The Heart Manual
Cardiac Rehabilitation, a
cognitive behavioural model, the Heart Manual and other topics
Prof. Bob Lewin (12/1/98)
This piece, originally a paper given at a conference
in Oxford, was written for a book, the publication of which was abandoned by
the editors. It is therefore copyright free.
Index
Part 1: The Background
Part 2: The Heart Manual
What is
cardiac rehabilitation?
There is little standardisation in CR practice in the UK and it is sometimes
said that ‘there is no right or wrong way’. Of course, within ethical
and economic constraints, it is immaterial how the ends are achieved but it
would be very wrong to conclude from this, as some have, that any intervention
aimed at post MI patients can be described as CR. It is now abundantly clear
that single modality treatments are largely ineffective. For example, early
rehabilitation programmes concentrated almost entirely on exercise training.
Although this demonstrated that many patients could achieve an improved level of
fitness the results were disappointing as far as the patient resuming a normal
life was concerned. Similarly, two recent, randomised trials of psychological
treatments, both aimed at reducing ‘stress’ in post MI patients have shown
no benefits1,2. Unfortunately these widely publicised results have
been taken by some to show that CR has no value, a conclusion that flies in the
face of all of the published reviews. The World Health Organisation has produced
a briefing letter setting out a model for CR recommending that it should
include; exercise training, relaxation and stress management, secondary
prevention and attention to the patient’s psycho-social adjustment. It stated
that rehabilitation should start as soon as the patient is medically stable and
that partners and other family members should be included in the process3.
back to index
The evidence for CR
Meta-analyses of randomised trials have demonstrated gains roughly equivalent
to those from beta-blockers, with a 20-25% reduction in total mortality and a
20% reduction in cardiovascular mortality 4,5. Economic studies
suggest that CR can be justified on financial grounds alone. In a Swedish study
of a comprehensive rehabilitation programme 51% of rehabilitated patients were
at work five years after their MI compared with 27% of those not rehabilitated.
This appeared to be due to lower levels of anxiety and depression and fewer
acute events. The authors concluded that this represented a saving of $10,000
per patient6. Some trials, but not others, have shown that CR can
produce improvements in quality of life and psychological adjustment7.
Recent evidence suggests that patient with heart failure8 and angina9
may also benefit. back
to index
Exercise training
Many randomised trials have shown that patients can achieve increases in
maximal functional capacity between 11%-56%. It is often asserted that exercise
helps to reduce anxiety and depression in post MI patients but there is
considerable evidence that it does not bring about any clinically
useful, medium or long-term, improvement or result in improved rates of return
to work7. It has been reported that in some centres as many as 50% of
patients drop-out of treatment before the end of an exercise programme and
follow-up studies have reported that as few as 30% may still be exercising one
year later10. Exercise does not need to be intensive to bring its
benefits11 and it has been shown several times that home based
exercise programmes are as effective as supervised hospital based programmes 12,13.
Brisk walking for 15 to 20 minutes, preferably daily or at least 5 times per
week, is adequate exercise for most post MI patients and for the great majority
of post MI patients exercise appears to be very safe10.
back to index
Psychological
adjustment to CHD
Reviews of the literature eg.7 have established that 15-25% of MI
patients remain clinically anxious or depressed indefinitely and that this
anxiety often leads to undue illness behaviour and the unnecessary use of health
resources. Relationship and sexual problems have been reported in 20-58% of
patients. In the weeks and months following MI the patient’s partner and other
family members may be as, or even more, upset than the patient. It has been
shown that poor psychological adjustment is not related to the severity
of cardiac illness but is predictive of subsequent mortality. It is
important to remember that a poor psychological outcome is far from inevitable.
In fact, without rehabilitation, as many as 40% of patients report that their
quality of life is ‘just as good’, or ‘better’ than it was before the
heart attack and 15% report that it has improved their sex
life!
back to index
Lifestyle change
There is no doubt that for many patients lifestyle changes are worth making.
