Be It Resolved: Lifestyle Changes for Patients Needing Cardiac Rehab May Be a Life or Death Matter

When the clock struck midnight on January 1st, countless individuals around the world resolved to eat better and get fitter in the New Year. But like the party hats, confetti, and deflated balloons cast aside in Times Square, the commitment to change is often swiftly abandoned. For the large number of people who have had a myocardial infarction or undergone coronary revascularization the previous year, however—not to mention patients with stable coronary disease or heart failure—changing how they live may be a life or death matter.

Each year, approximately 750,000 Americans have an MI, and more than 200,000 of these are recurrent events, according to the American Heart Association (AHA). Cardiac rehabilitation programs are specifically designed to prevent recurrences, yet just one in five eligible patients are referred and enrolled in such a program following a critical cardiovascular event.

Gary Balady, MD (Boston University Medical Center, MA), authored the most recent scientific statement from the AHA on the core components of a cardiac rehabilitation and/or secondary prevention program. He told TCTMD that nowadays when a patient has an MI or coronary procedure, the in-patient stay is simply too short for adequate counselling. Over a span of 24 or 48 hours, patients have little opportunity to take in meaningful information about the lifestyle changes required after their event.

“By the time the patient recovers from their heart attack or valve surgery, they are about ready to go,” he said. “There is almost no time for that inpatient teaching to go on. It’s really up to the people providing outpatient care, and that’s where cardiac rehab is very helpful.”

Gordon Huggins, MD (Tufts Medical Center, Boston, MA), agrees. One of the benefits of modern care, he told TCTMD, is that cardiologists have become so successful in treating coronary artery disease that the patient is less likely to become disabled following an MI and more likely to spend less time in the hospital. Whereas a stay in the cardiovascular care unit was once as long as 10 days or 2 weeks—giving time to educate patients on necessary lifestyle changes—people are now often back to work in a couple of days.

“Paradoxically we’re sometimes the victims of our own success,” said Huggins. “[Patients] can continue to work, and then they need to get the time off work to get to cardiac rehab, and some of them can’t get that time off. There’s work barriers, childcare barriers, transportation barriers. There are many, many reasons why participation [in cardiac rehab] is limited.”

Compliance to Meds, Nutritional Advice, and Getting Active

Core components of a cardiac rehabilitation/secondary prevention program include the initial patient assessment, counseling on nutrition and physical activity, tobacco cessation, and the management of blood pressure, lipids, diabetes, and psychological and social factors.

Balady noted, however, that since so few patients enroll, treating cardiologists need to take a more active role in what comes next, making sure they are knowledgeable about diet (or referring the patient to a nutritionist), as well as advising the patient to stop smoking and get active.

Regarding pharmacotherapy, Huggins said it is well known that lack of adherence to blood pressure, lipid, and diabetes medications is associated with poor clinical outcomes. As such, physicians should emphasize the importance of taking the various treatments after an event or intervention, he suggested. At Tufts Medical Center, they have instituted a “med-to-bed” program so that discharge medications are brought to the patient bedside, one way to ensure the patient at least leaves the hospital with the required therapies. They also have conversations about drug affordability and continued access to treatment.  

While these talks will focus on drug compliance, this is not done at the expense of discussions about the importance of quitting smoking, physical active, and diet. However, the “diet and lifestyle discussions need to continue after discharge, and that’s a nice role that cardiac rehab plays,” said Huggins.

Diet as a Cornerstone

In 2010, the AHA developed their 2020 Impact Goals, a strategic 10-year plan to improve the cardiovascular health of all Americans by 20% and to reduce the number of deaths from cardiovascular disease and stroke by 20%. To achieve those goals, physicians were encouraged to focus not only on curbing acute events but also on modifying the patient’s health behaviors and risk factors as part of a secondary prevention strategy.

