Best Practice Guidelines Services for Cardiac ...

1 Best Practice Guidelinesfor Cardiac Rehabilitationand secondary PreventionPRODUCED BY THE HEART RESEARCH CENTRE ONBEHALF OF DEPARTMENT OF HUMAN Services VICTORIAH umanServicesVictoriaBackground to Heart Research Centre and authorsThe Heart Research Centre was established in 1989 with three year seeding fundingfrom the National Heart Foundation of Australia. It became an independent centre in1993 and is now affiliated with The University of Melbourne and La Trobe Heart Research Centre conducts research into Cardiac rehabilitation and theprevention of heart disease, especially their psychological, behavioural and socialaspects. The Centre also conducts training programs for health Alan Goble is a practising clinical cardiologist, with a longstanding interest incardiac rehabilitation . He is a member of the Expert Advisory Panel onCardiovascular Diseases of the World Health Organisation, and a member and past-chairman of the Council on rehabilitation and prevention of the World HeartFederation.

2 He is Chairman of the Board of the Heart Research Marian Worcester has a doctorate in social and preventive medicine and aMaster s degree in criminology. She has a particular interest in psychologicalresponses to acute illness and social support. She has been Director of the HeartResearch Centre since its Best Practice Guidelines for Cardiac rehabilitation and secondary Preventionare dedicated to the late Dr John Shaw, former director of the National HeartFoundation of Australia, for his support of the Heart Research Centre, and tocardiologists, Dr Robert Goodwin and Dr W Anthony Seldon for their contributionsto the development of Cardiac rehabilitation in Practice GUIDELINESFOR Cardiac REHABILITATIONAND secondary PREVENTIONHEART RESEARCH CENTREP rincipal AuthorsAlan J Goble, MD, FRCP, FRACPM arian U C Worcester, PhD, MAProduced on behalf of Department of Human Services VictoriaBEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONiiBest Practice Guidelines for Cardiac rehabilitation and secondary PreventionGoble AJ & Worcester MUCH eart Research CentreACN 060 479 763A company limited by guaranteeLygon Court.

3 333 Drummond Street, Carlton, Victoria 3053 AustraliaPO Box 607, Carlton South, Victoria 3053 AustraliaTelephone (613) 9347 5544 Facsimile (613) 9347 6964 Email Website ~heart/Published by Department of Human Services VictoriaApril 1999 ISBN: 0 7311 5258 1 Designed by Outsource Design (03) 9645 5220 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONiiiFOREWORD xiiiFOREWORDxivINTRODUCTIONxvPREFACExviE XECUTIVE SUMMARY xviiiCHAPTER 11 Development of the Best Practice GuidelinesIntroduction1 Terms of reference2 Clinical Practice Guideline of the United States Agency forHealth Care Policy and Research3 Development of the Best Practice Guidelines3 Evidence from meta-analyses5 Strength of evidence rating systems5 United States Agency for Health Care Policy and Research6 National Health and Medical Research Council of Australia6 Consultative Committee7 Survey of current programs in Victoria8 Focus groups with health care providers8 Comparative study of four model programs8 CHAPTER 29 Cardiac rehabilitation and secondary prevention .

4 DefinitionsCardiac rehabilitation9 secondary prevention10 Phases of Cardiac rehabilitation11 Inpatient rehabilitation (Phase 1)11 Ambulatory outpatient rehabilitation (Phase 2)11 Maintenance (Phase 3)12 CONTENTSBEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONivCHAPTER 313 Cardiac rehabilitation and secondary prevention :historical backgroundUnited States of America13 Australia14 Europe15 United Kingdom15 Asia15 Participation in programs16 CHAPTER 417 The burden of cardiovascular diseaseCHAPTER 523 Recent Practice Guidelines and policy statementsScientific review23 United States Agency for Health Care Policy and Research23 Other Guidelines and statements23 American Association of Cardiovascular and Pulmonary Rehabilitation23 British Association of Cardiac Rehabilitation23 American College of Sports Medicine24 British Cardiac Society24 American Heart Association24 American College of Physicians24 rehabilitation Systems in Europe24 European Society of Cardiology24 National Heart Foundation of Australia25 World Health Organisation25 CHAPTER 627 Review of Clinical Practice Guideline No 17 Cardiac rehabilitation (1995)

