Background
“Cardiovascular rehabilitation is the sum of activities required to favourably influence the underlying causes of the disease, as well as to ensure the patients the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, a place as normal as possible in the life of the community” (World Health Organization, 1993).
Rehabilitation in France is organized according to two decrees and one circular letter . Follow-up care and rehabilitation (FCR) activities are now required. FCR for cardiovascular pathology is officially recognized as an FCR speciality with specific needs, which is subject to authorization by the Regional Health Authorities. Specialized FCR centres for cardiovascular pathology must be able to manage patients with cardiovascular problems, whatever the severity of the disease, either with conventional hospitalization or ambulatory care. To fulfil this last obligation, the French Society of Cardiology (FSC) recommends that a cardiologist takes responsibility for, and coordinates, specialized FCR for cardiovascular pathology.
The aim of rehabilitation in cardiovascular pathology is to enable patients to adapt their life as best as possible to their disease and to take responsibility for optimizing their health status. Cardiovascular rehabilitation is based upon the following three elements: exercise training and education on long-term physical maintenance; therapeutic optimization, which should be adapted to the state of the patient and their way of life; specific therapeutic education, which should be multidisciplinary and give the patient the means to improve their prognosis by adapted behaviours. The management of this approach must take into account the patient’s psychological state, as well as social, familial and vocational factors.
Cardiovascular rehabilitation is therefore a learning period in order to put in place a new way of life in the long term. It has proven effectiveness, which includes socioeconomics. It requires global patient management which must be generalized and also developed.
Recommendation 1: exercise training programme
Physiopathological basis
Physical exercise induces beneficial effects in both primary and secondary prevention. One metabolic equivalent ([MET] 3.5 mL/minute/kg of oxygen consumption) improvement in functional capacity is followed by an almost 15% reduction in mortality. The recognized beneficial effects are due to intertwined mechanisms: reduction of systemic inflammation, sometimes subclinical, associated with these chronic pathologies; antioxidant effects; antithrombotic effects; neurohormonal effects; effects on remodelling and vascular function; and effects on muscular remodelling. These favourable effects of training apply to: cardiovascular risk factors; ageing; coronary artery disease; chronic heart failure (HF); and peripheral vascular disease.
Initial evaluation
Initial evaluation before cardiac rehabilitation is based, at least, on the following : clinical evaluation (history and physical examination); resting electrocardiogram; transthoracic echocardiography; and exercise stress test (see below). Attention must also be paid to indications from other targeted examinations, including biological tests.
Exercise stress test
Exercise stress tests must fulfil the protocols and safety criteria for cardiological stress tests . These tests are often performed under medical treatment. The initial test must be: maximal if possible or limited by the symptoms; in some cases limited by a maximal heart rate (i.e. patients with implanted defibrillators); and in some cases limited by a maximal arterial systolic pressure (i.e. following aortic dissection or aortic aneurysm surgery).
Cardiorespiratory exercise stress test with analysis of gas exchange should be performed whenever possible. This allows evaluation of aerobic capacity (oxygen consumption [VO 2 ] max or peak) and determination of the ventilatory adaptation threshold, which corresponds to the first ventilatory threshold (VT1).
An intermediary exercise stress test is indicated in case of new symptomatology under exercise or a therapeutic modification that could affect the chronotropic function of the heart, or to update prescriptions according to the patient’s improved state of health. A final exercise stress test allows an objective evaluation of the patient’s physical capacities after rehabilitation.
A 6-minute walk test is used to evaluate the adaptation of the patient to submaximal efforts typical of everyday life . A muscular strength test (e.g. determination of maximal voluntary force) is useful for certain patients to guide resistance training.
Training modalities
This training includes endurance sessions and dynamic resistance sessions. Endurance training at a constant intensity is characterized by prolonged submaximal exercise (20 to 60 minutes), using the large muscles of the body. The intensity of the training can be prescribed according to the data shown in Table 1 .
