Even with awareness campaigns seemingly in every direction you turn, more than 60 percent of Americans are expected to experience some form of heart disease in their lifetime. If left untreated, common heart problems such as hypertension and high cholesterol can contribute significantly to the development of cardiovascular disease, which is the leading health risk in the United States today.
Cardiovascular disease often lands patients in the operating room for procedures including coronary artery bypass, percutaneous coronary intervention (PCI), coronary angioplasty and stenting, valve replacement and pacemaker or implantable cardiac defibrillator (ICD).
But there may be hope after surgery. Recent studies report that patients who attend outpatient cardiac rehab following cardiac surgery can reduce their chance of a future cardiac event by 25 percent.
Facilities often offer inpatient programs as the first line of defense for these patients as a means of educating about heart health and the role of diet and exercise as well as beginning closely monitored exercise plans.
"A recent assessment of our patient populations identified cardiac and pulmonary issues as either the primary or the major secondary disease process directly leading to the need for rehabilitation in the majority of our patients," said Nicole Sosa, PT, DPT, physical therapy team leader of the comprehensive rehab unit at MossRehab in Elkins Park, PA.
PT at the Helm
Cardiac rehab provides the information, the means (equipment/monitoring), and the social support necessary to guide a patient in making new commitments and developing healthier habits, according to Kathy McEwen, PT, MS, staff level IV PT, Einstein Medical Center Philadelphia.
"Physical therapists can serve a leadership role in promoting healthy lifestyle choices for both primary and secondary prevention," explained McEwen. "We can do that from a personal perspective by serving as role models and by providing education to our patients. And from a system perspective by advocating for processes that support referral to outpatient cardiac rehabilitation and that help to identify and address as many barriers to participation as possible."
Sosa believes that PTs can better serve this population by actively researching literature about suggested treatments and staying current on the evidence based practice and studies being performing. "And in turn, we may prevent readmissions from occurring due to preventable impairments," she said.
Einstein Health Network helps patients with complex cardiac issues to gain the skills they need to manage the disease process and return to activities of daily living. PT provides all inpatient rehabilitation at Einstein Medical Center Philadelphia, MossRehab in Elkins Park and Einstein Medical Center Montgomery.
Patients admitted to the comprehensive rehab unit (CRU) at MossRehab, part of Einstein Health Network, typically have other diagnoses along with a cardiac diagnosis. Multiple diagnoses often result in functional and mobility related impairments that require skilled PT services and an interdisciplinary team approach.
The interdisciplinary team includes nurses; physical, occupational and speech therapists; recreational therapists; neuropsychologists; social workers and physicians. The team meets weekly to discuss patient progress, concerns or issues that may develop and discharge planning. In addition, there is daily communication among team members about a patient's status.
Physical therapy is involved in the rehabilitation of patients with cardiac pathologies throughout the entire continuum of care beginning on the first day post-operative through PT or maintenance programs in outpatient settings.
Complicated by Comorbidities
Patients with cardiac conditions that require acute rehab services typically have comorbidities that impact the rehabilitation process. "The most frequent comorbidities we see include diabetes, obesity, hypertension, and peripheral vascular disease; however, there is no limit to the sequelae of cardiac diseases," said Rachelle Rigous, RN, BSN, CRRN, nurse manager, CRU at MossRehab.
The CRU at MossRehab's Elkins Park location is a 26-bed inpatient rehab unit designed to treat patients ranging from amputations and joint replacements to those who are medically complex due to various renal, hepatic, pulmonary, cardiac or neurologic diseases and injuries related to trauma.
MossRehab's 17-bed CRU located at the Einstein Medical Center Philadelphia has a similar patient population except the unit specializes in patients with ventricular assist devices (VAD) and those who are at risk for sudden cardiac arrest (SCA) and must wear personal defibrillators.
Many of the patients admitted to the two CRU locations have recently undergone cardiothoracic surgery such as coronary artery bypass graft surgery (CABG) or valve replacement. Many of the patients present with medical history of cardiac disease such as congestive heart failure (CHF), coronary artery disease (CAD), peripheral vascular disease (PVD), varying arrhythmias and recent myocardial infarction (MI) with resulting anoxic brain injury.
In the acute care setting, the team works with patients who have been admitted to the hospital with a wide range of suspected or confirmed acute cardiac conditions. The medical diagnoses most often seen on the cardiac care unit (CCU) include acute coronary syndrome, decompensated CHF, MI, valvular dysfunction, arrhythmias or syncope.
Patients with a primary diagnosis involving cardiac disease or pathology who do not have mobility impairments are most likely not candidates for an inpatient rehab program. "Because these patients don't require skilled physical therapy, they are referred to an outpatient cardiac rehab program," said Sosa.
