Getting patients with cardiovascular disease to move more: cardiac rehabilitation and beyond

KEYWORDS:

• Healthy living medicine
• aerobic capacity
• cardiorespiratory fitness
• prevention
• exercise training

1. Introduction

Exercise is a vital medicine that every individual should be taking, from apparently healthy individuals to those diagnosed with one or more chronic conditions [1]. In fact, expanding on this paradigm, we are gaining an appreciation that all forms of physical movement are medicine [2,3]. For those diagnosed with cardiovascular disease (CVD), cardiac rehabilitation (CR) is considered a standard of care [4]. While CR is a multifactorial healthy living (HL) intervention, supervised exercise training, and preparing patients to manage their training program independently are central components. Although CR is strongly endorsed by leading professional organizations [5], patient participation continues to be unacceptably low [5,6], particularly in those who would benefit most from HL medicine (HLM) [7]. This editorial will address the following: (1) Rethinking health professions training to include HLM as an integral curricular component; (2) key factors to consider in facilitating greater participation in CR; (3) the importance of improving cardiorespiratory fitness (CRF) with exercise training; and (4) the importance of getting all patients with CVD to move more independent of CR attendance.

2. Healthy living medicine

To increase the frequency of assessing exercise and movement behaviors and prescribe interventions to increase physical activity, health professions training must evolve to incorporate significant didactic content and practical experiences in HLM. The American Heart Association (AHA) recently published a scientific statement that provides guidance on experiences needed during medical training to achieve competency in HLM [8,9]. However, physician training is not the only profession in need of curricular revision; all health professions (e.g. nursing, pharmacy, dentistry, physical/occupational therapy, etc.) should include significant content on the importance of HLM and the role each profession plays in its delivery [9]. Clinicians who are trained on the importance of HLM are more likely to practice HLM, which includes endorsement and referral to CR and ensuring all patients under their care fully grasp the importance of moving more.

3. Cardiac rehabilitation

CR has been deemed a Class IA indication by the AHA and other professional organizations for all eligible patients (i.e. those with a qualifying diagnosis and without a medical contraindication to participation) [5]. Both aerobic and strength training programs that are individualized according to standard prescription parameters (i.e. Frequency, Intensity, Time, and Type) are core components of CR. Despite the well documented benefits of CR, actual attendance and completion by patients with CVD continues to be suboptimal [6]. How do we get the majority of patients to attend and participate? Initially, to counteract low referral rates which continue to be a significant challenge, efforts such as automated referral (e.g. AHA Get with the Guidelines [10]) and strong physician endorsement are excellent first steps but not enough to get patients to attend and participate. Strong endorsement of CR should be performed by all members of the interprofessional health team (e.g. physicians, nurses, social workers, physical and occupational therapists, etc.) caring for patients with CVD. The AHA has published a scientific advisory on the role of various health professions in promoting and facilitating referral to CR [6]. Following automated referral and a strong and consistent message of endorsement, patients should initiate CR as soon as they are stable and cleared to begin exercise training. There is an oftentimes unnecessary several week lag between referral/endorsement and CR initiation. Such an approach can diminish perceived value – ‘if CR was so important to my plan of care why aren’t I starting right away?’ Research has shown an early access model, where referral to initiation time is reduced to days as opposed to weeks, significantly increases CR participation and completion [11]. Even with all of the aforementioned steps in place, a significant number of patients will not participate in CR. Patient-perceived barriers to CR (e.g. weak physician endorsement, transportation issues, limited time off work, pain, etc.) significantly impact CR attendance [12]. Perceived barriers and patient motivations to attend CR should be assessed. When barriers or decreased motivation is identified, strategies should be employed to increase the likelihood of CR attendance and completion. A single 30–60 motivational intervention that entailed: ‘1) developing rapport; 2) clarifying and building importance (providing education as-needed, tying CR participation to personal goals/values); 3) building confidence and collaboratively problem-solving CR barriers, and; 4) summarizing the session’ significantly increased intention to attend and adherence to CR in patients suffering an acute coronary event [13]. Locating CR in close proximity to other outpatient services the patient attends regularly may also improve CR attendance. A recent publication described a unique model where a cardiology division’s heart failure clinic at a major academic medical center was imbedded in the same location where CR was provided (i.e. across the hall from one-another) [14]. This model provides the ability for heart failure patients to receive a significant amount of outpatient care they need in one location. The patients also experience a team approach, where cardiologists, nurses, dieticians, and clinical exercise physiologists work closely together, and all strongly and consistently endorse CR. Initial findings indicate this model increases CR attendance in a patient population that demonstrates particularly low referral and participation rates [14]. Lastly, a one-size-fits-all approach to CR will never capture all eligible patients for various reasons (e.g. distance traveled to nearest CR program, cost, capacity of a given CR program, etc.). In addition to the well documented benefits of supervised out-patient CR, research has demonstrated home-based CR programs [15] can result in significant improvements in HL behaviors, including adherence to an exercise program. Having several viable CR options for the health professional and patient to consider together, based upon individual patient presentation, preference, costs, ease of access, etc., can help to increase the number of patients adopting a healthier lifestyle. Once the supervised CR is complete, which often lasts ~12 weeks, efforts should be taken to increase the likelihood individuals will continue to adhere to a healthy lifestyle. Connecting individuals who complete CR to community-based fitness facilities or programs should be considered. Moreover, HLM should be an integral component of clinical follow-up visits; physicians and other health professionals overseeing the care of patients completing CR should obtain information on adherence to a healthier lifestyle at every encounter and view this information as a component of the vital sign assessment (i.e. heart rate, blood pressure, etc.). When a decline in healthy lifestyle adherence is identified, the physician should strongly encourage a recommitment to HL and consider referral to other health professionals with focused expertise, such as a clinical exercise physiologist, registered dietician, or cognitive behavioral therapist.