| Training heart rate | |
| If exercise stress test with VO 2 | HR at first ventilatory threshold (VT1) |
| If exercise stress test without VO 2 | THR = resting HR + [(max HR – resting HR) × K] |
| Karvonen formula | K = 0.6 if patient is without beta-blockers |
| K = 0.8 if patient is taking beta-blockers | |
| Heart rate limit | |
| If patient has angina | < 10 bpm under the threshold for angina |
| If implanted cardiodefibrillator | < 10 to 20 bpm under the pre-programmed triggering HR |
| Systolic arterial pressure < 160 mmHg | After aortic dissection |
| Patient’s sensations (respiratory, muscular) | Levels 12–14 on the 20-point Borg scale |
| Levels 4–6 on the 10-point VAS | |
| Able to speak easily without becoming breathless | |
Interval endurance training is characterized by alternating short-duration efforts of high intensity with periods of active recuperation. Several combinations are possible, with phases of high intensity (80 to 95% of maximal aerobic power) lasting from 10 seconds up to 1 or 2 minutes and with periods of active recuperation (20 to 30% of maximal aerobic power) for 1 to 4 minutes .
Dynamic resistance training is performed for muscular strengthening, with small weights, weighted wrist bands or elasticised bands, or by using weight benches with adapted equipment ; a succession of eight to ten different types of movement are repeated 10 to 15 times at a low intensity (30 to 50% of maximum strength). Two to three sessions lasting for 20 to 30 minutes are performed each week, adapted to each context (recent sternotomy or implantation of pacemaker/cardiodefibrillator) .
Gymnastic exercises on the floor, on a bar or in water optimize this reconditioning through workouts that include the upper and lower limbs to improve coordination, flexibility, balance and strength of muscles and ligaments.
Breathing exercises complete the programme (tidal volume, control of air flow and ventilatory rhythm). These may be performed individually or in training group sessions.
Electromyostimulation can be used alternatively or in combination with exercise training for patients in very poor physical condition or with HF .
Organization of training sessions
The training prescription must specify the type, intensity, duration and frequency of the sessions. Each endurance session includes a warm-up period of 5 to 10 minutes, a training period of 20 to 45 minutes and a cool-down period of at least 5 minutes. The optimal frequency of the sessions is three to six per week. A minimum of 20 sessions is required to obtain a significant improvement in functional capacity. In the most unfit patients and in patients with HF, a larger number of sessions are often necessary. Later on, supplementary sessions can improve compliance and allow exercise training advice to be updated. The organization of this must be personalized (i.e. number of sessions, frequency).
Regarding monitoring, a cardiologist must be present and available close to the training rooms in order to immediately intervene at the supervision team’s request. The presence of at least one qualified person is required in each training area during the sessions. The number of patients managed during an endurance or gym session should be adapted to ensure optimal supervision and patient safety.
Telemetric monitoring during the initial training sessions is recommended. If necessary, heart rate monitoring is subsequently maintained according to medical advice. Brachial artery pressure is monitored. Oxygen saturation monitoring is sometimes appropriate.
Recommendation 2: education programme
The education program must be structured and include education about the disease, signs, nutritional education, help in smoking cessation, management of antithrombotic treatment and prophylaxis of infective endocarditis.
Structured therapeutic education programme
The ministerial decrees of 2nd August 2010 outlined the specificities and authorization conditions for the therapeutic education programme (TEP) for patients , which should conform to the quality criteria and the approaches defined by the guidelines .
Cardiac rehabilitation centres allow integration of the TEP into patient care. At these centres there are several structured activities facilitated by a multidisciplinary team, to help patients to become actively involved in control of their risk factors and disease, and thereby work towards cardiovascular prevention . These collective group training sessions ( Tables 2 and 3 ) are run by the medical and paramedical rehabilitation teams. These teams must be trained in the techniques of TEP and be competent for the issues addressed. The group teaching should be complemented by individual sessions.
| Collective group themes (suggestions) |
|---|
| The heart and its function |
| Cardiovascular risk factors |
| Pathologies (coronary artery disease, heart failure, peripheral artery disease) |
| Cardiology investigations |
| Warning signs (angina, dyspnoea) |
| Self-assessment techniques (blood pressure, glycaemia) |
| Medications |
| Life-saving measures |
| Theme | Examples |
|---|---|
| Nutrition | Reading labels Choosing food at the supermarket Recognizing foods rich in salt, sugar and fat |
| Physical activity | Managing endurance training |
| Travel, sexuality, driving | Managing daily-life activities |
The organization of the TEP must be carefully planned and coordinated, and regularly reviewed by multidisciplinary consultations.
Nutritional education
Several nutritional factors are directly or indirectly implicated in the occurrence and progression of coronary artery disease. A Mediterranean diet and a high intake of omega-3 long-chain polyunsaturated fatty acids have been proven by intervention studies to reduce cardiovascular morbidity and mortality.
