Purpose: Cardiac rehabilitation aims to improve quality of life and reduce mortality of cardiovascular disease. In order to obtain this cardiac rehabilitation programmes aim to help patients make the necessary health related behaviour changes and as a result improve quality of life. This study was done evaluate if health changes occur in a short term cardiac programme and what effect this has on quality of life.
Method: To address these issues. We assessed health behaviour changes in relation to exercise and diet and effects of these on quality of life using 27 patients during a 6-8 week phase 3 cardiac rehabilitation programme. Instrument used to measure was a self-designed questionnaire based on SF-36 questionnaire.
Results : Among the 27 patients 24 (89%) were male and 3 (11%) were female. The mean age was 60.17 (±12.645). 40% had Myocardial infarction, 37% had coronary bypass surgery and 22% had Angioplasty. 44% had a family history of coronary artery disease. The Sturwood questionnaire scale detected behaviour changes in relation to diet and exercise and quality of life and outlook on life scores. Quality of life scores was significantly influenced by changes in exercise and diet scores, such that patients reporting high exercise changes and diets changes displayed higher quality of life scores (p<0.05)
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Conclusion: Quality of life is improved with physical and mental changes to improve health. Taking a multi-disciplinary approach to cardiac rehabilitation by using as exercise, dietary education, risk factor education and access to psychologists quality of life can be increased over a short period of time of 6 to 8 weeks. Therefore is it suggested to all cardiac rehabilitation programmes to take a multi-disciplinary approach for increased results of quality of life.
It is estimated by the British Heart Foundation that 2.6 million are affected by heart disease in the UK. In England, Wales and Northern Ireland there are 395 cardiac rehabilitation programmes. Cardiac rehabilitation is defined by the 1964 World Health Organisation as providing an optimal physical, mental and social environment for the cardiac patient that allows them to regain to maximal functional capacity in society.
Cardiac rehabilitation is a secondary prevention of cardiovascular events. Around 46% of people that have MI, angioplasty (PCI) and coronary artery bypass attend CR in the England PROBLEM OF CARDIAC REHAB.
In the 1930′-s those that survived an acute coronary event their cardiac rehabilitation was comprised of at least 6 weeks of bed rest which could be extended upto 12 weeks. This continued into the 1940’s however the patient was able to alternate between bed rest and chair sitting. In the 1950’s patients were allowed to walk 3-4 minutes at a slow pace after 4 weeks of bed to chair rest. During this time Dr Herman Hellerstein (Evans, Probert and Shuldham, 2009) discovered that during this time of bed rest that the patients were rapidly deconditioning and a large number of patients suffered pulmonary embolism after bed rest. As a consequence of these observations Dr Hellerstein introduced a multidisciplinary approach to the cardiac rehabilitation programme. Since the 1950’s cardiac rehabilitation has not changed appreciably apart from the exercise programme has been combined with dietary education, risk factor assessments and psychosocial support for patients in order to obtain the greatest benefit from cardiac rehabilitation. (Evans, Probert and Shuldham, 2009)
According to the British Heart Foundation cardiac rehabilitation now consists of a structured programme that involves exercise, education on diet and the use of appropriate medication in order to reverse the progression or slow down the rate of coronary heart disease. The main aims of cardiac rehabilitation is to educate the need for a change in lifestyle and to help patients overcome the fear of returning to everyday life activities and becoming part of society again.
A programme includes a medical, psychological, social assessment to discover the needs of the patient. It provides education pertaining to the causes of the illness and provides appropriate information describing the necessary lifestyle changes to enable the patient to have the best possible future health. It helps the patients to set up goals for lifestyle change and ensures they maintain them by reviewing and providing support for these goals.