A smoker who quits after an MI can expect a 50% reduction in their risk of
mortality in the next 5 years. Dean Ornish and others have shown that dietary
changes and exercise can produce a halting or a regression of coronary artery
disease 14. The value of group lectures in bringing about change
appears to be small but new approaches that use cognitive-behavioural methods
have been tested and, from these early reports seem encouraging7.
back to index
Relaxation
and Stress Management Training
Adding relaxation training to a post MI exercise programme can improve
training success and reduce ST segment abnormalities. Follow-up at 2-3 years
revealed that patients who received both treatments had significantly fewer
cardiac events (17% Vs 37%) than those who had undergone exercise training alone
15. Stress management training (SMT) programmes extend relaxation
training by including additional techniques. A controlled comparison between SMT
and relaxation showed that at six months the SMT patients had fewer cardiac
complications (10% Vs 31%) than those who had had relaxation alone16.
back to index
The
organisation of cardiac rehabilitation services
In the UK the most common form of CR is a 6-10 week hospital based programme
starting about 4-12 weeks after discharge. Typically the patients attend for an
hour or more once a week when they take part in an exercise class and a
programme of talks. These are usually delivered by a nurse, physiotherapist or
dietician and cover topics such as heart disease, smoking, stress and diet.
According to the skills available to the programme there may also be relaxation
or stress management classes
. back
to index
Current
deficiencies in the provision of cardiac rehabilitation
Exclusion. People who have transport problems, country dwellers,
women, ethnic minorities, the elderly, the disabled, the very poor, smokers and
depressed patients are less likely to attend hospital based programmes. In a
number of centres arbitrary criteria, often set by physicians who otherwise take
no interest in the programme, may exclude those with angina, any degree of heart
failure, physical disabilities or those over a certain age. Patients who are not
admitted to hospital because the MI is not discovered until it has resolved, or
who are admitted to general wards may be missed. Although some programmes invite
the families of patients to attend few do. The fact that many programme do not
start for up to 12 weeks post discharge means that many patients are back at
work by the time they are due to start. Attendance is voluntary. The result is
that in general, attendees are the motivated, with independent transport, mild
levels of disease and very little in the way of residual disability. A further
problem is the patchy nature of the current provision, large areas of the
country have no provision. A survey conducted in 1996 identified 273 programmes,
rehabilitating a total of approximately 50,000 patients a year not all of whom
were post MI patients17. This suggests that less than 1 in 3 of those
surviving an MI receive any form of
CR. back
to index
Regimented programmes. The UK guidelines suggest that programmes
should be ‘menu-based’. The patients rehabilitation needs are assessed at
entry to the programme and only the required components provided18.
At present almost all UK programmes follow a routine protocol of exercise and
talks and each patient is expected to take part in every element. Lifelong
non-smokers and vegetarians are lectured on the dangers of smoking or the need
to eat more vegetables and bread. Patients who have always exercised and are
relatively fit take part in low level exercise programme when they could simply
be given advice about resuming their exercise habits. Patients who are not
anxious or ‘stressed’ take part in relaxation and stress management
classes. back to index
Lack of assessment and audit. At present, few programmes practice
any valid form of assessment, other than an exercise test. Even fewer repeat the
assessments at the end of the programme to check that the desired gains have
been made17.
Quality. Most programmes were initiated by a nurse or
physiotherapist who saw an unmet need and took the initiative. These individuals
are often dedicated, hard working and only too aware of the deficiencies of the
service they provide. The programme often exists in an unbudgeted no-mans land
of time and resources ‘borrowed’ from other departments.
Although the majority of programmes claim to be multi-disciplinary and cite
four or five professions as ‘members of the team’ they often have no real
access to the time or skills of these professions. For example, most programmes
have a dietician who gives a talk, but in a recent survey we could not discover
any that carried out a validated assessment of the patients diet17.
To be effective in helping patients reduce their cholesterol level or loose
weight it is surely necessary to assess their diet and to work with an
individual patient over several weeks. In the UK there is virtually no practical
input to programmes from psychologists or doctors 17
In the UK there is no professional clinical training course for CR and those
staffing the programmes are often unaware of the years of previous research and
its main findings.