It is important to establish a dietary survey (questionnaires applicable to French dietary habits and adapted to prevention of cardiovascular events) , provide nutritional education (individual and/or collective), promote a Mediterranean diet enriched in omega-3 for patients with coronary artery disease ( Table 4 ) and adapt counselling according to the context (hypertension, diabetes, obesity, HF, renal insufficiency, malnutrition).
| Principles of Mediterranean diet adapted for coronary artery disease patients |
| Advise consumption of |
| at least five portions of fruit and vegetables every day |
| extra virgin olive oil, tea, cocoa and soya (rich in polyphenols) |
| fish at least three times per week, including two servings of oily fish |
| foods rich in ALA: nuts, nut oil, rapeseed oil a |
| foods with a low glycaemic index |
| dry vegetables twice per week |
| two to three servings of fruits per day |
| foods rich in starch |
| fermented foods |
| foods rich in fibre |
| The consumption of wine and/or beer can be maintained unless contraindicated (alcohol dependence, pathological link to alcohol), limited to one to two glasses per day, during meals |
| Reduce consumption of foods high in saturated fat |
| Restrict red meat (beef once or twice per week, mutton/lamb once a month) |
| Replace butter with a margarine rich in omega-3 fatty acids |
| Restrict cheese to 30 to 40 g per day |
| Restrict cooked meats to 70 to 100 g per week |
| Restrict eggs to four to six per week |
| Avoid partially hydrogenated oils and palm oil (pastries, cakes, biscuits, Viennese pastries, ordinary margarines) |
| Reduce consumption of salt (especially in cases of hypertension and/or heart failure) |
a The daily consumption of two spoonfuls of rapeseed oil provides two-thirds of the recommended intake of ALA.
Smoking cessation programme
Tobacco is a major cardiovascular risk factor and to stop smoking is one of the most effective secondary prevention measures . Controlling this risk factor is therefore part of all cardiovascular rehabilitation programmes.
In the initial assessment, tobacco consumption should be completely and precisely documented. The patient must be informed of the importance of stopping and must be offered support during the process of stopping and in the prevention of restarting. Nicotine substitutes can be provided on leaving the intensive care unit immediately following myocardial infarction . Patches can be combined with oral forms to eliminate the desire to smoke completely . The substitution is then reduced over a minimum period of 3 months, which can be prolonged if necessary. Behaviour and cognitive therapies are based on learning self-control, management of stress and self-affirmation techniques .
Anxiolytic/antidepressant treatments
Specific psychotherapy and/or medications to treat anxiety and/or depression may be essential in some cases. The nurses in the multidisciplinary team have the important role of listening to and motivating these patients . Prolonged follow-up should be ensured, with close co-operation with the cardiologist and treating physicians, who should be made aware of the programme . The patients should have a prescription for products to help them to stop smoking and prearranged follow-up consultations when leaving the rehabilitation centre. The medical report of the hospitalization addressed to the physician managing the follow-up must include details of the treatments started and the follow-up information. The multidisciplinary team should integrate a consultation with a tobacco addiction specialist. Alternatively, a member of the medical or nursing team should have received training about tobacco addiction.
Education on antithrombotic treatment
Because of the risks inherent in this treatment, patient education plays a crucial role in the correct use of antivitamin K treatment ( Table 5 ). It is important to provide education on the management of antivitamin K treatment (individual and/or collective), provide and/or update comments in the patient’s anticoagulant record book and provide the patient with record files containing details of antiplatelet treatments. General practitioners should be informed of the information and education provided to their patients.
| Anticoagulant medications | Antiplatelet agents |
|---|---|
| Knowledge of the name and dose | Knowledge of the name and dose |
| Indications and expected duration of treatment | Indications and expected duration of treatment |
| Course of action when missed | Course of action when missed |
| Drug interactions | Drug interactions |
| Notifying the presence of the treatment | Notifying the presence of the treatment |
| Biological follow-up, target INR | |
| Warning signs of overdose |
Prophylaxis for infective endocarditis
The European recommendations of September 2009 currently restrict prophylactic antibiotic use to: three categories of patients at the highest risk of infective endocarditis (carriers of prosthetic valves, those with a history of endocarditis and those with complete correction of cyanogenic congenital heart disease); only one situation of risk (dental treatment affecting the gums or the periapical region or accompanied by perforation of the buccal mucosa).