Cardiac rehabilitation has four phases in total. Phase 1 is when the medical condition of the patient is stable but is still an inpatient at hospital. In this phase the person is likely to be visited by a nurse that will educate the patient about the event and the reasons why it occurred, they will also provide information about lifestyle changes such as physical activity, smoking and diet. The nurse will also ensure that the secondary prevention medication has been implemented. This is usually done by a nurse that is a member of staff on the cardiac rehabilitation team and will refer the patient to the programme. (Bethell, Lewin and Dalal, 2009)
Phase 2 is early discharge and the period when the patient is at home waiting to start the 6-12 week exercise programme. Those that have been treated with angioplasty have to wait 2 weeks, Myocardial infarction (MI) patients have to wait 4 weeks and coronary bypass patients have to wait 6 weeks to begin the programme. Over this period the patient receives on-going education and encouraged to take healthy lifestyle choices by telephone calls, or visits from staff from the cardiac rehabilitation programme or by a primary care team. (Bethell, Lewin and Dalal, 2009)
Phase 3 is an out-patient 6-12 week programme. The main method of phase 3 cardiac rehabilitation is the use of a supervised group class that usually takes place in a local community centre such as a leisure centre. The patient is assessed before they join the programme. This involves a review of their medical history, the results of any examinations such as electrocardiograms, echocardiograms, blood lipid levels and blood sugar levels. The patient has a physical examination such as weight, height and blood pressure (Bethell, Lewin and Dalal, 2009). The patient is then asked to take part in a physical function test which is either a 6 minute walk test, treadmill test or a shuttle test to identify the exercise level at which the patient can perform and therefore how long they need to be enrolled on the programme. The patient also has a psychological and quality of life test to determine if the patient requires any psychosocial help. All the assessment findings are analysed and are used to classify the patient into one of three risk categories (high, intermediate and low). Those at high and intermediate risk will need additional supervision throughout the programme.
The Phase 3 of cardiac rehabilitation mainly involves a progressive exercise training programme and is supported by risk factor monitoring, relaxation training and education (involving the understanding of the causes and risk factor in heart attacks, diet and the use of medication to control the illness and how exercise is important after heart failure).
Phase 4 is the long term maintenance of behaviour change to continue to improve health and to carry on with lifestyle changes that were undertaken in phase 3. This is supported by cardiac rehabilitation centres providing exercise classes and annual check-ups of symptoms, exercise, diet, smoking, blood lipids, blood sugar levels and medication.
Referral to cardiac rehabilitation is restricted to one of three diagnostic groups, these are MI, elective angioplasty (PCI) or coronary artery bypass surgery (CABG). The majority of patients admitted have one or more risk factors that are significant on impacting health such as obesity, high systolic blood pressure (>140 mmHg) or diastolic blood pressure (>90 mmHg), smokers and those that did not meet the national exercise recommendations. Patients that have suffered myocardial infarctions represent the greatest proportion admitted to the programme from the three diagnostic groups followed by CABG group and PCI. Other patient groups are referred such as those with angina or heart failure but this is only a small minority of patients. Men outnumber women 2:1 this may be explained by the fact that there is a greater prevalence in heart disease in men, however women live longer than men so the prevalence of heart disease catches up in women. This is proved by the fact that women are on average 6 years older than men when attending the cardiac rehabilitation. However it may also represent the poor uptake of cardiac rehabilitation in women.
Most cardiac rehabilitation programmes over the past years have been through nurses and physiotherapists that have noticed a gap in the service of patients that have experienced a coronary event and through this have provided professional care through little or no budget.
It has been recognied by the British Heart Foundation that the quality of care in the England is variable they have acknowledged a large gap between the quality of care given as opposed to the quality that should be provided.
Cardiac rehabilitation is a multidisciplinary programme. The British Association for Cardiac Rehabilitation Minimum clinical standards recommend that for each team there should be at least one nurse, physiotherapist, dietician, pharmacist, a clinical psychologist and have administrative support . However from the National Audit for 2010 there is a great variance in the professionals involved with programme. Nearly all programmes have a nurse available (95%) and many of the programmes have a physiotherapist (70%) or an exercise specialist 56%. However very worryingly just over half of the programmes have access to a dietician (56%) and worse only 11% have access to a psychologist. 12% of patients have borderline depression and 8% have depression when admitted to the programme.