One of the major contributors to death and disability in the United States is a suboptimal diet. A lack of fruit and vegetables, fish, whole grains, nuts, and seeds plus way too much sodium is responsible for nearly 700,000 all-cause deaths each year, according to the AHA. Overall, just 1.5% of adults are meeting the requirements of an optimal heart-healthy diet. 

Sharon Smalling, MPH, RD (Memorial Hermann-Texas Medical Center), is a clinical dietician who works with cardiac rehabilitation patients. In addition to taking their medical history, Smalling likes to know what dietary advice patients might have received in the past and if they were following any restrictions prior to their event and/or procedure. She runs “the entire gamut” with patients, teasing out details not only on meals and snacks but also the amount of soda they are consuming daily.

In terms of recommendations, Smalling said there is no one-size-fits-all approach and that all dietary plans are individualized. For post-MI patients she typically recommends adherence to the Dietary Approaches to Stop Hypertension (DASH) or Mediterranean diet. Smalling said that when a patient arrives at her clinic, she might spend anywhere from 90 minutes to 2 hours in a consultation. “Education can’t be done in the hospital,” she said. “There’s just too much going on.”

Huggins noted that lifestyle questions—what can I eat? what can I do?—are regularly raised by the patients themselves during their hospital stay. And while that’s often “a nice entry point to having the discussion about changing behavior . . . I will say that a lot of those discussions are ineffective,” he said. “One of the reasons is that the patient generally remembers very little of what is told to them in the hospital. It’s such a strange and foreign environment. Oftentimes, they are sleep deprived, distracted, and have so many other things going on. They’re often not taking in that information in the hospital.”

Instead, Huggins looks toward the patient’s first visit back to his clinic. At that time, he will discuss, among other things, the importance of adhering to their medication, quitting smoking, increasing the amount of exercise, and changing their diet. When speaking with patients, Huggins said he tries to find out what worked for them in the past as well as find out their vices, such as cake, cookies, starchy carbohydrates, or soda.  

“I try in my own limited way—I’m not a dietician—to see if we can’t identify some of the major contributors [to their event],” Huggins said. He added that a discussion about portion control is also helpful, noting that people understand the importance of changing their diet’s composition but are less familiar with what constitutes a standard serving size.

Great Success for Some, Others Not So Much

Smalling said some patients do very well with nutritional and exercise counseling, though others struggle to adhere. In her clinic, there are patients who have lost as much as 8% of their body weight over a couple of months in cardiac rehabilitation, while others simply won’t show up. One patient has returned to rehab six times following different procedures but won’t stick with the recommendations.

“If you have an elephant sitting on your chest, you’ll do just about anything,” said Smalling. “Many of them do very well to start with, but maybe they slack off a little. We do lots of measurements at the beginning of the program and at the end of the program. We can show them what they have been doing and the changes. Some will have no changes, and they’ll admit it’s been hard to adhere. . . . Others, it’s just absolutely amazing.”

She added that it can be daunting for patients who need to overhaul too many things at once. “It’s very hard to figure out what motivates somebody,” said Smalling. “I think they can become unmotivated if they have too much to do, when you make too many changes. I really try to pick my poison. What changes have the biggest bang for the buck?”

For some, however, there may be no substitute for enrollment in formal cardiac rehabilitation programs, even as these continue to evolve. According to the AHA, in follow-up studies ranging from 1 to 15 years, cardiac rehab reduced the risk of all-cause mortality anywhere from 15% to 45%. Participation in a program was also shown to reduce the risk of cardiovascular mortality and lower the risk of hospital readmissions. It is also associated with improved adherence to medical therapy, better control of lipids and blood pressure, and improved exercise performance, among other benefits.

To TCTMD, Balady said the AHA is working to increase awareness about the importance of referring patients to cardiac rehabilitation and to encourage existing programs to think about ways they can make access easier for patients. The use of mobile applications, text messaging, social networks, and videoconferencing, as well as devices including blood-pressure and heart-rate monitors, can increase access while reducing costs for patients.

“There’s not a lot data about these things yet, but it’s coming,” said Balady.