The patients concerned should be provided with information on prophylaxis, education concerning buccodental hygiene and a specific treatment card.
Recommendation 3: psychosocial management
Psychological management
Negative effect (anxiety, depression, propensity to anger and hostility) is important among the risk factors for coronary artery disease . The type D personality profile (excessive negative effect and social inhibition) is associated with an increased risk of mortality or restenosis after stent implantation . Depression is predictive of unfavourable outcomes in coronary artery disease patients and should be screened for, and integrated into, the therapeutic objectives . Following a cardiac rehabilitation programme significantly reduces mortality among depressed patients with coronary artery disease . Job stress is a factor favouring progression of atherosclerosis and is a precipitating factor in major cardiovascular events.
Screening for psychological risk factors should be done using specific validated questionnaires (14-item Hospital Anxiety Depression scale, shortened version of the 13-item Beck Depression Inventory) .
Role of the psychologist or the consultant psychiatrist
The presence of a psychologist in the cardiovascular rehabilitation team is highly desirable. It is essential that the psychologist makes themselves available to all patients; they participate in the TEP, inform patients on the role of psychosocial factors and the notions of perceived stress, detect eventual sexual dysfunction in patients and take part in group meetings .
Non-pharmacological approaches may consist of patient discussion groups complemented by individual interviews, meditation exercises (yoga, relaxation sessions) and techniques to help to control stress .
Pharmacological approaches may comprise hypnotics, which can be prescribed very occasionally on request, and antidepressants, which are prescribed in cases of diagnosed depression, panic attacks, symptoms of phobia and post-traumatic stress. The prescription of antidepressants should be combined with a prolonged personal follow-up beyond the rehabilitation period.
Return to work
Resuming work is one of the aims of cardiovascular rehabilitation and has personal as well as medicoeconomic consequences .
Some studies on the factors influencing restarting work after acute coronary syndrome confirm the poor predictive value of clinical variables (20%) compared with demographic and socioeconomic variables (45%) . Depression during the acute phase may also be a negative factor for resuming work, independent of clinical and sociodemographic data . Furthermore, work perceived as restrictive (heavy load and little decisional latitude) may be associated with an increased risk of recurrence of cardiovascular events . Stress management plays a determining role when resuming one’s professional life through the optimization of stress capacity and, psychologically, through the positive self-image generated by the patient.
The balance between the functional capacity of the patient and their work can be evaluated using scales, although this approach has limitations . The results of the exercise stress test, particularly the cardiopulmonary exercise test, can be exploited to advise the patient and the occupational physician. The physical difficulty of the patient’s work can be assessed during ergonomic assessments or in on-site situations by ambulatory measurements of blood pressure and heart rate.
All cardiovascular rehabilitation programmes must include support for professional reintegration, particularly for patients in whom the clinical and/or psychological characteristics or the physical difficulty of the work are risk factors for not resuming work.
A decision by the occupational physician of partial or complete unsuitability for the current job can have substantial consequences for the patient and should only be taken as a last resort.
All patients are encouraged to consult their occupational physician before returning to work in cases where it will be necessary to temporarily or permanently adapt their work (altered working hours, restructuring, changing jobs, training course). Therapeutic part-time work offers an opportunity to gradually return to work while allowing the patient to follow an ambulatory rehabilitation programme in parallel.
Recommendation 4: daily life
Driving motor vehicles
Aptitude for driving is dependent on the risk of loss of consciousness. The decree of 31st August 2010 modified the decree of 21st December 2005, establishing the list of medical conditions incompatible with driving light vehicles (private) and heavy vehicles . Drivers of light vehicles are not subject to a preliminary medical aptitude test or regular examinations, whereas drivers of heavy vehicles — mostly professional drivers — are subject to tighter regulatory constraints.
Any physician expressing restrictions about the patient’s aptitude for driving must respect medical confidentiality and should therefore try to convince the patient to contact the medical commission of aptitude and provide all elements relevant to making a decision. The opinion, with supporting arguments, of the rehabilitation service must be clearly present in the patient’s medical file and, if the patient has no objections, in the release documents. Consultation of the tables specifying the aptitudes according to pathologies published in the French Official Journal is recommended before all decisions.
Travel advice
Coronary artery disease is one of the most frequent causes of hospitalization of Europeans abroad and is the second most frequent cause of death and repatriation of French citizens abroad . Cardiac arrest is rare during flight. Since January 2010, all planes passing over French territories must be equipped with a semiautomatic defibrillator.