There are many benefits of cardiac rehabilitation in the literature : one of the main findings in heart failure patients is a reduction in resting heart rate and systolic blood pressure which increases the ability of the muscles to extract oxygen for energy at a given work intensity. Patients with heart failure often experience myocardial ischaemia during low physical exertion but with exercise training the patient is able to perform the same work at a higher intensity and therefore the threshold at which myocardial ischemia or angina occurs increases. (Leon 2005). Wenger et al (1995) found that performing aerobic exercise three times a week over a three month period increased maximal oxygen consumption by 15% to 20% when working at an intensity of between 70% to 85% of maximum heart rate. Taylor et al (2004) produced a systematic review and a meta-analysis which included 8940 patients, the discovered that all-cause mortality and cardiac mortality was reduced with cardiac rehabilitation. They also found a decrease in systolic blood pressure, total cholesterol levels, and triglyceride levels. However they did not find any reductions in diastolic pressure, non-fatal MI or improved quality of life due to increased health.
Benefits of diet
Although most research concentrates on improved physical health there have been relatively few studies reporting how short term cardiac rehabilitation programmes impacts on quality of life and outlook on life and health especially in those patient who have had coronary revascularisation surgery (Hung et al, 2004). Belardinelli et al (1999) showed that quality of life improved in cardiac patients improved with exercise however this was measured over a longitudinal period with out-patients in long term rehabilitation care. Stahle et al (1999) used the Karolinska questionnaire with older cardiac patients which evaluated the efficacy of impact of a one year exercise only rehabilitation on quality of life. More recently Yohannes et al (2004) and Freitas et al (2011) looked at 6 and 4 week intense exercise rehabilitation using SF-36 questionnaire they evaluated that the short term effects of rehabilitation improved quality of life scores and also found decreased levels of depression and anxiety evaluated by the HAD scale. A follow up study (Yohannes et al, 2010) after 12 months reported that the benefits of the programme were maintained. However, the Freitas et al (2011) study was conducted in France and therefore the main objective of this study was to determine if the phase 3 cardiac rehabilitation programmes in England could produce a positive impact on quality of life and outlook on life, as well as a quantitative analysis to discover if there are behavioural changes relating to exercise and diet. If changes have occurred and are initiated in the programme we will need to determine if there are factors that influence these changes such as age, gender, coronary event, weight and family support rather than the aspect of the benefits of the programme. This study will also investigate three cardiac events including MI, CABG and PCI the latter two of which are the least studied in assessing exercise and its impact on quality of life. The study will also include the impact of diet on quality of life……
It is predicted that patients that have made behavioural changes in relation to exercise and diet will have an improved quality of life than those that do not make behavioural changes. The null hypothesis is that cardiac rehabilitation has no effect on behavioural changes and therefore no effect on quality of life.
Diet improvement and quality of life – more on multidisciplinary how should be looking at diet as well.
The population of interest were adults that had recently undergone a coronary event and as a result had been referred to a cardiac rehabilitation programme. The population that was accessible to this study consisted of people that were patients at cardiac rehabilitation centres that met the following criteria: had undergone a recent coronary event (e.g. myocardial infarction, coronary by-pass surgery or angioplasty); currently at phase 3 of the rehabilitation programme; must be over the age of 18 years. Permission was asked at five cardiac rehabilitation centres that included phase 3 patients, all 32 patients met the criteria throughout the centres. Out of the 32 patients that were asked to participate in the study 27 returned a response.
The sample composed of 24 males and 3 females (88.9% and 11.1% respectively). The age of the sample ranged from 24 to 79, the average age 60.17 ± 12.645 years. From a diagnosis point of view the sample was comprised of 11 myocardial infarction (40.7%), 10 coronary by-pass surgery (37%) and 6 percutaneous coronary angioplasty (22.2%).
Although the sample cannot be considered to be representative of all cardiac rehabilitation programmes in England and the type of coronary event, this was not the main goal of this study. The main purpose of this study was to determine if cardiac rehabilitation could improve quality of life. Any results reported in this study could be generalised to local cardiac rehabilitation programmes in Yorkshire and Nottingham and also to programmes that have similar patients and implement a similar programme.
