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AHCPR Health Technology Assessments. Rockville (MD): Agency for Health Care Policy and Research (US); 1990-1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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AHCPR Health Technology Assessments.

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Cardiac Rehabilitation Programs

Health Technology Assessment Reports, 1991 Number 3

, M.D., Ph.D.

Created: .

Foreword

The Office of Health Technology Assessment (OHTA) evaluates the risks, benefits, and clinical effectiveness of new or unestablished medical technologies that are being considered for coverage under Medicare. These assessments are performed at the request of the Health Care Financing Administration (HCFA). They are the basis for recommendations to HCFA regarding coverage policy decisions under Medicare.

Questions about Medicare coverage for certain health care technologies are directed to HCFA by such interested parties as insurers, manufacturers, Medicare contractors, and practitioners. Those questions of a medical, scientific, or technical nature are formally referred to OHTA for assessment.

OHTA's assessment process includes a comprehensive review of the medical literature and emphasizes broad and open participation from within and outside the Federal Government. A range of expert advice is obtained by widely publicizing the plans for conducting the assessment through publication of an announcement in the Federal Register and solicitation of input from Federal agencies, medical specialty societies, insurers, and manufacturers. The involvement of these experts helps assure inclusion of the experienced and varying viewpoints needed to round out the data derived from individual scientific studies in the medical literature.

After OHTA receives information from experts and the scientific literature, the results are analyzed and synthesized into an assessment report. Each report represents a detailed analysis of the risks, clinical effectiveness, and uses of new or unestablished medical technologies considered for Medicare coverage. These Health Technology Assessment Reports form the basis for the Public Health Service recommendations to HCFA and are disseminated widely. Individual reports are available to the public once HCFA has made a coverage decision regarding the subject technology.

OHTA is one component of the Agency for Health Care Policy and Research (AHCPR), Public Health Service, Department of Health and Human Services.

  • Thomas V. Holohan, M.D.
  • Director
  • Office of Health Technology Assessment
  • J. Jarrett Clinton, M.D.
  • Administrator
  • Questions regarding this assessment should be directed to:
  • Office of Health Technology Assessment
  • AHCPR
  • Executive Office Center
  • 2101 East Jefferson Street, Suite 400
  • Rockville, MD 20857:(301)227-8337

Introduction

Cardiac rehabilitation is a continuing process whereby patients with cardiac disease are encouraged to achieve their maximal functional capacity and attain acceptable psychological, social, emotional, vocational, and economic status. Cardiac rehabilitation programs are offered as comprehensive packages of services for patients who have had a variety of heart disorders. They usually consists of a prescribed regimen of physical exercise that is primarily intended to improve functional work capacity and is secondarily intended to increase the patient's confidence and well-being. Psychological, nutritional, and vocational counselling are often included as part of the programs.

The Health Care Financing Administration previously determined that cardiac rehabilitation programs are reasonable and necessary for patients who have had a myocardial infarction or coronary artery bypass graft (CABG) or have stable angina pectoris. This current review assesses the benefits of cardiac rehabilitation programs for patients who have undergone heart transplantation, percutaneous transluminal coronary angioplasty (PTCA), or heart valve surgery.

Rationale

The physical fitness of cardiac patients may deteriorate to varying degrees, depending on the limitations on activities imposed by the cardiac condition and the length of time since the onset of cardiac debilitations. Cardiac rehabilitation programs were developed to enhance the improvement in physical fitness of cardiac patients so that they might resume their normal pre-cardiac-event activities safely and as soon as possible.

Depending on the degree of debilitation, cardiac patients may or may not require supervised rehabilitation programs. The effectiveness of physical training programs in improving the functional capacity of individuals is demonstrated by athletes participating in competitive sports. Whereas athletes may use physical training programs to increase their abilities to become competitive in an activity of their choosing, some cardiac patients may require physical training programs or rehabilitation programs to attain the ability to carry out daily activities that are necessary for their survival as functioning individuals. In some cases, however, the resumption of normal daily functions, including a return to work, may involve more than a simple improvement of the cardiac patient's exercise capacities and require other nonphysical components of rehabilitation programs.

Background

Cardiac rehabilitation is a continuous process that has been arbitrarily divided into three phases. It begins as soon as possible after a cardiovascular event, usually within 24 to 48 hours, and continues as phase I of the process while the patient is in the hospital. Phase II consists of planned cardiac rehabilitation programs that are generally administered during the 6 months following discharge from the hospital. This phase generally involves the prescription of a supervised, planned program to increase the functional capacity of the patient to allow the individual to resume normal life activities. The patient's progress is monitored at appropriate times by means of standard cardiac function tests. Phase III consists of a lifelong program committed to encourage exercise and a healthful lifestyle to minimize recurrence of cardiac problems.

