Getting on with life after a heart attack
Americans who have had a stroke or a hip replacement take for granted that they’ll need a few weeks or months of rehabilitation to relearn speech or movement and to figure out how to care for themselves.
But when people have a major heart problem, more often than not they leave the hospital with nothing more than a bottle of aspirin and a couple of prescriptions. They receive very little training and education in how to eat, exercise, manage stress and otherwise pick up their lives and care for their damaged tickers. A study in the Oct. 9 journal Circulation found that among 267,427 Medicare recipients who had suffered a heart attack or had coronary artery bypass surgery, only about 18% had even one session of cardiac rehabilitation within a year of their hospital discharge.
About 1.2 million people suffer a heart attack each year (about 40% of them die), and about half a million of them have had a previous heart attack, according to the American Heart Assn. For more than a decade, evidence has been accumulating that cardiac rehabilitation can reduce the risk of death from a second heart attack by as much 30%.
Called secondary prevention, rehabilitation after a heart attack or other serious cardiac problem is designed to reduce the risk of further heart damage, or even death, while the patient returns to a life as normal as possible. It provides heart-strengthening, supervised exercise, along with nutrition and stress counseling and social support.
And it works. A review of studies in the May 15, 2004, American Journal of Medicine found that patients who had exercise-based rehabilitation for heart disease had greater reductions in blood pressure and total cholesterol and lived longer than patients who did not receive rehabilitation. The American Heart Assn., in a 2002 scientific statement, calls rehabilitation the best way to provide education, counseling and behavioral interventions to reduce future risk.
Medicare and most private insurers pay for rehabilitation therapy. Yet, in most of the country including California, fewer than 1 in 5 heart patients receive such services. For some, it’s because their physicians never wrote a referral. Others get the referral but never follow through.
Patty Block of Long Beach is one who has decided cardiac rehabilitation is worth her time, despite the responsibilities of helping to care for her husband, who has Parkinson’s disease, as well as her 96-year-old mother. Since her Sept. 13 heart attack, she’s been going to the Long Beach Memorial Medical Center Cardiac Rehabilitation Center for one-hour sessions three times a week.
“I’m 67, and I’m just not ready to have my heart go out on me now,” she says. She’s had nutrition counseling and is beginning to learn how long, and at what pace, to walk on the treadmill and pedal on the stationary bicycle, all the while hooked up to an electrocardiograph whose squiggly readings are watched by a nurse.
The use of this therapy varies dramatically in the United States, according to the recent Circulation study. With only 6.6% of heart patients getting rehabilitation, Idaho has the lowest rate of follow-up therapy in the country; Nebraska, with 53.5% of heart patients getting the therapy, has the highest rate.
And in California, with 29 centers listed with the American Assn. of Cardiovascular and Pulmonary Rehabilitation, only 2,642 of 14,389 eligible heart patients in 1997, the year studied, received cardiac rehabilitation after a heart attack or bypass surgery, according to the Circulation report.
Researchers were at a loss to explain the wide geographic variations in follow-up therapy. “It’s recommended more vigorously in some parts of the country, particularly the Midwest,” says Donald Shepard, an author of the study and professor of health policy at Brandeis University. It could be that medical training in some areas promotes prevention more than in other areas, he said, though the study didn’t address that.
How hard a doctor pushes for rehabilitation is the best predictor of whether a patient will follow up, according to research published in the May 1992 issue of Archives of Internal Medicine. Dr. Philip Ades, director of cardiac rehabilitation and preventive cardiology at the University of Vermont College of Medicine, is an author of the Circulation study. He was also the lead author of the 1992 study in which he asked 262 heart patients 62 and older to rate how strongly their doctor recommended cardiac rehabilitation. “If the physician was strong in recommending rehabilitation, 70% of patients participated,” he says. “If it was a weak recommendation, only 2% participated.”
In New York, the referral rate to cardiac rehabilitation is about 13%, says Murray Low, director of cardiac rehabilitation at four hospitals in New York and Connecticut, and president of the American Assn. of Cardiovascular and Pulmonary Rehabilitation. “Do you realize how outrageous that is?” he says. “We spend millions putting in stents, bypassing arteries. And then we say, ‘See you in six months.’ The patient goes home and leads the same lifestyle that led to the problem in the first place.”
There are other barriers to the therapy, says Dr. Randal Thomas, director of the Cardiovascular Health Clinic at the Mayo Clinic. Some patients aren’t aware of the benefits of rehabilitation; others see it as little more than a gym membership; and some simply would have to travel too far to reach a center. “The benefits of cardiac rehabilitation are on the same level as aspirin, beta blockers and statins -- about a 30% reduction in mortality.”
Dr. Henry Van Gieson, a Long Beach cardiologist, says he recommends cardiac rehabilitation for almost all of his heart attack and bypass patients. After a heart scare, “patients start seeing themselves as fragile and vulnerable,” he says. “When you see a patient in your office a week or a month later, there’s no way you can do an adequate job of doing all of the counseling they need. This is a great way to take that first step back to recovery.”
One of his patients, Maurice Greeson, 65, of Long Beach makes twice-weekly trips to Long Beach Memorial. He has used up his insurance coverage of cardiac rehabilitation, following bypass surgery in February 2006, but continues the therapy, paying $45 a month himself. Because he’s been doing well for more than a year, his therapy is less intensely monitored. “This was a lifestyle change, big time,” he says. “This place is relaxed and friendly but with underlying professionalism.”
Greeson is one of a small percentage of people who continue rehabilitation long after they’ve gotten answers to their questions about how long and hard to walk, what to eat and when they can resume sex.
“They feel safe,” says Greg Jones, program director of the Long Beach center. “And it’s very social. People make friends with other people who have the same problems they do. You see a patient who might have been depressed. Then they meet some other patients, and there’s a different person than walked in here the first day.”