The measure used was developed specifically for this study and was administrated through the use of a questionnaire. The questionnaire was divided into five sections. First section includes 13-item questions that are composed of open and closed type questions and aims to collect basic information such as age, type of coronary event, smoking habits and lifestyle choices prior to the coronary event. Sections two, three, four and five were 10-item Likert-type response scale questions where 1 = ‘strongly disagree’ and 9 = ‘strongly agree’ and the scale scores was the sum of the 10 items. Scores from 1 to 4 were considered minus scores (for example: 1 = -1, 2 = -2), 5 = neutral and was scored 0 and scores from 6 to 9 were plus scores (for example 6 = 1, 7 = 2). The total scale score was the sum of the four scale sections of 40 items. Each scale section measures behaviour change, changes in perception and awareness and physical changes in relation to exercise, diet, quality of life and outlook on life and health due to cardiac rehabilitation programme. The entire questionnaire is provided in Appendix A.
The patients were recruited at five separate programmes; three of the programmes were based in Yorkshire, and two programmes Nottingham. All patients were attending a phase 3 of the cardiac rehabilitation programme referred by a hospital cardiac nurse to attend.
The Yorkshire rehabilitation programmes all took place in local community leisure centres. It was an 8 week programme in which the patients had an exercise session and an education session twice a week. Patients participated in an exercise class for one hour with a warm up, circuit exercises and then a cool down. The level of exercise that the patient preformed at was determined by a bleep test before the exercise programme. After the exercise the patients attended an education class. Throughout the programme the patients had two education sessions with the dietician, one with the fitness instructor on the importance of exercise and the rest of the sessions with the cardiac nurse on the education of cardiovascular disease, managing stress, medicine management and two sessions on basic life support.
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At the Nottingham cardiac programmes the phase 3 programme was carried out in a hospital. It was a 6 week programme and comprised of an exercise session and education session twice a week. A physiotherapist took the exercise classes and a nurse that took the education classes. The exercise lasted for 50 minutes with a warm up, circuit exercise and a cool down and had a 15 minute relaxation period. The patients in the cardiac rehabilitation also had other members of a multidisciplinary team to raise any issues with such as an occupational therapist, a pharmacist, dietician and an administrator. If requested the patient also has access to a psychologist.
For those patients that agreed to participate the purpose of the study was fully explained. Participants were ensured confidentiality and had the opportunity to withdraw participation from the study at any time. The questionnaire was handed out to the patients directly after rehabilitation session, most of the patients filled out the questionnaire at the session however there were some patients that preferred to take the questionnaires home and sent the questionnaire back in the mail. For those that completed the questionnaire at the session if they had any questions regarding the questionnaire they could be answered.
The Sturwood questionnaire in this study was based on a health related quality of life questionnaire designed by Ware (1998). The Short Form (SF-36) Health questionnaire is composed of 36 items and measures the following eight health aspects: physical functioning, role-physical, bodily pain, general health which assesses the physical component score and vitality, social functioning, role-emotional, and mental health compose the mental component score. It is a generic measure that does not focus specifically on age, gender, disease or treatment group. It can assess general and specific populations and has been used by over 5000 publications. The SF-36 has high internal consistency Bohannon and DePasquale (2010) found the questionnaire in elderly was supported by a Cronbach alpha of .82 between its items. The reason for designing a questionnaire based on the SF- 36 was that we wanted to make the questions specific to cardiac rehabilitation and also health behaviour changes associated with exercise and diet.
The patients used in the cardiac rehabilitation programmes were patients of the NHS. Cardiac exercise and education session were taken by professional cardiac nurses physiotherapists and exercise specialist employed by the NHS. Ethical Permission for this study was granted by University of Leeds that produced an ethics proposal form. This ethics proposal, along with the questionnaire was shown to the head cardiac nurse in each of the two areas for permission to be used with their patients. Ethics Proposal form and Risk Assessment form is provided in Appendix B and C.