Cardiac rehabilitation programs have been developed to help patients leaving the hospital regain their physical and psychological abilities so that they may return to functional and productive lives. A 1987 Public Health Service (PHS) assessment report concluded that these cardiack rehabilitation program are safe and, as evidenced by periodic tolerance testing, effectively increase the functional capacity of patients who have had myocardial infarctions or coronary artery bypass surgery or have stable angina.(1) The PHS report (1). and other reviews(2-6). have indicated that although the functional capacity of cardiac patients may have been improved by exercise programs,the actual time to return to work and the long-term morbidity and mortality were not significantly different from those of similar patients who did not participate in the prescribed exercise programs.

A relative scale of energy requirements related to heart function necessary for performing various daily activities has been used to describe the functional status of cardiac patients. For example, approximately 3 METs are required for walking, sitting, or other ordinary activities necessary for an individual to be self-sufficient. A MET is an energy unit defined as the use of 3.5 mL of oxygen per minute per kilogram of body weight.(7). Patients with a functional capacity of 7-9 METs have the capability of undertaking vigorous activities such as sawing wood, mountain climbing, and heavy calisthenics and of resuming their normal pre-cardiac-event activities.(2) Generally, any cardiac patient minimally attains the ability to exercise to 3 METs without cardiac symptoms before leaving the hospital. Most patients entering the phase II cardiac rehabilitation program have the ability to carry out activities requiring more METs. The approximate relationship of METs to various activities and functional cardiac classes is illustrated in Table 1.

Table 1. Approximate energy requirements for selected activities.

Table

Table 1. Approximate energy requirements for selected activities.

The rates of improvement in physical abilities of cardiac patients in response to exercise programs increase linearly during the early weeks and begin to plateau at about the 8th to 12th week of the programs.(2,8) Based on the review by Greenland and Chu, (2). the American College of Physicians(8). concluded that the goals of supervised cardiac rehabilitation can be achieved typically within 12 weeks in appropriately selected patients. They concluded that some low-risk patients may not require formal cardiac rehabilitation services. Low-risk patients were considered to be those who were asymptomatic at rest and who had the exercise capacity to resume most vocational or recreational activities after an uncomplicated myocardial infarction or a successful coronary revascularization. On the other hand, cardiac rehabilitation programs under intensive surveillance were recommended for high-risk patients, such as survivors of sudden cardiac arrest, those with severely depressed ventricular function (ejection fraction < 30), or those with ventricular arrhythmias. A time-limited medically supervised rehabilitation program was recommended for patients with functional capacities of less than 8 METs or patients considered at intermediate risk for a recurrent cardiac event. Patients attaining the ability to exercise to 8 or more METs without cardiac symptoms were considered to be prepared to exit the supervised programs.

Standards and guidelines for performing the exercise tests and training the patients without provoking clinical manifestations of the cardiovascular disease were recently published independently by the American Heart Association(7). and the American Association of Cardiovascular and Pulmonary Rehabilitation.(9). These were developed to be of help to health professionals who are engaged in cardiac rehabilitation programs.

Review of the Literature

The published data concerning the beneficial effects of cardiac rehabilitation programs for heart transplant recipients and patients who have had percutaneous transluminal coronary angioplasty and/or valvular surgery are limited. It is clear that these patients share, more or less, many of the problems encountered by all patients suffering from cardiac diseases. Heart transplant recipients may have psychological problems that require psychiatric assistance as part of their rehabilitation program.(10,11) Patients who have had PTCA may not be physically debilitated, but they may need only counseling services to help them gain the confidence necessary to resume normal activities. These varied needs for services in addition to the physical fitness program in some of the patients indicate that one or more parts of a comprehensive cardiac rehabilitation program may play a significant role in the rehabilitation of many patients after the cardiac surgeries of concern in this review.

Heart Transplant

Since the first human heart transplant in 1967, a total of 7,365 transplants had been done in the United States by the end of 1989; 1,673 of these were done in 1989. The primary indications for heart transplantation were cardiomyopathy and coronary artery disease. Contrary to earlier beliefs, older transplant patients did not appear to have increased morbidity and mortality. For instance, Miller et al(12). observed that all eight of their patients older than age 55 had good exercise tolerance and returned to work within 3 months after transplantation.

