Page 880 - Cardiac Nursing

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856 PA R T V / Health Promotion and Disease Prevention
in skeletal muscle, higher-than-normal systemic vascular resist- receive cardiac rehabilitation services despite reductions in reim-
ance, higher-than-normal pulmonary pressures, and ventilatory bursement. In addition, physicians have not been particularly ef-
abnormalities that increase the work of breathing and cause exer- fective in assisting patients in achieving defined risk factor
tional dyspnea. 66,76,77 Studies performed over the past decade goals, 14,16,82–85 and strategies have been suggested to facilitate a
have demonstrated that many of these abnormalities can be im- greater proportion of patients meeting evidence-based treatment
proved by exercise training. 62,66 guidelines.
Most patients with reduced left ventricular function who are Models that have been developed to meet these needs include
clinically stable and have reduced exercise tolerance are candidates the transformation of rehabilitation centers into “secondary pre-
for exercise programs. It is often necessary to exclude patients with vention centers,” 79 the “inclusive chronic disease model,” 86 the
signs and symptoms of right-sided failure or to treat them judi- implementation of affordable, evidence-based, comprehensive
ciously before entry into a program. An exercise test is particularly risk reduction in primary and secondary prevention settings, 79,87
important before initiating the program to ensure safety of partic- home exercise programs, 88–90 and case-management sys-
ipation. Rhythm abnormalities, exertional hypotension, or other tems. 91–94 The concept that cardiac rehabilitation should be the
signs of instability should be ruled out. Expired gas exchange primary medium to implement comprehensive cardiovascular
measurements are particularly informative in this group because risk reduction has been embraced by the AHA, 80 the Agency for
they provide an improvement in accuracy and permit an assess- Health Care Policy and Research (AHCPR) Clinical Practice
ment of ventilatory abnormalities that are common in this condi- Guidelines, 11 and the American Association of Cardiovascular
tion 76,78 (see Chapter 21). ECG monitoring during exercise is and Pulmonary Rehabilitation (AACVPR). 13,65 The recent AHA
more often indicated in this group. Attention should be paid to consensus statement on “Core Components of Rehabilitation/
80
daily changes in body weight, rhythm status, and symptoms. Secondary Prevention Programs” defines specific evidence-based
Increasing numbers of patients have undergone cardiac trans- risk factor goals for management of lipids, blood pressure, weight,
plantation for end-stage heart failure, and approximately 75% of smoking cessation, diabetes management, and physical activity
these patients remain alive after 5 years. These patients are (Display 37-10). This model provides an integrated system that
presently considered good candidates for rehabilitation programs. includes appropriate triage, education, counseling on lifestyle in-
Because the transplantation patient’s heart is denervated, some in- terventions, and long-term follow-up.
triguing hemodynamic responses to exercise are observed. The Several studies have demonstrated the efficacy of comprehen-
heart is not responsive to the normal actions of the parasympa- sive risk factor management using a case management approach. In
thetic and sympathetic nervous systems. The absence of vagal tone each of these studies, a nurse, as case manager, functions as the co-
explains the high resting HRs in these patients (100 to 110 beats ordinator and point of contact who identifies, triages, provides
per minute) and the relatively slow adaptation of the heart to a surveillance on safety and efficacy, performs follow-up, and, in
given amount of submaximal work. As a result, the delivery of many instances, quantifies patient outcomes. Case management
oxygen to the working tissue is slower, contributing to earlier- has been the cornerstone of recent multidisciplinary efforts to re-
than-normal metabolic acidosis and hyperventilation during exer- duce cardiovascular risk. In addition, it has provided a framework
cise. Maximal HR is lower in transplantation patients than in nor- for comprehensive management of existing disease, particularly
mal subjects, which contributes to a reduction in cardiac output for patients with CHF. 90–95 This approach involves the coordina-
and exercise capacity. tion of risk reduction strategies for targeted groups of patients by
A growing number of reports have addressed the effects of a single individual, most commonly a nurse or exercise physiolo-
training after cardiac transplantation. These studies have demon- gist, with appropriate medical supervision. The case management
strated increases in peak oxygen uptake, reductions in resting and concept is based on the idea that risk factors are strongly interre-
submaximal HRs, and improved ventilatory responses to exercise lated, and an individualized, integrated approach to management
after periods of training. Whether the major physiologic adapta- will optimize care such that clinical outcomes will be improved
tion to exercise is improved cardiac function, changes in skeletal and costs will be saved. The case management approach has been
muscle metabolism, or simply an improvement in strength re- applied in various settings over the past decade and has been suc-
mains to be determined. Psychosocial studies of rehabilitation in cessful in reducing risk markers for coronary artery disease and
transplantation patients are lacking, as are studies of the effects of improving outcomes in patients with existing disease. Some of the
regular exercise on survival. more prominent studies performed in recent years using case
management approaches are described.
The Butterworth Heath System in Michigan reorganized their
New Models of cardiac rehabilitation program to focus on improvement in long-
93
Cardiac Rehabilitation term outcomes using a case-management model. The model in-
cluded the use of referral pathways, education sessions, and inter-
Changes in reimbursement patterns over the past 15 years, along vention by social workers as necessary. In addition, they added
with the demonstration that clinical outcomes can be improved regular telephone follow-up to assess the effectiveness of the risk
by multidisciplinary risk factor intervention, 79–81 have led to the reduction interventions. One year after initiating the program,
development of new models of cardiac rehabilitation. The need 77% of patients were on appropriate lipid-lowering therapy, 78%
for new approaches has also been fueled by the recent observa- reported exercising at least 3 days per week, and 66% of previous
tions that a wider spectrum of patients can benefit from cardiac smokers reported smoking cessation.
91
rehabilitation (e.g., valvular surgery, CHF, posttransplantation, The MULTIFIT program of DeBusk et al. has been a model
peripheral vascular disease, postcardiac resynchronization ther- for other case management programs, and its success led to it be-
apy, and the elderly). Moreover, innovative strategies have been ing adopted by the Kaiser Permanente Health Care System.
proposed to increase the proportion of eligible patients who MULTIFIT is a case-managed program for patients hospitalized