Cardiac rehab reduces death, but is under-utilized

Less than 20 percent of patients eligible for cardiac rehab are referred to a program, which can reduce mortality by up to 35 percent.

After two heart attacks and 10 stents, Rick Vinson had a decision to make — do nothing and likely die from heart disease like his father or take a chance at having a long life.

Vinson chose the latter. After receiving his last stent in October 2010, he entered a cardiac rehab program at the University of Alabama at Birmingham. Since then he has dropped 20 pounds, his cholesterol has dropped to 141 from 315 and his triglycerides are down to 149 from 465.

Unfortunately, many heart patients never get the chance reap the benefits of cardiac rehab.

“Research has shown fewer than 20 percent of patients eligible for cardiac rehab are actually referred to a program,” says Vera Bittner, M.D., section head, Preventive Cardiology, medical director of the UAB cardiac rehab program and co-author of a January 2012 scientific advisory for the American Heart Association on increasing referral and participation rates in cardiac rehab. “A recent analysis from the Medicare database estimated that there is a 35 percent reduction in mortality among people who attended cardiac rehab compared to those who did not. And other research studies have shown a 15 to 25 percent reduction in the number of recurrent heart attacks in people who have been to cardiac rehab. These definitely are not negligible health benefits.”

Bittner is giving a presentation on the benefits of cardiac rehab titled “Cardiac Rehabilitation: Why Break a Sweat?” during the 2012 American College of Cardiology Scientific Sessions Monday, March 26, 2012, in Chicago.

Within five years of an initial heart attack, 15 percent of men and 22 percent of women ages 45-64 and 22 percent of men and women older than 65 will suffer another heart attack or fatal coronary event. Outpatient cardiac rehab offers a cost-effective, multidisciplinary approach to reduce risk factors for patients who have had a first cardiac event and helps restore them to health and prevent this from happening again, Bittner says.

“Cardiac rehab should be looked at as a comprehensive way to address secondary prevention in individuals who already have had an event,” Bittner says. “We know that people who have had a myocardial infarction, bypass surgery or stenting are at high risk of having another event within the next five years. And we know that risk-factor modification lowers these event rates. Cardiac rehab is an excellent setting to teach patients and their families ways to lower their risk.”

Vinson, 55, is a textbook example. He has a family history of heart disease. His father died of a heart attack in 1987 at the age of 61. Vinson is the youngest of seven children; three of his siblings have heart disease and have had bypass surgery. In October 2000 he had his first heart attack, and stents were placed to correct blockages in his arteries. He was 44. Five years later, he needed additional stents to correct more blockages. Two more sets of stents and another heart attack later, he is taking cardiac rehab seriously.

“I didn’t do cardiac rehab after my first heart attack, but I did after I got stents in 2005,” he says. “I did well, lost some weight, but I didn’t have the mindset at that time to continue what I had learned. I just went back to my regular routine. I had the mindset that heart disease runs in the family so I may just as well accept it.”

For patients who attend cardiac rehab, Bittner says previous research shows a nearly 80 percent survival rate after three years for those who participated in cardiac rehab versus 64 percent for those who did not; there also is a 25 percent reduction in the risk of suffering a recurrent heart attack.

“This is huge and very much on par or better than what we traditionally achieve with medications,” Bittner says.

Bittner says the typical cardiac rehab prescription is 36 sessions during a 12-week period. It includes lifestyle counseling, helping patients understand better why they are taking certain medicines, improving functional capacity and assessing psychosocial aspects, including the stress that comes from having had a cardiac event.

“This is not the idea of having someone exercise for 12 weeks then go back to their couch potato-dom,” she says. “The idea is to teach a healthier lifestyle that they can continue once they complete the program.”

Bittner says the biggest barrier to cardiac rehab is lack of physician referral.

“I don’t think there is a full appreciation in the medical community for how much the contemporary cardiac rehab program does and how much of an impact it has on morbidity and mortality, i.e., the same hard endpoints we typically discuss when evaluating medications and procedures,” she says. “And I don’t think it’s something traditionally emphasized in training programs. Physicians tend to do what they learn while training. If they are not exposed to that type of therapy and disease management then they are less likely to refer patients to it.”

She says right now it is up to the individual physician taking care of the patient to initiate the cardiac rehab referral but “patients come in contact with a whole host of health-care providers who could help in this referral process.” She says this includes nurses, physical therapists, dieticians and even home-health workers.

“We are trying to figure out how to get more eligible patients into a cardiac rehab program so that they can ultimately benefit from what they have to offer,” she says. “We are trying to encourage a broad referral policy, a referral process that is a little bit more distributed than we traditionally do, and more than is currently in place at most institutions.”

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