Cardiac transplant recipients appear to regain exercise capacities that are acceptable for resumption of relatively normal lives. This was demonstrated by Savin et al, (13). who compared exercise capabilities of 15 transplant recipients, returning for annual evaluations 12 to 95 months after transplantation, with those of 14 normal, age-matched control subjects. Exercise capacities were tested by having the patients and control subjects perform 3-minute work loads on the treadmill, beginning at a 2.5 grade at 2 mph (equivalent to about 3 METs)and progressing by increments to higher work loads at prescribed times. The responses of the transplant patients to the graded, symptom-limited treadmill exercises reflected those of the denervated heart and were characterized by decreased chronotropic reserve, altered ventilatory patterns, decreased work time, and elevated postexcercise lactate levels. Although a few of the transplant patients were unable to complete treadmill work requiring 6-7 METs, about half of the patients were able to complete work loads that required an estimated 7-8 METs. Normal control subjects began to falter at work loads of 9-10 METs, with about half of them completing work loads requiring 10-11 METs. Because the participation of the transplant recipients in cardiac rehabilitation programs was not reported, it is not possible to determined whether supervised rehabilitation programs influenced the test results.

Exercise training was shown to effectively increase the work capacity and decrease the submaximal heart rate in transplant recipients. Savin et al(14). demonstrated these effects by comparing five denervated transplant recipients and seven innervated control subjects after they participated in a 16-week training program consisting of 30 minutes of cycling at > 75 peak heart rate for 5 or more days per week.

Kavanagh et al(15). also demonstrated the effectiveness of an exercise program in improving the functional capacities of heart transplant patients. Thirty-six male heart transplant patients were enrolled in an exercise program that began with walking 1.6 km five times per week and progressed to walking/jogging for 6.4 km five times per week, each session lasting 30-60 minutes. At the end of the 16-month training program, the patients showed increases in lean tissue and evidence of increased functional cardiac capacities as indicated by increased peak power output, peak oxygen uptake, and absolute ventilatory threshold and a trend toward reduced resting and submaximal heart rates.

In a subsequent study, Kavanagh et al(16). compared the effects of exercise rehabilitation in 10 heterotopic cardiac transplant patients and 14 age-matched male orthotopic transplantation recipients. Similar effects of improved physical capacities, as seen in the previous study, were noted in both groups of transplant patients.

Squires(17). reviewed the roles played by exercise training, counseling, education, and nutritional guidance in the rehabilitation of heart transplant patients. He concluded from the available information that comprehensive rehabilitation programs were effective in improving the exercise capacities, cardiac functions, and psychological profiles of cardiac patients. He also noted that the question of why many able cardiac patients failed to return to work was an important issue that remained unresolved.

Although most heart transplant recipients were physically capable, many of the patients did not resume their normal daily activities. For example, Harvison et al(18). found that only 62 of the 51 patients who had had heart transplants between February 1984 and March 1987 could be considered "successfully rehabilitated," according to an analysis of the responses to questionnaires they sent to transplant recipients. Findings such as this suggest that the inclusion of psychosocial services in cardiac rehabilitation programs might be helpful.

The effects of a comprehensive rehabilitation program that included psychosocial as well as physical rehabilitation services on 62 heart transplant patients were studied by Niset et al.(19) In addition to the personnel involved in the physical rehabilitation services, the program included the services of a psychologist to offer psychological assistance to the patients and a social worker to help with administrative and financial tasks. One year after surgery, heart transplant patients showed increases of 34 in maximal working capacity, 33 in maximal oxygen uptake, 11 in maximal heart rate, and 18 in blood pressure. Four months after transplantation, 71 of the patients who had been working 6 months before the operation had returned to work. This rate of return to work compared favorably with Niset's earlier observations of an 80-90 return rate for cardiac patients who had recovered from myocardial infarctions, coronary artery bypass surgery, or percutaneous transluminal coronary angioplasty. The psychosocial assistance given to the transplant recipients was thought to have influenced the relatively good rate of return to work of these

The reasons for returning to work or not returning to work may be complex and may involve factors other than those addressable by rehabilitation programs. For example, Meister et al(20). examined the return to work of 47 transplant recipients and found that at 6 months after the operation about a one-third of the patients had returned to work, about a one-quarter had retired, and about a one-third were able to, but did not return to work. The return to work was influenced by the age of the patient, length of time of debilitation, control over the working conditions, and the type of health insurance. Similar poor rates of return to work have been noted by others.

Percutaneous Transluminal Coronary Angioplasty

Increasingly, PTCA has been used as an alternative to CABG for symptomatic relief in properly selected patients with atherosclerotic coronary artery disease. PTCA was thought to be associated with less morbidity and was considered to have the advantages of avoiding major surgery, a prompter recovery with a shorter hospital stay, and a rapid return of exercise capability.

