Cardiac Rehabilitation
Patient Perspective Paper 4
These notes are a patient’s view on the situation on cardiac rehabilitation, particularly for those with an ICD. They follow an interesting talk
given to an ICD seminar in Oxford by Marion Elliot of JRH.
I must emphasise once again that notes such as these are very much my personal interpretation and I apologise
but take no responsibility for any inaccuracy. If you are worried in any way concerning your own position, please consult
your own doctor or consultant.
Introduction.
The aim of CR is to return people who have experienced a heart condition to return to normal life as soon as possible. If carried out correctly, it should help people to make life-style changes and therefore reduce the fear and occurrence of further heart attacks. It is however part of an overall strategy for the well-being of the patient following a spell in hospital. Unfortunately at the moment those who have been fitted with an ICD do not automatically get CR unless there are some other problems associated with their heart: it is hoped that release of resources might allow a change of this policy by the end of 2008.
It is important that any CR programme is not restricted to medical matters. It should include psychological and social considerations.
It should involve other members of the patient’s family and also any carer. There should be a comprehensive personal assessment of cardiac risk
and should include follow-up (possibly by telephone) and education seminars as well as the more obvious gym sessions. All this does not always happen but Marion through her work at Oxford and Banbury is willing to put people in touch with heart groups staffed by volunteers in our area.
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We carry a list of these contacts and details of Marion’s programme at the Horton in Banbury on our website.
Phases of CR.
The usual pattern is:
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Information sessions over 6 weeks
- Pre-exercise assessment (possibly done individually).
- A series of exercise sessions done over a period of 6-10 weeks.
- Exercise maintenance done in an outside group, or supervised in a gym or through a home exercise programme.
In my case I was given the series of information and exercise sessions. When I joined the outside group(in Bletchley), I found it unstimulating and, as it was on a fixed day in the week, I found it difficult to get to the sessions regularly, because of my conference work which took me out of the area.. The staff there would not let me move between the alternative sessions they did on other days so in the end I gave up the struggle to keep it up.. I therefore decided to enrol through my GP at my local gym in Buckingham. I found the staff there fairly unsympathetic and certainly not knowledgeable about someone in my condition and they gave me the most incredibly boring exercise work (amongst lycra clad females!). I therefore decided to work up a walking programme and I have taken up line-dancing (again with great number of females!), which I find gives me some exercise and a lot of fun. I quote my example to show that a structured physical CR programme is not easy to maintain.
- See my Occasional Paper No 3 on Physical Activity.
Risk factors.
- A patient is able to alter levels of cholesterol, blood pressure, obesity, physical activity, alcohol intake, smoking and stress.
- A patient is not able to alter diabetes, family and genetic factors, their age or gender.
High blood pressure. A target blood pressure might be 140/85 or, if you are diabetic 130/80. A high blood pressure makes you more at risk from stroke or heart attacks and, if untreated, can cause kidney problems. As you get older, it becomes more common and, of those of 60+, six out of 10 experience it.
Control of blood pressure will be helped by more physical exercise, avoidance of obesity, reduction of salt in a diet, reduction of alcohol consumption, quitting smoking, eating more fruit and veg and taking appropriate medication.
Healthy eating and drinking.
The summary of the factors might be:
- 5 portions of fruit and veg. Fresh or frozen fruit better than tinned. Potatoes do not count. Try and include a dessert bowful of salad at least once or twice a week. 150 ml of fruit juice counts as one portion.
- Reduction of fat intake. Replace saturated fats (found in butter, hard cheese, lard, ghee, coconuts and palm oil) by mono or polyunsaturated fats (found in olive oil, walnuts, rapeseed, avocado, cornflower, sunflower, soya and fish).
- Ways of avoiding fats might include the trimming of fat from meat before cooking, grill, steam or poach rather than fry, the cutting out of anything fried (those lovely chips), crisps, cakes, biscuits and fast foods and full-fat milk and the inclusion of reduced fat spreads, yoghurt and low fat cheese.
- Use unsaturated oils for cooking.
- Eat 2 portions of oily fish per week (eg herring, mackerel, pilchards, sardines, trout and fresh (not tinned) tuna.
No more than 6 gms of salt per day. This is not very much. A lot of processed food contains salt (even things like Allbran and tinned soup). Avoid fast food. Don’t add salt when cooking.
- Control alcohol intake. Maximum 21 units for men or 14 units for women per week. A unit is about 125 mls of wine or half pint of beer. Beware that pubs and restaurants often now serve wine in 250 ml glasses.
- See my Occasional Paper no 1 on Food
Physical activity.
The aim is to do at least 30 minutes of moderate exercise on at least 5 days out of 7 in any week. Any activity should be enough to get you slightly out of breath. As I have mentioned earlier, it is important to do something you enjoy and preferably in the company of others with whom you find agreeable.
In my case I found the structured walking programme quite helpful and I did it round my local Broughton Park. The recovery stages after leaving hospital might be:
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1. 5 minutes – several times a day
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2. 10 minutes strolling at least twice a day
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3. 15 minutes once or twice a day up to a moderate pace
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4. 20 minutes daily at a moderate pace
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5. 25 minutes daily at a brisk pace
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6. 30 minutes daily at a brisk pace to reach the target mentioned above.
Exercising with an ICD.
Considerations might be:
- Carry your ICD card with you at all times and take your GTN spray with you.
- Contact sports should not be undertaken (I had to give up my beloved cricket!).
- Always warm up and cool down.
- Avoid heavy lifting and get advice in the gym.
- In recreational activities have someone around, particularly when swimming.
- Only exercise when you are feeling well.
- Wear appropriate clothing and do not exercise in extremes of temperature.
Try and do exercise to a point where you can just carry out a conversation but stop exercising if you experience:
- Chest pain (use your GTN spray)
- Excessive shortness of breath
- Nausea or dizziness
- Persistent palpitations
- Muscular aches or pains
- You feel unwell.
Experts may be able to give you advice as to how your ICD is programmed for the type of anti-tachycardia pacing or shocks and how long episodes might last before therapy is delivered by your ICD in your case. Medication will affect your ability to do certain types of exercise.
GCS/03.06.08
Geoff Shaw