4. Cardiorespiratory fitness

Getting patients to attend and complete CR, which includes an exercise training program at its core, is a success but does not ensure improved prognosis. We are beginning to appreciate the ‘non-responder’ phenomenon, where patients who participate in CR and an exercise training program but do not improve CRF (i.e. aerobic capacity) have a significantly poorer prognosis compared to patients who do significantly increase CRF [16]. Therefore, when a non-response to exercise training is identified, titration of one or more training parameters should be considered (i.e. Frequency, Intensity, Time, and Type) in an attempt to elicit a CRF improvement. The AHA has recently recognized CRF as a vital sign with important prognostic insight [17]. As such, the treatment effect of exercise training through participation in CR should be assessed, ideally through a maximal exercise test at program completion.

5. Movement as medicine

We are rapidly gaining an appreciation of the fact that movement in general, beyond the movement derived from structured exercise training during CR, portends significant health benefits [2]. Decreasing sitting or screen viewing time and taking more steps per day are both independently associated with improved health outcomes. As such, perhaps the ‘exercise is medicine’ paradigm should be revised to a ‘movement is medicine’ paradigm. Beyond referral and ensuring attendance to CR, clinicians should continually be assessing and intervening to increase their patient’s movement portfolio. With movement as a vital sign, the questions that should be asked clinically are:

1) How many steps do you take each day?; 2) How many hours do you spend sitting each day?; 3) Do you interrupt sitting time with movement and if so what type and how often?; and 4) Do you participate in a regular exercise program and if so how many times per week, what intensity, how long is each session and what type of exercise do you perform?. [3]

Patients who sit >10 h and take <1000 steps per day and do not participate in a structured exercise training program are at particularly high risk for future untoward events. Irrespective of participation in CR, patients should be counseled to move more in any way possible – decreasing sitting time, taking more steps and initiating an exercise program. While sitting <4 h and taking >10,000 steps per day as well as performing >150 min of moderate-intensity exercise training per week is ideal, any reversal of the sedentary phenotype by moving more should be viewed as beneficial. Perhaps a pragmatic approach, for example counseling a patient to initially go from: (1) sitting >10 to <7 h per day; (2) 1500 to 3500 steps per day; and (3) No exercise training to 2–3, 20-min brisk walks per week would be viewed as much more achievable, particularly at the onset of contemplating a significant lifestyle change. Albeit unintentionally, clinicians may be sending a dichotomous, all or none message to patients, where anything below the recommended ideal exercise guidelines is not viewed as beneficial. Additionally, patients who are starting from a sedentary lifestyle may view compliance with the ideal exercise guidelines as unachievable. Segar et al [18] performed interviews in women to determine physical activity goals, values, and beliefs. Women who led an inactive lifestyle tended to view what counts as physical activity more narrowly in alignment with current ideal physical activity guidelines (i.e. higher intensities and longer durations). Inactive subjects who viewed physical activity in this way felt pressured and thought leading an active lifestyle in this context was unachievable. One subject who led an inactive lifestyle reported ‘walking her dog was a barrier to being active, which implied that she did not believe dog-walking counted as valid physical activity’ [18]. These perceptions do not align with the body of evidence indicating the type or amount of physical movement needed to improve health trajectory [2]. In this context, clinicians should consider how we assess physical activity and counsel all patients move more every day.

6. Conclusions

In conclusion, movement is medicine that, if prescribed and adhered to, has tremendous health benefits. CR is an important way to get patients with CVD to begin and hopefully maintain an exercise training program and move more daily; every effort should be made to get eligible patients to attend and complete CR. Clinicians are strongly encouraged to adopt the strategies described in section II (e.g. automated referral, strong physician endorsement, motivational interviewing, etc.) to improve CR attendance and adherence. More broadly, clinicians should view physical movement as a vital sign by: (1) assessing movement habits at every encounter; (2) continually prescribing sitting less, taking more steps, and participating in a structured exercise program; and (3) Following-up at every subsequent encounter to ensure patients are adhering to this integral component of HLM.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.