Most observations indicated that patients undergoing successful restoration of coronary circulation by PTCA had minimal need for formal rehabilitation programs, especially the exercise training aspects. Representative of these observations are two reports(21,22). that showed that PTCA patients recovered functional capacities that permitted their resumption of normal daily activities in a few weeks without supervised rehabilitation programs. However, participating in an exercise program may increase the functional capacity of these patients further, as demonstrated in a study by Ben-Ari et al, (22). where 68 patients participating in 12 weeks of a monitored, exercise rehabilitation program were compared with 60 patients having the usual standard post-PTCA care. The exercise group attained a functional capacity of about 11 METs compared with about 9 METs for the control group.

Early observations tended to support the belief that patients had a rapid rate of return to work and quickly resumed recreational activities after successful angioplasty. For instance, Jang et al(23). reported a significantly higher rate of return to work of patients after PTCA over that of those undergoing CABG. Others, such as Kelly et al, (24). did not observe a significant difference in rates of return to work between patients undergoing PTCA or CABG. The early reports of excellent return-to-work rates after PTCA may have been the result of selecting "healthier" patients for PTCA who had single-vessel coronary artery disease and well-preserved left ventricular function. In addition, the earlier patients undergoing PTCA were generally younger and had a relatively low incidence of previous myocardial infarction and shorter durations of angina. These patients were also thought to have had lower levels of physical disability before treatment and were expected to show a high rate of return to work.

The rate of return to work has changed over the years as seen by comparison of the work resumption of patients ,who underwent PTCA in the early years of its development with that of patients treated at a later time. Danchin and associates(25). sent detailed questionnaires to two groups of consecutive patients, one group consisting of 109 patients who underwent the procedure between April 1980 and October 1982 and a second group consisting of 171 patients who underwent the procedure in 1985. The information they received showed that the patients in the later group were older and had a higher percentage of previous myocardial infarction and of multivessel coronary artery disease. The primary success rate for the angioplasty procedure, defined as a gain of at least 20 of intraluminal diameter, had increased with experience, being 89 in the later group and 73 in the early group.

The overall rates of return to work were similar for the two groups. However, when patients who had had successful angioplasty procedures were compared, the rate of return to work in this subset of patients was significantly higher in the early group (85 vs 64). The good rate of return to work in the early group was representative of the rates found among patients undergoing PTCA in the early 1980s. Age, health status at time of surgery, level of physical activity involved in the pre-PTCA occupation, and the occurrence of angiographic restenosis were factors that decreased the rate of return to work.

Although the patients were functionally capable, their return to work and the lag time in resumption of work after PTCA appeared to be influenced by other factors, such as occupational, medical, physical, and psychosocial factors. Furthermore, Fitzgerald et al(26). found that only 34(41) of 82 patients were working 1 month after PTCA, while the number working increased to 71 (87) at 6 months. Many patients had delayed returning to work after PTCA although they were physically capable of working. Even among patients selected for a high probability of returning to work, 41 failed to return to work in the expected time period of 1-2 weeks. Fitzgerald et al indicated that self-efficacy, a psychosocial concept concerned with the confidence in one's ability to return to work, appeared to be the best predictor of return to work. Thus, many PTCA patients were found to lack self-efficacy and retained the "sick role" for relatively long periods after PTCA.

Cardiac Valve Surgery

The outcomes of 267 patients who had aortic and/or mitral valve operations during the years 1963 through 1970 were reviewed by Carey et al.(27) At the time of the review in 1972, only a small fraction of the 157 survivors were found to be employed, either full-time or part-time. In response to a questionnaire, 76 of the survivors reported that they were either greatly or slightly improved and about 10 reported being the same or worse. The majority of the unemployed patients believed that they were not able to work, while a small number of the unemployed were either retired or unable to find work. The large percentage of patients not returning to work in this study may have been influenced by the fact that many of the patients were receiving pension benefits from the Veterans Administration.

Ungerman-de Ment et al(28). demonstration that early mobilization and exercise instructions, provided soon after surgery, improved the independent functional activities and decreased the fear of normal activities in patients undergoing coronary bypass and/or valvular surgery. Forty-four patients, who had had CABG, valve replacement, or both (31 CABG, 12 valve replacement, 1 both) were started on a regimen or twice-daily exercise and walking sessions 1 day after surgery and progressed from supine exercises to sitting exercise and short distance ambulation in the surgical intensive care unit. The patients then progressed through a series of standing exercises, ambulation to 1,200 feet, stair climbing, and on to additional exercise sessions that were performed with or without nursing supervision. Patients participating in this exercise program demonstrated improved activity levels and a readiness for discharge earlier (1.9 days, P < .001) than those (36 with CABG, 4 with valve replacement, and 3 with both) not participating. Patients who had been most restricted (<3.5 METs) at admission demonstrated the greatest benefit from the exercise sessions.