Lack of attention to secondary prevention. Few of those running CR
programmes see it as within their remit to check for appropriate medical
treatments for secondary prevention. back to
index
The
case for providing CR in the community
Post MI rehabilitation is increasingly taking place in the community. What
advantages are there in this approach?
- primary care is better placed to identify all patients in need
- The British Cardiac Society have stated that the responsibility for
secondary prevention rests with Primary care19 and an acute event
is often the best time to identify high risk patients for secondary
prevention interventions
- patients live within a family and community known to primary care
- for many patients, especially the elderly and unwell, cardiac centres are
awkward to access, busy and anxiety provoking environments
- it is easier to involve the whole family in a community based programme
- the elderly and the disabled can be seen at home and work at their own
pace
- primary care purchasing groups are well placed to organise and manage
appropriate local services
There are, of course, some disadvantages in moving CR to the community. In
large rehabilitation centres the staff are often working in, or have recently
worked in, cardiology. They see large numbers of patients every year and can
build up a high level of expertise. These problems can be overcome if community
rehabilitation services are organised across GP Practices so that the staff see
enough patients every year to develop similar expertise and if a good system of
liaison with the local cardiology service can be established by those involved
in the programme.
It is often said that patients benefit from meeting with their peers in group
treatment sessions. There is no evidence for this and it is equally true that
there are people who do not like group activities. One solution, for those
patients who do wish to have contact with fellow ‘sufferers’, is to join a
local ‘cardiac support group’. There are many of these across the UK and if
there is not a local one, it is relatively easy to establish one with the
guidance and practical help available from the British Heart Foundation.
A more important problem is one of risk management. The great majority of
post MI patients can exercise safely in the community. Those who wish to return
to very demanding sports or other activities may require exercise testing and
specific exercise advice from a cardiologist. The safety of any treatment can
only be established with extensive clinical experience and the data is not yet
available for CR programmes designed especially for patients with heart failure
or chronic angina. These patients may achieve physiological and symptomatic
benefits from exercising at a greater intensity than that required for secondary
prevention in MI patients. At present it is best to assume that these patients
require greater caution and that they should be screened by exercise tolerance
testing prior to beginning an exercise programme. At present few programmes
exist for these patients in the UK. Moving routine post MI programmes to the
community might have the added advantage of freeing up resources in
hospital-based programmes so that they could offer special programmes to these
patients.
In reality neither venue holds all of the advantages and the best solution is
likely to be shared management that provides a seamless service between
secondary and primary care with each performing those parts it does best. An
attempt at such a solution, built around a system called the Heart Manual, is
described in the final section of this
chapter. back
to index
What is the Heart
Manual?
The Heart Manual (HM) is a comprehensive rehabilitation method for post MI
patients that was developed and evaluated with research funding from the
Scottish Office. It approaches the task of rehabilitation from a cognitive-behavioural
framework. To understand what this means and why the HM differs from other
approaches will involve a brief detour.
In the early days of CR it was believed that strengthening the undamaged
areas of the heart muscle through exercise would compensate for any impairment
caused by the infarct. However, by the mid 70’s it had become clear that many
patients, although achieving improved fitness and having little or no
discernible residual impairment were still living an unnecessarily restricted
and fearful life. Again and again the size of the infarct was shown to have
little bearing on the residual disability. Psychologists became involved in
trying to understand why this should be so and over the succeeding twenty years
it became increasingly clear that the reasons were a complex mixture of
psychosocial factors. A number of demographic predictors were identified, these
included; a manual job, lower socio-economic status and being younger. Less
expected was the finding that amongst the strongest predictors of poor recovery
would be the patients perceived health status, beliefs about heart disease
called ‘cardiac misconceptions’ and the patients belief about what ‘actually
caused’ his or her heart attack. back to index
Perceived
health status following a heart attack
Mæland demonstrated the profound effect that MI has on patient beliefs about
their health; 67% of patients rated their pre-MI perceived health as high, this
was reduced to 21% at discharge, 31% at six weeks and 42% at 3-5 years. Almost
all improvement was seen in the first six weeks of convalescence. There was no
significant relationship between perceived health and the severity of the MI or
other medical variables but perceived health was predictive of psychological
recovery, return to work and readmission to hospital20.