Each patient receives a PT evaluation including assessment of cardiovascular parameters, at rest and with graded activity, in order to determine an appropriate exercise prescription. According to McEwen, because these patients often have multiple comorbidities, the program must be individualized to address any related impairments or functional limitations.
"The treatment program is often creative so that one activity can meet more than one goal," explained McEwen. "Doing dance steps with a patient who is on a bedside monitor in the CCU, for example, will meet the goals of improving balance and endurance while observing the patient's physiologic response on the monitor."
Patients who are admitted with significant cardiac issues are often followed by a cardiologist, internist or physiatrist. "We're fortunate to be a rehab hospital within an acute care facility, so the consulting doctors are readily available for concerns or questions regarding patient parameters, changes or limitations," Rigous shared.
Attending physicians provide the clinicians with cardiac parameters and diagnosis-specific precautions including specific heart rate, blood pressure and oxygen saturation levels that must be maintained throughout therapy sessions.
The clinicians incorporate these parameters as well as patient and family/caregiver education into the plan of care when treating patients with comorbidities, said Sosa.
The PTs rely on various interventions to address each patient's deficits and limitations. The patients range from those with short, uncomplicated hospitalizations without functional decline, to those who have been ventilator- and inotrope-dependent for an extended time and are profoundly deconditioned.
The most commonly used interventions are mild-to-high intensity endurance training based on the patient's tolerance level and precautions, strength training, and respiratory and pulmonary strengthening as permitted, according to Sosa.
The PTs use a variety of tools to provide exercise at an intensity that matches the patient's ability and provides the best opportunity to make progress. This is accomplished by using the Borg scale and understanding metabolic equivalent levels. And in the case of patients with VADs, PTs must have participated in structured education including a competency and possess an intimate understanding of the physiologic differences compared with patients without VADs.
Activities and interventions are progressed based on patient tolerance, medical stability and constant reevaluation of the patients' progress, according to Sosa. Some patients, for example, have suffered multiple acute problems such as stroke or amputation along with a cardiac event which may affect the patient's balance and endurance.
Physical therapy and nursing work closely together with this specific population in regards to patient response to mobility, patient tolerance to increasing time out of bed and actively participating in their own care, according to Sosa.
PTs and nurses frequently communicate about the best ways to assist patients with transfers, bed mobility skills, and ambulation with an assistive device while maintaining sternal precautions, weight bearing or activity restriction precautions.
"A multidisciplinary approach is crucial to managing this patient population," said McEwen. "Nurses often have crucial information to share such as medication changes, timing of medications and pain management strategies."
Because their findings often impact medical management, PTs' communication with the team is critical. "A therapist may determine that a patient is a high fall risk, which may contraindicate anticoagulation, or detect orthostatic hypotension which may require IV fluid repletion or an adjustment in medications," shared McEwen.
A patient with atrial fibrillation, for example, may demonstrate a normal heart rate at rest, but it may rise to an unacceptable range with ambulation to the bathroom, indicating that the medications used to control the ventricular rate need to be adjusted.
Diagnosis and Education
Clinicians make it their jobs to educate patients, family members and caregivers on lifestyle and behavior modifications such as diet, exercise and use of tobacco and/or alcohol. The goal of PT in this setting is to safely improve the patient's current functional and medical status to the pre-morbid activity level or better.
"Because of the limitations some of these patients may have, we bring family members and caregivers in early to observe therapy sessions and participate as needed if they will be providing the patient with assistance at home," Sosa shared.
The team educates the patient and family about self-monitoring vital signs, energy conservation and specific signs and symptoms to be aware of due to the diagnosis.
Many patients have extensive teaching needs related to movement strategies to maintain precautions after surgery, others need teaching related to dyspnea management. "Our patients after VAD placement have the greatest teaching needs, as they must learn many new techniques related to drive line care, equipment maintenance, changing to battery power to ambulate outside of their rooms, symptom recognition and sternal precautions," McEwen stated.
All eligible patients receive education about outpatient cardiac rehab and are assisted in making a connection with a program of their choice. Follow-up appointments and continued outpatient or home health therapies are set up before a patient is discharged.
If upon discharge from MossRehab the patient is able to participate in a formal cardiac rehab program, and no longer has pressing outpatient PT needs, the patient will be followed by a team of nurses and exercise physiologists.
"Having regular contact with a healthcare provider focused on making health and lifestyle modifications helps patients stay focused on their goals," McEwen said. "It provides the patient with information which builds confidence, and at the same time, holds the patient accountable."
Rebecca Mayer Knutsen is a senior regional editor at ADVANCE and can be reached at email@example.com.