Participating in a rehabilitation program was shown to increase the physical working capacity and the rate of return to work of patients who had undergone mitral or aortic valve operations.(29) Of a total of 209 patients, 132 participated in a rehabilitation program that involved therapeutic exercises, controlled walking, stair climbing, bicycle ergometric exercises, and psychological events such as psychotherapeutic talks. The physical abilities in the participating patients improved about 50 compared with less than 10 in the nonparticipating patients. About 65 of the participating patients returned to work compared with about 45 of the nonparticipating patients.

Sire(30). also showed that physical training and occupational rehabilitation benefited patients who had had aortic valve replacement. Forty-four patients were randomly allocated to either a training group or a control group. The 21 patients who participated in the rehabilitation program increased their physical work capacity by 58 and decreased their perceived exertion at the highest comparable work load by 13, while the 23 nonparticipating patients showed little change in these parameters. Although 81 of the participants and 65 of the nonparticipants were working after 1 year, the difference in rates was deemed as not significant in this small series of 44 patients. Re-employment was correlated with the physical work capacity of the patient and was inversely correlated with the duration of sick leave taken by the patient prior to the operation.

Discussion

Cardiac rehabilitation programs are effective in improving the functional abilities of patients who have undergone treatment and stabilization of their cardiac diseases. Since the goal of rehabilitation programs is to increase the functional capacities of cardiac patients to that they can manage the daily rigors of a relatively normal life, the necessity for enrollment in such a program would be dependent on the degree of debilitation experienced by the cardiac patient. The degree of debilitation varies from patient to patient and is influenced by such factors as the length of time of incapacitation before relief from the cardiac condition. For example, patients undergoing PTCA may have minimal debilitation and may resume normal daily activities in a very short time without participation in a formal program. Thus, all cardiac patients may not require a formal supervised program, depending on the extent of their functional limitations. A number of reviews have been conducted in recent years that discuss the usefulness of rehabilitation programs in cardiac patients and have suggested the need for the programs in selected patients.(2,6,8,31-35)

The American College of Physicians(8). concluded that the need for various rehabilitation services vary greatly from patient to patient, such that some patients require supervised continuous electrocardiogram-monitored exercise programs, while others require only education/counseling services. They further suggested that the need of any patient for posthospital rehabilitation programs are best determined and prescribed by the physician.

Much of the early attention in the care of cardiac patients was focused on improving their physical exercise capabilities. This was effectively accomplished by the institution of planned exercise programs. Enrolling all eligible cardiac patients into these programs may have incurred costs that were unnecessary for increasing the already adequate functional capacities of some of the patients. However, the inclusion of other nonphysical services in these rehabilitation programs appears to have helped many cardiac patients regain confidence in their abilities to cope with the resumption of normal functional activities and their return to productive lives. Although these programs have improved the rate of return to work in some cases, many able patients have continued to remain unemployed for a multitude of reasons that appear not to be addressed by rehabilitation programs. Since any delay in work resumption may be an expense to society through absence from the labor force and increased disability insurance payments, it would seem important to determine how people with low self-efficacy for return to work might be stimulated to resume working as soon as they are able. Simple clinical interventions, including early treadmill testing and physician counseling, have been shown to improve self-efficacy estimates for physical activity and have been linked to improved exercise outcomes in some patients after a myocardial infarction.(36-38)

Studies that illustrate the effect of exercise programs on the work capacities of patients who had heart transplantation, precutaneous transluminal coronary angioplasty, or heart valve surgery are summarized in Table 2. In all of the studies, the work capacities of the patients (except heterotopic heart transplant patients) were increased by more than 30 by participation in an exercise program.

Table 2. Increased work capacity with exercise programs.

Table

Table 2. Increased work capacity with exercise programs.

Heart transplant patients present physical and psychological problems that might be addressed in rehabilitation efforts. Exercise programs can take care of the preoperative deconditioning resulting from physical inactivity and severe limitation of cardiac output. Although exercise prescriptions may follow guidelines developed for general post-cardiac surgery patients, target heart rates should be used with caution in these patients because of the delayed heart rate acceleration response of the denervated transplanted organ to exercise. Since the transplanted heart is devoid of the usual anginal pain accompanying exertion, the exercise intensity should be guided primarily by using the Borg scale of perceived exertion and by using oxygen costs of various activities as a percentage of the maximum oxygen uptake and the gas exchange anaerobic threshold. A majority of the transplant patients appear to have psychological problems and may benefit from counseling and emotional support. They appear to respond to comprehensive cardiac rehabilitation services that include educational and psychological assistance in managing stress, acquiring practical skills to deal with the medical regimen, and restoring self-confidence.