5 US Agency for Health Care Policy and ResearchExercise training29 Education, counselling and behavioural interventions30 Organisational issues30 CHAPTER 731 Exercise training in Cardiac rehabilitationMeta-analyses31 Ambulatory (convalescent) Cardiac rehabilitation trials32 Longterm exercise studies where exercise training alone is comparedwith standard medical care32 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONvLongterm multifactorial interventions compared with standard medical care32 Comparisons of high and low intensity exercise training32 The benefits of exercise training33 Physical performance33 Exercise tolerance33 Muscular strength34 Symptoms34 Psychological functioning35 Social adaptation and functioning35 Return to work36 Major risk factors37 Lipids37 Smoking habit37 Body weight38 Blood pressure38 Subsequent exercise habits39 Morbidity, recurrent events, hospital readmissions and mortality40 Conclusions41 CHAPTER 842 The amount of exercise trainingIntensity of exercise training42 Categorisation of exercise intensity44 Low intensity exercise44 Moderate intensity exercise45 High intensity exercise45 Measuring exercise intensity46 Heart rate46 Determination of training heart rate from exercise stress test46 Determination of training heart rate from formula47 Formula-based percentage of maximal heart rate48 Formula-based percentage of heart rate reserve48 Perceived exertion49 Frequency of exercise sessions and duration of program49 Frequency of sessions50 Duration of program51 Home exercise programs52 Continued exercise beyond convalescence53 Eligibility for exercise programs55 Exclusion from exercise training55 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONviCHAPTER 957 Risk stratificationHigh risk groups57 Technological

6 Assessment of risk58 Clinical assessment of risk58 Conclusions59 CHAPTER 1060 Conducting exercise programsSite of exercise program60 Safety protocols61 Equipment62 Content of exercise classes62 Staffing63 Staff to patient ratio64 Exercise testing before exercise training64 Patient assessment before entry to the program65 Time of starting the exercise program66 Monitoring during exercise sessions66 Exercise testing after exercise training67 High intensity exercise training68 CHAPTER 1169 Exercise programs for specific groupsPatients with heart failure and transplantation69 Patients with pacemakers and implantable cardioverter defibrillators70 Patients with other forms of heart disease71 Obese patients and diabetic patients71 Unfit patients72 Elderly patients73 Female patients74 CHAPTER 1276 Education, counselling and behavioural interventionsKnowledge77 Health behaviours and risk factors79 Smoking79 Lipids82 Blood pressure84 Body weight85 Physical inactivity86 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONviiPsychosocial well-being87 Stress92 Type A behaviour pattern93 Return to work94 Conclusions96 CHAPTER 1397 Content of education and counselling groupsCore education program97 Medical topics98 Risk factors99 Smoking100 Raised lipids, nutrition and dietary fat100 High blood pressure102 Overweight.

7 Obesity and diabetes102 Physical inactivity103 Other modifiable risk factors104 Non-modifiable risk factors104 Behaviour change and adherence to regimens105 Mood and emotions107 Psychosocial risk factors and social support109 Stress110 Impact upon the spouse and family111 Sexual activity and activities of daily living112 Return to work112 CHAPTER 14114 Structural aspects of group education and counselling programsGroup versus individual counselling114 Principles of adult learning115 Range of topics115 Duration and frequency of sessions116 Time of entry to the education program116 Size of groups117 Style and level of presentation117 Individual counselling and referrals118 Protocol for education programs118 Review of education program119 Session facilitators119 Training of facilitators120 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary prevention viiiCHAPTER 15121 Programs for specific groupsPatients resuming work121 Patients who have had percutaneous transluminal coronary angioplasty123 Patients with other forms of heart disease124 Younger patients125 Patients of non-English speaking background126 Aboriginal Australians with heart disease127 Patients from rural and remote areas and others unable to attend a group program128 Spouses of patients129 CHAPTER 16131 Cardiac rehabilitation teamsMembership131 Roles of team members132 Nurse132 Physiotherapist133 Dietitian134 Occupational therapist136 Social worker137 Psychologist138 Cardiologist139 Cardiac surgeon140 General practitioner141 Exercise physiologist142 Exercise therapist143 Diabetes educator143 Welfare worker143 rehabilitation physician144 Pharmacist144 Psychiatrist144 Vocational counsellor145 Community health worker145 Other health practitioners146 Program co-ordinator146 Regional co-ordinator147 Team meetings147 Core

