CARDIAC REHAB

Home vs centre-based cardiac rehabilitation
Overview: Cardiac rehabilitation can bring significant benefits to patients following a myocardial infarction (MI). Meta-analyses of randomised trials of cardiac rehabilitation have demonstrated gains roughly equivalent to those from beta-blockers, with a 25 per cent reduction in cardiovascular mortality. Economic studies suggest that cardiac rehabilitation can be justified on financial grounds alone, with a Swedish study showing 51 per cent of rehabilitated patients were at work 5 years after their MI compared with 27 per cent of those not rehabilitated, representing a saving of £6,500 per patient. However, participation has been suboptimal, which patients tend to attribute to difficulties in attending a centre-based rehabilitation course because of time constraints, lack of accessibility or a dislike of groups.
Current treatment: In the UK, a common form of cardiac rehabilitation is a 6 to 10 week hospital-based programme starting 4 to 12 weeks after discharge. Typically the patients participate in an exercise class and attend talks covering heart disease, smoking, stress and diet. There may also be relaxation or stress management classes. During the last decade, home-based programmes have become more common, often built around the Heart Manual's guidance. You can find more information on NHS Evidence - Cardiovascular, in NICE's commissioning guide for cardiac rehabilitation service and NICE guidance on secondary prevention in primary and secondary care for patients following a myocardial infarction.NICE is currently updating its clinical guideline on chronic heart failure and will review the latest evidence for cardiac rehabilitation, with publication scheduled for August 2010.New evidence: A Cochrane systematic review (Dalal et al. BMJ 2010; 340:b5631) of randomised controlled trials compared home- and centre-based cardiac rehabilitation in adults who had experienced a myocardial infarction, angina or heart failure, or who had undergone revascularisation. Most studies had recruited patients with a low risk of further cardiovascular events. There was no difference between the two settings for cardiovascular rehabilitation for mortality, cardiac events, blood pressure, health-related quality of life and other factors. The evidence suggested that adherence might be greater for home-based participants. There was no difference in costs between the two approaches. Taken together, these findings support the continuing development of home-based rehabilitation programmes.Commentary: "This Cochrane review emerges alongside other evidence of telehealth and secondary preventive programme benefits being achieved in the community."The early adoption of home based practices including exercise is advantageous, providing that all rehabilitation needs are met. Individual choice is key."Home and centre based services are not just alternatives, more or less equivalent in outcome on current assimilated evidence. Both options should be included in a prevention and rehabilitation programme."Evidence, that high quality home based cardiac rehabilitation is not a cheap alternative, facilitates an objective discussion surrounding the needs of each individual patient."Today, a cardiac patient's life history could include several cardiac rehabilitation episodes and chronic heart disease register monitoring. Patients are being diagnosed earlier and will live longer, if they adhere to a healthier lifestyle choice and secondary prevention. Towards the end of life patients may develop heart failure requiring closer supervision of exercise prescription, with the need to armchair base it at home, along with other palliative support."We must be flexible and creative to construct the ideal long term care pathways, with optimisation of function at any stage and all rehabilitation components sourced conveniently when required." - Dr Jane Flint, National Clinical Adviser for cardiac rehabilitation to NHS Improvement.