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This introductory chapter will briefly describe the evidence for the use of car-
diac rehabilitation (CR) in the management of coronary heart disease and how
this evidence has influenced the shift from exercise-only programmes to the
comprehensive multidisciplinary CR programmes that are prominent in the
UK today.
Background
By 2005 coronary heart disease (CHD) had become the leading cause of death
in the UK, killing more than 110,000 people each year in England alone
(Department of Health, 2005). Furthermore, approximately 275,000 people
experienced a myocardial infarction (MI), or heart attack, each year, with a
further 1.4 million people suffering from angina (Department of Health, 2005).
Currently coronary heart disease accounts for approximately one in five deaths
in men and one in six deaths in women (British Heart Foundation, 2008). The
National Service Framework (NSF) for Coronary Heart Disease, published in
March 2000, set out the government’s intention to improve the care of patients
with CHD over a 10-year period (Department of Health, 2000). The NSF for
CHD set out 12 standards for the improved prevention, diagnosis, treatment
and rehabilitation of people with coronary heart disease and aimed to secure
fair access to high-quality services. One such service is cardiac rehabilitation,
and chapter 7 of the NSF, “Cardiac Rehabilitation”, outlined a national standard
(Standard Twelve) for the rehabilitation of patients with CHD:
NHS trusts should put in place agreed protocols/systems of care so that, prior
to leaving hospital, people admitted to hospital suffering from coronary heart
disease have been invited to participate in a multidisciplinary programme of
secondary prevention and cardiac rehabilitation. The aim of the programme will
be to reduce their risk of subsequent cardiac problems and to promote their return
to a full and normal life.
(Department of Health, 2000)
Cardiac Rehabilitation
Cardiac Rehabilitation
In 1993 cardiac rehabilitation was defined by the World Health Organization
(WHO) as:
The stated aim of the WHO definition of cardiac rehabilitation that it must “be
integrated within secondary prevention services” has been accepted as the norm
for CR services today. The drive towards helping individuals to return to “their
former way of life” facilitated the rise of multidisciplinary cardiac rehabilitation
(Dusseldorp et al., 1999). Multidisciplinary CR involves using a team of nurses,
exercise specialists, psychologists, dieticians and other health professionals to
bring together medical treatment, education, counselling, exercise training,
risk-factor modification and secondary prevention (Thompson and De Bono,
1999). The definition of cardiac rehabilitation in the NSF for CHD acknowl-
edges these factors and updates the earlier WHO definition, incorporating the
concepts of lifestyle change and individual confidence:
To enable people to achieve the lifestyle changes that they want to make and to
regain their confidence so that they can enjoy the best possible physical, mental
and emotional health and so return to as full and as normal a life as possible.
(Department of Health, 2000)
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Multidisciplinary Cardiac Rehabilitation
3
Cardiac Rehabilitation
4
Multidisciplinary Cardiac Rehabilitation
have shown wide variance in how, by whom and to whom this “comprehensive”
cardiac rehabilitation is delivered. Bethell found that, of the 236 CR centres
that provided survey data, 194 had nurse involvement in their programmes,
compared to only 37 programmes that had a psychologist involved in deliv-
ering cardiac rehabilitation (Bethell et al., 2001). An earlier study by Lewin
et al. (1998) found that, although 70 per cent of CR programmes in their sur-
vey reported having five or more health-care professions represented in their
CR teams, in only a small number of these teams did physicians (16 per cent),
a psychologist (9 per cent) or a health promotion officer (6 per cent) give talks
to patients or take any other part in the CR programme. Brodie et al. (2006),
in a random sample survey of 28 CR programmes across England, reported
that co-ordinators of the services considered lack of psychologists to be the
greatest deficiency in the service (57 per cent) followed by lack of physiother-
apists (43 per cent). These data become even more important when considering
the findings of the meta-analysis by Linden et al. (2007), which showed mor-
tality benefits in men, at two years post-cardiac event, when they were given
a psychological treatment in addition to usual care as part of their cardiac
rehabilitation. Overall the data suggest that CR in the UK can be described
as multidisciplinary, but the distribution of health professionals across dif-
ferent CR programmes is inconsistent, ultimately affecting the quality of
patient care.
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Cardiac Rehabilitation
Seki et al., 2003; Stagmo et al., 2001; Sundin et al., 2003; Vestold Heartcare
Study, 2003), most studies have considered MI patients alone. Furthermore,
if certain multidisciplinary aspects of CR are missing or poorly delivered it
might well be that CR then becomes less effective. Psychological and social
factors in particular are often poorly assessed and addressed in CR (Lewin,
1998), despite the fact that the government recognises that tackling these areas
is an important goal of cardiac rehabilitation (Department of Health, 2000).
The important psychological factors involved in CR will be discussed in more
detail in Chapter 2.
While certain CR programmes have three or more different health pro-
fessionals attending the programme for its duration (Cardiac Rehabilitation
Gloucestershire, 2004), other CR programmes that would be described
as “comprehensive” may not adhere to the guidelines laid down in the
NSF for CHD. Brodie et al. (2006) stated that many programmes did not
meet the Scottish Intercollegiate Guideline Network for CR (SIGN, 2002),
which states that there should be 6.2 full-time equivalent staff to every
500 patients. This guideline was adopted by the British Association for Cardiac
Rehabilitation (BACR), the recognised national body for cardiac rehabilitation
in the UK, in its Standards and Core Components for Cardiac Rehabilitation in
2007, setting minimum requirements for CR teams that include, among others,
psychologists, dieticians and audit and clerical staff.