Cardiac Misconceptions
Wynn21 identified the most common reasons for psychological
distress or undue illness behaviour following MI. He identified a number of
common problems; 22% percent of patients were considered by him to have had the
majority of their anxiety caused by medical attendants,
"often it was the symbolic significance of the doctors remarks, rather
than his words, which did so much harm. In the convalescent phase, some
patients interpreted comments such as "you will be alright if you are
careful" as, "If I am not very careful I will die".
He believed that in 38% of cases the distress was primarily due to an
inadequate understanding of what had happened. Patients made comments such as
"half my heart is dead and the other half is
dying". back to
index
Beliefs about the
cause
Feilding22 interviewed 102 serial admissions to the CCU for
acute MI. Patients listed factors that they "….felt caused their heart
attack" in order of perceived importance and then rated them for
controllability. All patients had been strongly advised to stop smoking and had
received other health education relating to their MI. The primary causes most
frequently given were; overwork, smoking and worry. Patients believed that the
psychological causes were more important than all of the biological causes, with
the exception of smoking, and the biological causes were generally seen as more
controllable than the psycho-social causes.
The
cognitive-behavioural approach to rehabilitation
It is implicit in the cognitive-behavioural explanation of disability that
mistaken beliefs lead to mistaken, albeit logical, attempts to reduce risk. For
example, the belief that, after an MI a person is perpetually at risk of sudden
death leads some patients to behave in a manner that they regard as reducing the
chance of this happening. This is often resting and being careful not to ‘overdo
things’ by no longer playing boisterous games with grandchildren, giving up
sporting activity, taking early retirement and so on. They are aware that that
they could do these things but regard them as risky. Many patients regard the
ability to do things and the risk of sudden death as unrelated. This
assumption is not unreasonable given that many of them had manual jobs and were
physically fit at the time of the MI and that athletes and other fit people
sometimes ‘drop dead’.
Patients who believe that they are very ill also tend to monitor somatic
sensations more closely than before in an attempt to spot and avert any new
problems. Feelings of fatigue, breathlessness on exercise, or minor non-cardiac
sensations from the chest may be interpreted as a further deterioration in
health. This often leads to a reduction in social and physical activity and an
increased preoccupation with symptoms and can become a vicious circle if the
patient loses sufficient fitness to develop increasing symptoms of fatigue or
angina. It is hardly surprising that patients who believe this also consult
their doctor more readily.
Faulty causal attributions may lead to some activities being dropped whilst
others are maintained or increased. For example, if a patient regards his work
as his main cause of stress and stress as the main cause of his heart attack the
obvious thing to do is to stop working. He may not regard smoking as anything
like as dangerous. Indeed he may regard the stress of trying to quit and the
domestic rows it causes as more lethal than smoking itself and therefore
continue to smoke. Of course avoiding stress often has other consequences. For
example, giving up work may lead to financial and housing problems, a perceived
loss of power within the family and feelings of guilt at the families’ reduced
circumstances.
back to index
The
implications for treatment of the cognitive-behavioral model
This explanation raises the possibility that reversing these beliefs may
reduce disability and this was the basis on which the HM was designed. The
content of the HM used by a specially trained facilitator, attempts to reverse
these damaging beliefs and mistaken coping strategies. This is achieved partly
through re-education and partly through using alternative strategies, such as
carefully planned increased in activity.
