- Status-post Ventricular Assist Device placement
- Pacemaker or Implantable Cardioverter-Defibrillator
IV. Protocol: Cardiac Rehabilitation Phases
-
General
- Standard programs
- Intensive programs (limited availability)
- Intensive programs may include up to 72 sessions over up to 18 weeks
- Medicare approved programs
- Dean Ornish Program for Reversing Heart Disease
- Pritikin Intensive Cardiac Rehab Program
- Benson-Henry Institute Cardiac Wellness Program
- Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
- Supervised, structured early Physical Activity
- Patient Education
- Risk stratification (low level, graded, Exercise tolerance testing)
- Phase II Cardiac Rehabilitation (Early Outpatient)
- Supervised Physical Activity program
- Reassess symptom-limited Exercise tolerance
- Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
- Monitoring of Blood Pressure, pulse, cardiac rhythm
- Maintain Blood Pressure <140/90 mmHg
- Nutrition counseling
- May involve education on cooking and grocery shopping
- Diabetes Mellitus Type II control with Hemoglobin A1C <8%
- LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
- Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
- Cardiac Risk Factor modification
- Reassess cardiac symptoms at rest and with activity
- Psychosocial support to screen for and manage Major Depression
- Supervised Physical Activity program
- Phase III Cardiac Rehabilitation (Late Outpatient)
- Maintain and reinforce phase I and II management
- Reinforce medication use, Patient Education
V. Protocol: Activity restrictions following acute Myocardial Infarction
- Gradually increase activity over 6-8 weeks following MI
- Return to work by 8 weeks after MI
- Activity program may start by 3-4 weeks after MI
- Sexual activity restarted at 4-6 weeks after MI
- See Sexual Intercourse after Myocardial Infarction
VI. Protocol: Other Measures
- Influenza Vaccine each year
VII. Efficacy
- Reduced Angina, Dyspnea, and Fatigue
- Reduced Major Depression after acute coronary event
- Exercise performance improved
- Activities of Daily Living (ADL) performance improved
- Quality of life improved
- Decreased re-hospitalization rate
- Decreased work absence
- Reduced age-adjusted cardiovascular mortality by 50%
- References