If PTCA patients are similar to patients who have undergone coronary artery bypass surgery, their return to work may not be influenced to any great extent by participation in rehabilitation programs. This may be a reasonable assumption when one considers that the participation in a rehabilitation program did not appear to effect a significant improvement in return-to-work rates by coronary bypass patients as seen in studies such as those conducted by Boulay et al(39). and Gutman et al.(40) This is not to say that supervised planned exercise programs are not useful for PTCA patients, but that selected patients who need improvements in their functional capabilities can benefit from such programs.

Clinicians should not assume that, because PTCA is a generally safe and minimally invasive procedure, patients perceive it as such. Efforts to identify those patients with concern about their ability to return to work in the first month after PTCA may identify a subset of patients who are at high risk for delay in work resumption. The effects of nonphysical rehabilitation services and studies that test self-efficacy-enhancing interventions, such as early treadmill testing or early institution of cardiac rehabilitation, may provide insight into how these determinations might be made in order to develop means to help these patients.

Since the early years, improvements in the PTCA technique have led to increased success rates and have extented the patient selection criteria for PTCA to include a greater percentage of older patients with previous myocardial infarctions and multivessel coronary artery disease. Although the primary success rate of the procedure has markedly increased with experience, the rate of return to work following the procedure has decreased, as illustrated by the Danchin et al study.(25) The decreased rate of return to work may be related to the older age of the patients, to the deterioration of the general socioeconomy with the resultant increased unemployment, or to the increased number of patient with multivessel coronary artery disease. In many cases, the return to work of capable patients was unnecessarily delayed until after the administration of the exercise tests that were routinely scheduled for 2 to 3 months following the procedure.

Patients who have undergone cardiac valve surgery benefit from exercise programs that are instituted during phase I or II of the rehabilitation period. Although Ungerman-de Ment et al(28). demonstrated that early mobilization and exercises soon after cardiac valve surgery were effective in improving the activity levels of the patients, they did not report whether their patients needed further supervised rehabilitation programs after discharge from the hospital in order to resume normal daily activities. However, in view of the demonstrated effectiveness of cardiac rehabilitation programs in outpatients, it would seem that rehabilitation programs, both in and out of the hospital, are beneficial to patients who have had cardiac valve surgery and have the potential but lack the necessary functional capacities to resume normal daily activities.

Comments received from the National Institutes of Health were generally supportive of these findings. They noted that the postoperative management of heart transplant patients varied greatly among the various heart transplant centers, ranging from structured, formal programs to less formal programs where exercises were suggested for patient use. They also made mention of the fact that there is very little information available concerning the effects of rehabilitation programs on cardiac patients considered in this report.

Comments that also corroborated our interpretation of the use of rehabilitation programs in cardiac patients who have undergone heart transplant, PTCA, or cardiac valve surgery were received from the American College of Physicians, the American College of Cardiology, the American Medical Association, the American Association of Cardiovascular and Pulmonary Rehabilitation, the Arizona Heart Institute, the Cleveland Clinic Foundation, and the Missouri Association for Cardiovascular and Pulmonary Rehabilitation.

Summary

Cardiac rehabilitation programs are safe and effective in improving the functional activities of patients with cardiac disease, but they may be hazardous to those patients whose life might be in jeopardy if subjected to exercise. It is clear that not all cardiac patients require supervised rehabilitation programs to return to normal pre-cardiac-event activities. Many patients who have suffered cardiac events recover from the events without much functional debilitation, usually because they were normally active prior to the cardiac event.

Patients who have had heart transplant, percutaneous transluminal coronary angioplasty, or heart valve surgery have no unique characteristics that differentiate them from cardiac patients who have had a myocardial infarction or coronary artery bypass graft or who have stable angina in terms of the necessity for participating in supervised rehabilitation programs. Therefore, patients who have had these surgical procedures might be selected for enrollment in cardiac rehabilitation programs on the basis of their physical and psychological conditions. Those patients who benefit from rehabilitation programs usually accomplish their goals within the 12-week sessions of the usual programs. Patients with stable cardiac conditions who are at high risk and have minimal functional capacities (3-5 METs) appear to benefit most, while patients who are of low risk and have functional capacities of 7-9 METs have minimal need for the program. High-risk patients have been described as including those who develop ventricular arrhythmias or marked ischemia with exercise.(8) Low-risk patients have been described as including those who have functional capacities at 3 weeks postoperation of 8 METs or more, which allows them to resume most of their vocational and recreational activities. Patients with intermediate risk and functional capacities benefit from the programs, but they may not require the full 12 weeks of participation. The latter group may safely exit the programs when they attain the goals of the cardiac rehabilitation programs, e.g., the resumption of pre-cardiac-event activities and return to a relatively normal life.