Examples of the cardiac misconceptions that are specifically targeted are:
- my heart is worn out by years of worry (or stress, or overwork)
- the safest course of action is to withdraw from an active lifestyle
- any form of excitement or arousal could trigger a further heart attack
- once you’ve had a heart attack there is nothing you can do to reduce
risk
The HM facilitator is asked to spot these misconceptions and is shown ways to
discuss and hopefully reverse them. Improved coping strategies are taught to the
patient. For example, one of the biggest problems facing patients and their
caregivers is knowing when it is safe to return to various activities. Some
rehabilitation programmes give out a list of activities with advice about the
number of weeks that should pass before patients can start them again. This
method is unhelpful. Firstly, because it is too inflexible, some younger
patients with mild MIs will find it too restrictive and older patients may find
it too demanding. Secondly, there is that there is no way it could possibly be
standardised or cover every eventuality. For example, the suggestion
"return to gardening at 4 weeks" is meaningless unless you know what
kind of gardening, at what time of year and with what implements! Finally, it
reduced the patient to a passive recipient of information, forever dependent on
a ‘experts’ permission to act. The HM teaches patients a method that they
can use to answer all such questions, it is based on ‘self perceived exertion’.
Patients judge how hard they find a task on a sliding scale of effort from ‘too
hard’ to ‘too easy’. Initially they use a visual analogue scale to do
this. Then they carry out that task at a level that is in the middle of the
range practising regularly until this level becomes ‘too easy’ when they
step up the level of activity. For patients who still struggle to return to a
normal activity level facilitators are shown an additional technique, originally
developed in the management of chronic pain, ‘pacing and goal setting’.
Patients frequently fear that their personality has been permanently changed
in the days and weeks after an MI. They may become weepy, or experience the
symptoms of acute anxiety for the first time in their life. When they get home
most are less able than they expect to be and often view this as a setback. A
lower mood after discharge is almost universal and has been called homecoming
depression. Patients are often grumpy and uncommunicative with their partner.
The manual specifically warns patients and partners of these possibilities and
explains them as due a temporary increase in adrenaline levels that will abate
over time, especially if they use the relaxation and other techniques in the
HM. back
to index
Development
and evaluation of the HM
The HM was developed over a period of a year. Individual, and later small
groups, of patients were presented with sections of the HM and asked to work
through them. As each week’s assignments were completed they were questioned
to discover which parts had been complied with and found useful. Each section
was repeatedly rewritten in the light of this feedback.
The main features of the system are;
- a six-week home based programme consisting of written materials, a work
book to record progress and 2 audio tapes
- a specially trained facilitator guides the patient and their family in its
use
- it provides all of the elements of a comprehensive rehabilitation
programme, exercise, health education and attention to psychological
sequelae.
- it can be used in primary, secondary or community settings
- it is suitable for the majority of post MI patients
Contents of the
Heart Manual
The Heart Manual contains:
- the answers most often want (and sometimes don’t ask) following MI
- an explanation of what happens in an MI deliberately constructed to
undermine misconceptions and faulty attributions
- a simple home based exercise programme leading to brisk walking
- a systematic method for pacing activity levels back to normal
- simple advice as to what to do in the event of a further suspected heart
attack
- advice about risk factors and lifestyle change
- a six week relaxation and stress management programme
- vignettes of typical patients’ experiences in recovering from heart
attack
- quizzes specially designed to trap misconceptions
- an audio cassette for the partner and the family giving advice on how best
to help the patient and themselves, after discharge
- information about the most commonly used cardiac medications
- short self-administered questionnaires designed to determine if the
patient is having adjustment problems (e.g. anxiety, sexual relations, panic
attacks)
- special sections of self-help advice, including appropriate advice on
asking for a specialist referral, to be read if the patient has
identified adjustment
problems
back to index
Treatment
protocol of the Heart Manual
In order to make the HM as cost effective as possible, in the trial, the
facilitation was conducted by phoning the patient and conducting semi-structured
interviews at one week, three weeks and six weeks after discharge. The
facilitator introduced the patient to the HM using a specially devised interview
designed to "hook" and motivate them and their partner. The initial
interview took place one or more days prior to discharge. At the initial meeting
the correct way to do the exercises, the method of self-recording increasing
fitness and the method for increasing the amount of exercise was shown to the
patient. Wherever possible the patient’s partner, or another family member,
was encouraged to join in with the programme and help the patient to adhere to
it. Partners were given an audiocassette of information to take home and listen
to, this was designed to reduce their anxiety, reduce their misconceptions and
encourage compliance. Wherever possible spouses were also spoken to during the
phone calls. Within these brief interventions patients were asked to rate their
confidence (out of 10) in their ability to make a full recovery and the degree
to which they felt they have achieved a recovery.