8 Competencies and staff training148 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONixCHAPTER 17149 Organisational issuesEstablishing programs149 Eligibility for referral to the program150 Hospital discharge plan151 Method of invitation to the program151 Invitations in other languages152 Initiating referrals and motivating patients152 Invitations to spouses153 Selection of program154 Time of commencing the program154 Entry assessment155 Selection of program modules156 Encouraging participation in programs and monitoring attendances157 Discharge review158 Referral to maintenance program158 Referral to community health Services and support groups159 Communication with doctors159 Longterm follow-up of patients160 CHAPTER 18161 Program evaluationProgram evaluation161 Outcome evaluation162 Instruments assessing functional capacity162 Graded exercise test1626 minute walk test162 Shuttle walk162 Duke Activity Survey Index163 Specific Activity Questionnaire163 Intruments assessing symptoms163 New York Heart Association163 Canadian Cardiovascular Society163 Seattle Angina Questionnaire163 Minnesota Living with Heart Failure Questionnaire163 Quality of life163 Generic measures of health related quality of life164 Medical Outcomes Study Short Form 36 (SF-36)

9 164 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONxThe Nottingham Health Profile164 Profile of Moods States165 Sickness Impact Profile165 Psychosocial Adjustment to Illness Scale165 Specific measures of health related quality of life165 Quality of Life after Myocardial Infarction Questionnaire165 Minnesota Living with Heart Failure Questionnaire165 Heart Patients Psychological Questionnaire165 Instruments measuring single psychological states166 State Trait Anxiety Inventory166 Hospital Anxiety and Depression Scale166 Beck Depression Inventory166 Cardiac Depression Scale166 Other questionnaires166 Visual analogue scales167 Measures of other psychosocial outcomes167 Selecting methods of assessing quality of life167 Knowledge169 Cardiac Health Knowledge Questionnaire169 Coronary Angioplasty Risk Factor Inventory170 Victorian Cardiac rehabilitation Questionnaire170 Open-ended questions170 Risk factors and health behaviours170 Smoking170 Cholesterol170 Blood pressure171 Body weight171 Physical activity171 Dietary habit171 Adherence to medication and advice171 Attitudes towards changing health behaviours172 Intention to change172 Attitudes towards change172 Self efficacy regarding change173 Work173 Outcome indicators173 Functional capacity174 Activities of daily living174 Physical status174 Quality of life174 Knowledge174 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONxi Risk factors.

10 Health behaviours and attitudes174 Smoking174 Cholesterol174 Blood pressure175 Body weight175 Physical activity175 Dietary habit175 Adherence to medication and advice175 Work176 Hospital readmissions176 Process evaluation176 Patient satisfaction176 Delivery of the program177 Process indicators177 Communication177 Program referrals177 Liaison with general practitioners178 Patient management179 Assessment of patients179 General practitioner follow-up179 Program evaluation179 Program attendance179 Program modules180 Consumer input180 Participation of general practitioners180 Documentation181 Staff issues181 Minimum data sets181 External audit or peer review182 Conclusion182 CHAPTER 19183 Cost, cost saving and cost effectivenessVictorian public hospitals183 Victorian private hospitals185 Canada185 United States of America186 United Kingdom186 Cost saving187 Cost effectiveness188 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONxiiCHAPTER 20189 Recommendations for future researchREFERENCES193 GLOSSARY227 ACKNOWLEDGEMENTS236 TABLEST able 1: Deaths from CVD (1994)17 Table 2: Hospital separations: number of patients with a diagnosis of CHD (Victoria)18 Table 3: Strength of evidence ratings for benefit (AHCPR 1995)28 Table 4: Number of exercise studies reviewed (AHCPR 1995)Scientific basis for recommendations: exercise training29 Table 5: Number of studies reviewed reporting education, counselling andbehavioural interventions (AHCPR 1995)30 Table 6: Correlation with exercise training levels (approximate)47 FIGURESF igure 1: Age-adjusted death rates 1950 19