According, heart transplant patients and patients who have undergone percutaneous transluminal coronary angioplasty or heart valve surgery could benefit from prescribed cardiac rehabilitation programs if they have the need as described. The available information implies that many heart transplant, PTCA, or heart valve surgery patients are in excellent functional status after the surgical intervention and require minimal or no supervised exercise programs. However, a significant number of patients may lack confidence in their capabilities and may be benefit from earlier exercise testing that would demonstrate to them their functional capabilities. Some patients who require an increase in self-confidence in order to resume normal daily activities may also need educational and/or counseling services as part of their rehabilitation programs.

References

1.
[no authors listed] Cardiac Rehabilitation Services Health Technology Assessment Report. 1987, . No. 6., Rockville, MD:National Center for Health Services Research and Health Care Technology Assessment .
2.
Greenland P, Chu JS Efficacy of cardiac rehabilitation services with emphasis on patients after myocardial infarction Ann Intern Med 1988; . 109:650–663. [PubMed: 3048165]
3.
Gleichmann U Will there be less need for cardiac rehabilitation programmes when acute treatment is intensified and shortened? Eur Heart J 1987. 8 (suppl F)29–33. [PubMed: 3499321]
4.
O'Connor GT, Buring JE, Yusuf S, et al An overview of randomized trials of rehabilitation with exercise after myocardial infarction Circulation 1989. 80:234–244. [PubMed: 2665973]
5.
Keith RA Observations in the rehabilitation hospital: Twenty years of research Arch Phys Med Rehabil 1988. 69:625–631. [PubMed: 3408334]
6.
Squires RW, Gau GT, Miller TD, Allison TG, Lavie CJ Cardiovascular rehabilitation: Status, 1990 Mayo Clin Proc 1990. 65:731–755. [PubMed: 2190053]
7.
Fletcher GF, Froelicher VF, Hartley LH, Haskell WL, Pollock ML Exercise standards: A statement for health professionals from the American Heart Association Circulation 1990. 82:2286–2322. [PubMed: 2242557]
8.
Health and Public Policy Committee Health and Public Policy Committee, American College of Physicians. Cardiac rehabilitation services Ann Intern Med 1988. 109:671–673. [PubMed: 3421577]
9.
Leon AS, Certo C, Comoss P, et al Exercise conditioning component J Cardiopulmonary Rehabil 1990. 10:79–87.
10.
Kuhn WF, Davis MH, Lippmann SB Emotional adjustment to cardiac transplantation Gen Hosp Psychiatry 1988; . 10:108–113. [PubMed: 3282986]
11.
Christopherson LK Cardiac transplantation: A psychological perspective Circulation 1987. 75:57–62. [PubMed: 3539398]
12.
Miller LW, Vitale-Noedel N, Pennington G, McBride L, Kanter KR Heart transplantation in patients over age fifty-five years J Heart Transplant 1988. 7:254–257. [PubMed: 3049975]
13.
Savin WM, Haskell WL, Schroeder JS, Stinson EB Cardiorespiratory responses of cardiac transplant patients to graded, symptom-limited exercise Circulation 1980. 62:55–60. [PubMed: 6991158]
14.
Savin WM, Gordon E, Green S, et al Comparison of exercise training effects in cardiac denervated and innervated humans J Am Coll Cardiol 1983. 1:–.
15.
Kavanagh T, Yacoub MH, Mertens DJ, Kennedy J, Campbell RB, Sawyer P Cardiorespiratory responses to exercise training after orthotopic cardiac transplantation Circulation 1988. 77: 162–171. [PubMed: 3275506]
16.
Kavanagh T, Yacoub MH, Mertens DJ, Campbell RB, Sawyer P Exercise rehabilitation after heterotopic cardiac transplantation J Cardiopulmonary Rehabil 1989. 9:303–310.
17.
Squires RW Cardiac rehabilitation issues for heart transplantation patients J Cardiopulmonary Rehabil 1990. 10:159–168.
18.
Harvison A, Jones BM, McBride M, Taylor F, Wright O, Chang VP Rehabilitation after heart transplantation: The Australian experience J Heart Transplant 1988. 7:337–341. [PubMed: 3058902]
19.
Niset G, Coustry-Degre C, Degre S Psychosocial and physical rehabilitation after heart transplantation: 1-Year follow-up Cardiology 1988. 75:311–317. [PubMed: 3048669]