Randomised
trial of the Heart Manual
The first evaluation of the HM was at a General District Hospital, St Johns
in Livingston. The main catchment area for the hospital is West Lothian, a
deprived ex-mining area with high rates of coronary disease and unemployment. A
total of 176 patients were randomised, stratifying for age, social class and
anxiety into a group that received the HM and a control group. The control group
received a package of leaflets from sources such as the BHF, the Flora Heart
Campaign and the Scottish Health Promotion Group about MI and lifestyle change
in CHD. They also received the same protocol of phone calls at weeks 1, 3 and
six post discharge, from the facilitator who asked them the same questions as
the HM group but leaving out any mention of the HM. She answered any questions
they had in a truthful manner. The main results were a significant reduction in
anxiety and caseness on the General Health Questionnaire, a reduction in visits
to the GP in the first 6 months after discharge and a reduction in readmission
to hospital. The incidence of clinical anxiety was reduced by 50% in the HM
group23.
Similar results were obtained in a partial replication conducted in a London
teaching hospital 24 and HM has been successfully evaluated in
clinical use in more than 16 local pilot studies for purchasers. It is
increasingly being tried out abroad; American, Dutch and Italian versions are
currently under trial. back
to index
Clinical
dissemination of the Heart Manual
Following publication of the results of the randomised trial in 1992 the
British Heart Foundation, the Scottish Office and the Edinburgh Healthcare NHS
Trust initiated The Heart Manual Project. The HM Project is a non-profit making
NHS organisation that provides support for the Heart Manual within the health
service. It maintains an office and 3 staff at the Astley Ainslie Hospital in
Edinburgh where it arranges the printing, distribution and when required the
updating of the materials. It conducts and monitors the training of HM
facilitators and ‘facilitator trainers’. The project disseminates ‘evaluation
packs’ and copies of the many local audit reports to those interested in using
the HM.
To maintain quality, as well as for safety reasons, the HM is not supplied
directly to the public, or to untrained staff and the project maintains a
register of ‘qualified’ facilitators. At the time of writing, the number
stood at 1,050 of whom the majority are nurses and health visitors in primary
care or community trusts. The facilitator training is an essential part of the
method. It introduces the standardised interviews, audit and additional
educational material that are an integral part of the system. Facilitators are
shown how to cope with any problems that may occur. There is a regular programme
of training days throughout the year in Edinburgh. In areas where there are many
heart manual facilitators local trainers have been trained so that replacement
and additional staff can be trained for that area. As yet unpublished data
suggests that the quality of the facilitator and the degree to which they adhere
to the protocol is a major variable in the degree of benefit produced by the HM
system.
The HM is currently in routine clinical use in approximately 125 different
locations. In the year 1997-8, more than 5,000 patients took part in the
programme, a number approximating to 10% of all those receiving cardiac
rehabilitation in the UK that year17. Users range from a
single-handed GP practice, to several entire Health Authority or Health Board
areas. In secondary care it is used in a number of ways. Some programmes use it
for those patients who live too far away from the hospital to attend. Some give
it to patient in the first six weeks after discharge whilst they are waiting to
attending a hospital based programme. In some it is the main programme.
In a number of areas of the country, for example; Dumfries and Galloway,
Northumbria, Cumbria, Avon, Tyneside it is used as a cross-district method. Each
of these areas has a cohort of community based facilitators who liase with the
acute hospital to identify and recruit patients. In some of these schemes the
manual is introduced to the patient during the hospital stay in others after
discharge. Most of the community based facilitators have chosen to make home
visits to conduct the structured
interviews back to
index
The East Riding Scheme
The advantages and disadvantages of community verses hospital based CR have
been discussed above. The ideal solution may be to utilise the expertise of
both. A scheme designed for East Riding Health and currently in the first stages
of its implementation is designed to achieve this aim.