It is recommended to know the local health care structures prior to travelling (available at www.cimed.org ), as well as the time typically taken to provide care locally. Contraindications to air travel for the coronary artery disease patient are : coronary angioplasty or acute coronary syndrome less than 2 weeks prior to travel; coronary artery bypass surgery less than 3 weeks prior to travel; unstable HF; and uncontrolled supraventricular arrhythmia or ventricular arrhythmia.
Some general precautions are recommended before travelling: obtain health insurance for medicalized repatriation, covering the repatriation fees of patients with prior known cardiovascular disease; have a summary of the patient’s medical files translated into English if needed; have a reference electrocardiogram trace; have the name (international non-proprietary name) of prescribed medication; have a sufficient stock of medications to cover the journey; have the necessary treatment readily available in the aircraft and be in possession of a prescription; ensure sufficient time in airports (boarding, transit, etc.).
Trips to high altitude
An adapted physical condition and at least 4 weeks of clinical stabilization are required before considering physical activity over 1500 to 2000 m, following a negative exercise stress test .
Trips to tropical areas
There is no specific contraindication to vaccinations, but prophylaxis for malaria should be adapted as appropriate .
Sexual activity
Sexual health is a quality of life criterion according to the World Health Organization and requires appropriate management. The cardiologist is involved because there is a very strong statistical association between erectile dysfunction and cardiovascular disease; this is due to endothelial dysfunction .
Sexual activity involves a moderate physical effort (2.5 to 3.3 METs), added to which there is a non-negligible emotional component. Sexual activity should not be limited if the patient can achieve 60 watts on the bicycle or easily climb two flights of stairs. The risk of triggering an acute coronary syndrome following sexual activity is low, especially if the patient practices regular physical activity .
Several treatments for coronary artery disease have an effect on erectile dysfunction. It is important to speak to patients to reassure them and adjust the choice of treatments on an individual basis. Do not hesitate to work in a network with the help of other specialists (to screen for other possible causes: endocrine or urological). Specific inhibitors of type 5 phosphodiesterase, which are nitric oxide donors for the treatment of erectile dysfunction, have good haemodynamic tolerance and can be prescribed for stable coronary artery disease patients. The only contraindication is coprescription of nitrate derivatives, which carries the risk of a major hypotensive episode. Patients must be informed .
Cardiovascular rehabilitation favours the resumption of a sex life following a cardiac event .
Physical activity in sedentary patients
The rehabilitation period is the time to start or restart physical activity. The benefits should be maintained by continuing regular physical activity. The activities chosen should be appropriate for realistic integration into the professional, social and family life of the patient.
The objectives are as follows : suggest new behaviours (walking, using the stairs, reducing the time spent in front of the television or the computer); encourage the practice of physical activity tailored towards endurance (walking, cycling, swimming), equivalent to 30 minutes of walking per day (or 3 or 4 hours per week), of moderate intensity (breathing easily, “slightly difficult” on the Borg scale), possibly in a heart rate target “zone”; include strength training (gym, aquagym) twice per week; ensure regularity (support from family and friends, activity at a club, indoor activities); advertise the Heart and Health Clubs ( www.fedecardio.com ); avoid intense static efforts and bad weather (cold, wind); report all unusual symptoms (pain, dyspnoea, malaise); reduce or stop training in case of febrile episodes .
Physical activity in physically active patients
A history of sport activity is a factor that should be systematically investigated at the start of the programme. This is an excellent criterion favouring adherence to a training programme. It is, however, necessary to warn a patient who was physically active that stopping physical activity for a few weeks to a few months results in a loss of physical gains, especially endurance , and that physical activity must always be resumed progressively.
Resumption of regular exercise training at the start of rehabilitation is often easier but the programme needs to be monitored to ensure that it is reasonably adapted to the current abilities of the patient. The training programme will often be more intense than that used for inactive patients of the same age. Evaluation at the start of rehabilitation is essential to help select the appropriate sport and intensity of training.
Previously published recommendations help to provide advice to patients about the types of non-competitive activities appropriate to the pathologies concerned . For patients wishing to resume competitive sport, specific recommendations are available to identify the sports that can be practiced in competition, according to the cardiovascular pathologies concerned; these are often restrictive because it has been demonstrated that participating in competition is a factor that can increase the risk of complications, particularly sudden death .
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