20.
Meister ND, McAleer MJ, Meister JS, Riley JE, Copeland JG Returning to work after heart transplantation J Heart Transplant 1986. 5:154–161. [PubMed: 2956399]
21.
Okada RD, Lim YL, Boucher CA, Pohost GM, Chesler DA, Block PC Clinical, angiographic, hemodynamic, perfusional and functional changes after one-vessel left anterior descending coronary angioplasty Am J Cardiol 1985; . 55:347–356. [PubMed: 3155895]
22.
Ben-Ari E, Rothbaum DA, Linnemeir TJ, et al Benefits of a monitored rehabilitation program versus physician care after emergency percutaneous transluminal coronary angioplasty: Follow-up of risk factors and rate of restenosis J Cardiopulmonary Rehabil 1989. 7:281–285.
23.
Jang GC, Gruentig AR, Block PC, et al Work profile of patients following coronary angioplasty or coronary bypass surgery: Results from a national cooperative study Circulation 1982; . 66 (suppl II)–.
24.
Kelly ME, Taylor GJ, Moses HW, et al Comparative cost of myocardial revascularization: Percutaneous transluminal angioplasty and coronary artery bypass surgery J Am Coll Cardiol 1985. 5: 16–20. [PubMed: 3155456]
25.
Danchin N, Juilliere Y, Selton-Suty C, et al Return to work after percutaneous transluminal coronary angioplasty: A continuing problem Eur Heart J 1989. 10 (suppl G)54–57. [PubMed: 2627950]
26.
Fitzgerald ST, Becker DM, Celentano DD, Swank R, Brinker J Return to work after percutaneous transluminal coronary angioplasty Am J Cardiol 1989; . 64:1108–1112. [PubMed: 2816763]
27.
Carey JS, Hughes RK, Plested WG, Nelson CB, Sacks E, Salvay H Functional rehabilitation after cardiac valve surgery Ann Thorac Surg 1973; . 16:492–504. [PubMed: 4746076]
28.
Ungerman-deMent P, Bennis Bemis A, Siebens A Exercise program for patients after cardiac surgery Arch Phys Med Rehabil 1986. 67: 463–466. [PubMed: 3729692]
29.
Gladkova MA, Kassirsky GI Topical problems in rehabilitation following valve replacement Cor Vasa 1984. 26:394–399. [PubMed: 6509995]
30.
Sire S Physical training and occupational rehabilitation after aortic valve replacement Eur Heart J 1987. 8:1215–1220. [PubMed: 3691557]
31.
Hoffmeister JM, Gruntzig AR, Wenger NK Long-term management of patients following successful percutaneous transluminal coronary angioplasty and coronary artery bypass grafting Cardiology 1986. 73:323–332. [PubMed: 2944587]
32.
Russell RO Jr. Abi-Mansour P. Wenger NK Return to work after coronary bypass surgery and percutaneous transluminal angioplasty: Issues and potential solutions Cardiology 1986. 73:306–322. [PubMed: 2944586]
33.
Wenger NK, Alpert JS Rehabilitation of the coronary patient in 1989 Arch Intern Med 1989; . 149:1504–1506. [PubMed: 2742422]
34.
Wenger NK Rehabilitation of the coronary patient: A preview of tomorrow J Cardiopulmonary Rehabil 1991. 11:93–98.
35.
Squires RW Rehabilitation after cardiac transplantation: 1980 to 1990 J Cardiopulmonary Rehabil 1991. 11:84–92.
36.
Ewart CK, Stewart KJ, Gillian RE, et al Usefulness of self-efficacy in predicting overexertion during programmed exercise in coronary artery disease Am J Cardiol 1986. 57:557–561. [PubMed: 3953439]
37.
Ewart CK, Taylor CB, Reese LB, DeBusk RF Effects of early post-myocardial postmyocardial infarction exercise testing on self-perception and subsequent physical activity Am J Cardiol 1983. 51:1076–1080. [PubMed: 6837450]
38.
Dennis C, Houston-Miller N, Schwartz RG, et al Early return to work after uncomplicated myocardial infarction: Results of a randomized trial JAMA 1988. 260:214–220. [PubMed: 3385897]
39.
Boulay FM, David PP, Bourassa MG Strategies for improving the work status of patients after coronary artery bypass surgery Circulation 1982. 66 (suppl III)43–49. [PubMed: 6982123]
40.
Gutman Gutmann MD, Knapp DN, Pollock ML, Schmidt DH, Simon K, Walcott G Coronary artery bypass patients and work status Circulation 1982. 66 (suppl III)33–42. [PubMed: 6215187]

AHCPR Pub. No. 92-0015

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