We have seen that many patients make a good recovery and achieve the required
lifestyle changes spontaneously and that even more achieve a good outcome with
the use of the HM. Inevitably there remain some patients who appear to require
more than a simple self-help approach can provide. It is not possible to
identify these patients in advance so the method of triage adopted in this
scheme is for all patients to use the HM system after which their remaining
needs are assessed using validated assessment measures. On the basis of this
assessment patients will be triaged to one of three dispositions,
- Patients for whom the Heart Manual has been sufficient will be discharged
with an invitation to join the nearest patient support group.
- Patients with only one or two remaining needs will be referred to the
appropriate specialty (e g. dietitian, physiotherapy, psychologist).
- Patients whose remaining needs are complex, or many, will be referred to
one of the current multi-disciplinary hospital based programmes in East
Yorkshire.
At the centre of the system is a computer database. Trained facilitators on
all of the wards, in each of the trusts receiving MI patients in East Yorkshire
will supply the name and address of every new MI patient to a clerk who will
enter it onto the database. At discharge the clerk will alert one of 24 health
visitors facilitators that the patient has been discharged, with the HM. The
Health Visitor will act as the post-discharge facilitator for the HM.
At 6 weeks all patients will receive the formal assessment of their needs
using validated and standardised questionnaires. The assessment will follow the
National Guidelines for Cardiac Rehabilitation18 and will include; -
- lifestyle change- smoking, diet, exercise.
- psychological adjustment- anxiety and depression.
- quality of life
- social assessment- inc. return to work, need for referral to social
services.
- medical status- use of beta-blocker and aspirin, new symptoms and blood
pressure
these measures will be administered by the community HM Facilitator.
The patients’ GP and cardiologist will receive a letter informing him or
her of the findings of the assessment, including whether the patient is taking
aspirin or beta-blocker as recommended. Any other needs the patient may have
will be highlighted and their agreement to the triage decision will be sought.
The community-based facilitators will repeat the assessment at 6 months to
provide an audit of the success of the scheme and to make any adjustments to the
scheme that this reveals.
The model has the following advantages;
- it uses an evidence based treatment
- it follows the recommendations for individual assessment of need
- all post MI patients regardless of their area of residency receive the
same care
- it shares care and information between primary and secondary sectors
- much of the structure and personnel are already in place
- it provides an audit
- it may, based on previous trials reduce the use of medical services
- it may improve the uptake of secondary prevention measures (eg. use of
aspirin and beta-blockers) which may significantly reduce reinfarction and
medical costs
- it could be the first step in establishing a central cardiac register for
all CHD patients that could be used to improve the management of CHD
back to index
Conclusions
- all authoritative reviews have agreed that the majority of patients benefit
from CR
- benefits include, reduced morbidity and mortality, improved quality of life
and lower medical and social costs
- CR must includes attention to secondary prevention and psychological
sequelae
- less than a third of the 150,000 MI survivors in the UK receive CR
- many programmes are poorly supported and do not meet UK guidelines
- those who attend may be those with the least need for rehabilitation
- the HM appears to be a useful way of delivering CR in the community
- it has been enthusiastically adopted into practice in many parts of the
country
- it has helped to make CR geographically equitable in areas that have adopted
it
- its best use may be as part of a system of shared care of CHD
Further information about the HM can be obtained (here) or by contacting Mary
Ramsay, The Heart Manual Project, Astley Ainslie Hospital, Grange Loan,
Edinburgh. EH9 2HL
References
- Jones D.A., West R.R, (1996) Psychological rehabilitation after myocardial
infarction: multi-centred randomised controlled trial. BMJ, 313: 1517-1521.
- Frasure-Smith N, et.al, 1997, Randomised trial of home-based psychosocial
nursing intervention for patients recovering from myocardial infarction. Lancet,
350:473-79
- WHO (1993) Cardiac rehabilitation and secondary prevention: long term care
for patients with ischaemic heart disease. Briefing letter, regional office
for Europe, Copenhagen, Denmark.
- Oldridge, N.B., Guyatt, G.H., Fischer, M.E., Rimm, A.A., (1988) Cardiac
rehabilitation after myocardial infarction, combined experience of randomized
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