The results were analysed using a SPSS statistical programme (Version 17.0.1) Non-parametric testing was used for categorical variables. Preliminary analysis of the data were performed to assess the normality of the data in terms of skewness and kurtosis to ensure there was no violation of the assumptions of normality. Continuous variables were assumed to be normal and therefore parametric statistical testing can be used. Categorical variables were compared using Spearman’s Rank Order Correlation. A paired t-test was used to analyse the effects of the rehabilitation programme on the amount of physical activity done a week, physical activity was reported before entering the programme and physical activity reported after completing the programme. Continuous variables were compared using Persons Product-Moment Correlations between average scale scores from the Sturwood Questionnaire An independent t-test was used to analyse difference between groups such as gender, those with family history and those that smoked prior to the programme against scale scores for each section on the on the questionnaire. A one-way ANOVA test was used to analyse difference between more than two groups such as age groups, attendance to the programme, the different cardiac centres, type of coronary event and weight group between average scale scores from the questionnaire.
Twenty seven cardiac patients participated in this study after an acute coronary event.
Table 2. Means, standard deviations, minimum, maximum, skewness and kurtosis for scale scores in each section of the Sturwood questionnaire.
The relationship between average scale scores was investigated using Pearson product-moment correlation coeffiecient. The direction of the relationship between all variables is positive which suggest that with high exercise score patients are likely to score highly in the diet and quality of life categories of the questionnaire. This is also the same for high scores for quality of life are associated with high scores on diet and overall outlook on life and health. The strength of the relationships is medium strength according to Cohen (1988, pp79-81) guidelines for all relationships apart from the correlation of average quality of life score and average outlook on life score which has a large positive relationship.
A paired-samples t-test was conducted to evaluate the impact of a cardiac programme intervention on amount of physical activity a week. There was a statistically significant increase in the number of times a week the patient performed physical activity from prior to the event (M=2.38, SD=1.267) to after the event (M= 3.5, SD, 0.99), t (25) = 6.257, p<. 0005 (two-tailed). The mean increase in physical activity was 1.115 with a 95% confidence interval ranging from 0.748 to 1.483. The eta squared statistic (0.50) indicates a large effect size.
An independent samples t-test was conducted to compare the exercise scores for those that had a family history of a similar cardiovascular event. There was a statistically significant finding in exercise scores for those with a family history of cardiovascular disease (M = 23.92, SD = 6.694) and those without a family history of cardiovascular disease M = 15.67, SD = 8.304; t (25) = 2.858, p= 0.05 (two-tailed). The magnitude of the differences in the means (mean difference = 8.250, 95% Confidence interval: -2.305 to 14.195) was large (eta squared = 0.25). This significance in the data suggests that those patient that had a history of cardiovascular disease in their family had overall higher scores on the exercise category than those that did not have a family history of the disease.
Quality of life
A one-way between-groups analysis of variance was conducted to explore the impact of type of cardiovascular event the patient suffered on the average quality of life score as measured by the Sturwood questionnaire. Subjects were divided into three groups according to the type of cardiovascular event they were referred to the rehabilitation programme for (Group 1: Myocardial infarction; Group 2: Coronary bypass surgery; Group 3: Percutaneous coronary angioplasty. There was a statistically significant difference in mean scores at the p< 0.005 level in quality of life scores for the three groups: F (2, 27) = 3.934 p=0.05. The effect size, calculated using the eta squared was 0.25. Post-hoc comparisons using Tukey HSD test indicated that the mean score for Group 1 (M = 9.09, SD = 10.625) was significantly different from Group 3 (M = 22.5, SD = 6.091). Group 2 (M = 16.4, SD = 10.233) did not differ significantly from either Group 1 or 3. The PCI group had a greater quality of life mean score than the MI group.
A one-way ANOVA test was used to assess the difference between the five cardiac rehabilitation programmes and scores on the Sturwood questionnaire. There were no significant findings between the programmes and exercise, diet, quality of life, outlook on life and health and overall score.
The relationship between the amount of family support given to the patient and the amount of change in healthy lifestyle in family was investigated using Spearman Rank Order Correlation. Preliminary analyses were performed and found violation of the assumption of normality. There was a medium strength positive correlation between the two variables, rho = 0.466, n = 27, p < 0.05, which high amount of family support associated with high family change in healthy lifestyle.
A Chi square test for independence (with Pearson Chi square) indicated a significant association between gender and family support, X² (1, n = 27) = 14.9, p = 0.001, phi = 0.742. Females are offered less support by their family than males.
Exercise and diet.
