Coronary heart disease caused approximately one of every six deaths in the United States in 2008, according to the American Heart Association (AHA). Each year close to 785,000 Americans experience a new cardiac event and about 470,000 will have a recurrent event. This means that about every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.
A recently published presidential advisory from the AHA highlights the importance of outpatient cardiac rehabilitation in patients with cardiovascular disease. However, few patients take advantage of this therapy. The Agency for Health Care Policy and Research, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the National Heart, Lung and Blood Institute have recognized the wide variation in awareness and understanding of the role of cardiac rehabilitation among physicians, ancillary health care providers, third-party payers, and patients with heart disease. Past research found that only about 11 percent of patients participated in cardiac rehabilitation programs following an acute coronary event.
Vera Bittner, MD, professor of medicine in the UAB Division of Cardiovascular Disease and Section Head of Preventive Cardiology at UAB, said that some physicians don't refer patients for the therapy because they realize that a patient has logistical barriers (e.g. transportation problems, caretaking roles). "There is also a perception that cardiac rehabilitation may not add anything to the standard of care therapy for individuals with coronary artery disease who have already undergone revascularization and are on a good medicine regimen," Bittner says. "Also, relatively few physicians were exposed to cardiac rehabilitation programs during their training, so many don't know exactly what happens in one of these programs and may not fully appreciate the benefits beyond improving a patient’s functional capacity."
Bittner says a lack of patient enrollment and adherence is a chronic struggle for most cardiac rehabilitation programs for a number of reasons. "However, a strong physician recommendation is one of the most powerful predictors of cardiac rehab enrollment. A lack of physician endorsement usually means a lower likelihood of attendance," she says.
Cardiac rehabilitation programs are designed to improve a patient's functional capacity, quality of life, ability to cope with the illness, and knowledge of the disease and its treatment. And the benefits of this therapy are many. "Data show that attending a cardiac rehabilitation program after a myocardial infarction or revascularization improves survival and lowers the chance of a subsequent heart attack," Bittner says. Recent studies in the Medicare population suggest a mortality reduction of more than 30 percent. She adds that it is hard to know what leads to this improved survival and decrease in subsequent heart attacks.
"My personal belief is that education about the disease process and its risk factors and better adherence to lifestyle measures and prescribed treatments because of a greater understanding of how they work is making the biggest impact on these patients," Bittner says,
Currently, cardiac rehabilitation is the standard of therapy for most patients with symptomatic coronary heart disease, and there are significant benefits for patients with heart failure and impaired pumping function as well as for patients who have had other types of open-heart surgeries. "Ideally, cardiac rehab should start before somebody has a heart attack or requires bypass surgery or stenting. We know so much now about cardiac risk factors and can identify patients who are at increased risk for the disease," Bittner says. "It would be great to have them go through the program before they have an event so they can learn about the disease and how to prevent it."