The present study showed that even over a short period of time cardiac rehabilitation can increase exercise and diet habits. One of the findings in this study was that the cardiac rehabilitation did increase the number of times physical activity done a week. Patients were asked the number of times they participated in physical activity prior and after the rehabilitation programme. The mean increase in physical activity participated in a week was 1 exercise session a week. This is not a large increase however it does suggest that the programme has encouraged behaviour change. This small increase in physical activity may be due to the fact that that programme was only 6-8 weeks long and patients may feel they have not built up the stamina to take part in more physical activity.
The exercise score in the Sturwood questionnaire was the highest out of the other sections on the questionnaire. This suggests that cardiac rehabilitation has the greatest effect on behaviour and awareness change in exercise. Those patients that increased the amount of exercise undertaken and had more awareness of the health benefits of exercise also had greater levels of quality of life. The National Audit for Cardiac rehabilitation found the greatest improvement in quality of life scores was in the perceived fitness and activity section. Patients’ perceptions on overall health and problems with social activities improved. This was also seen in patients that had improved their diet and awareness of the benefits of a healthy diet had higher levels of quality of life. Those patients with little behaviour and awareness change reported lower levels of quality of life……
An interesting finding in this study was those with a family history reported a greater improvement in exercise change compared with those that had no family history.
Quality of Life
The results of this study show two important findings. First cardiac rehabilitation resulted in an improvement in behaviour change and awareness of health. Second, an increase in health changes resulted in an improved quality of life. In fact analysing the scores obtained on the Sturwood questionnaire revealed an improvement of physical and awareness health lifestyle in exercise and diet in all types of coronary events. These data matches the results from Stahle et al and Yohannes et al that reported long term benefits of exercise cardiac rehabilitation with improved quality of life. These data also confirm with the data of Hung et al that showed physical exercise (weight lifting for 8 weeks, three times a week) to improve quality of life in patients with coronary heart disease measured with a MacNew heart disease health related quality of life questionnaire in elderly patients. Lastly the results show similarity to Freitas et al study that showed using a multi-disciplinary cardiac rehabilitation programme for 4 weeks that there was improved quality of life and found physical and mental improvements in health measured by the SF-36 questionnaire. In this study it was found that health changes had been implicated for the lowest attendance in the programme which was three weeks. A possible explanation for improved quality of life over such a short period of time could possibly be a result of using a multi-disciplinary approach in the rehabilitation programme. Both in this study and in Freitas et al study there was the use of relaxation sessions, and supplemented dietary education sessions and necessary information for changing health lifestyles by a nutritionist and cardiac nurse. Also in this study some of the patients had access to a psychologist and occupational therapists. Based on this finding it therefore shows the importance of cardiac rehabilitation taking a multi-disciplinary approach to increase health related changes that reduce cardiovascular risk factors such as exercise, diet and cessation of smoking to reduce the risk of repeating coronary events.(Chow et al 2010)
One interesting finding was that there was no significant difference between improved health behaviour and quality of life between different cardiac rehabilitations centres. Two of the centres were based in a hospital and three in community leisure centres. These findings present a number of clinical interventions in relation to the use of health services. Based on these data, cardiac rehabilitation could be accessed by a greater number of people after a coronary event provided that there is an increase in leisure centres implementing a phase three cardiac rehabilitation programme. In many centres, especially hospital cardiac rehabilitation there is a high demand and limited amount of spaces on a cardiac programme. Not only will there be more availability for patients to be admitted to the programme but it will allow for more high risk patients to be closely monitored at hospital based cardiac centres.
One finding from this study was found when comparing between coronary event groups of each of the scale sections. There were no significant findings between groups in terms of exercise, diet, outlook on life health and overall score of the questionnaire apart from in quality of life score. There was a significant finding between PCI treated patients and MI patients in quality of life scores with PCI patients reporting higher scores. A study by Cohen et al 2011 found a significant difference in quality of life scores between PCI patients and CABG patients measured by SF-36 questionnaire. The study also used a Seattle Angina Questionnaire (SAQ) to measure frequency of angina; higher scores on this measure indicated a better health status. CABG patients reported higher quality of lif
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