Topic Overview

What is cardiac rehabilitation?

Cardiac rehabilitation (rehab) teaches you how to be more active and make lifestyle changes that can lead to a stronger heart and better health. Cardiac rehab can help you feel better and reduce your risk of future heart problems.

In cardiac rehab, you work with a team of health professionals. Often the team includes a doctor, a nurse specialist, a dietitian, an exercise therapist, and a physiotherapist. The team designs a program just for you, based on your health and goals. Then they give you support to help you succeed.

If you have a heart problem or had surgery, you may be afraid to exercise. Or if you have never exercised, you may not know how to get started. Your cardiac rehab team will help you start slowly and work up to a level that is good for your heart.

Many hospitals and rehab centres offer cardiac rehab programs. You may be part of a cardiac rehab group, but each person will follow his or her own plan.

Who should take part in cardiac rehab?

People with many types of heart or blood vessel disease can benefit from cardiac rehab. Your doctor may suggest cardiac rehab if you have:

• Had a heart attack.
• Coronary artery disease with stable angina.
• Heart failure.
• Had angioplasty or bypass surgery.
• Had heart valve surgery.
• Had a heart transplant.

Often people are not given the chance to try cardiac rehab. Or they may start a program but drop out. This is especially true of women and older adults. And that's not good news, because they can get the same benefits as younger people. If your doctor suggests cardiac rehab, stay with it so you can get the best results.

What happens in cardiac rehab?

In cardiac rehab, you will learn how to:

• Manage your heart problem and other conditions you may have such as high blood pressure and high cholesterol.
• Exercise safely.
• Take medicine correctly and safely.
• Eat a heart-healthy diet.
• Lose weight.
• Quit smoking.
• Reduce stress and depression.
• Get back to work sooner and safely.

Exercise is a big part of cardiac rehab. So before you get started, you will have a full checkup, which may include tests such as an electrocardiogram (EKG or ECG) and a "stress test" (exercise electrocardiogram). These tests show how well your heart is working. They will help your team design an exercise program that is safe for you.

At first your rehab team will keep a close watch on how exercise affects your heart. As you get stronger, you will learn how to check your own heart rate when you exercise. By the end of rehab, you will be ready to continue an exercise program on your own.

Changing old habits is hard. But in cardiac rehab, you get the support of experts who can help you make new healthy habits. And meeting other people who are in cardiac rehab can help you know that you're not alone.

What are the benefits of cardiac rehab?

Cardiac rehab may also help you to:

• Have better overall health and a better quality of life.
• Lower your risk for a heart attack or dying from heart disease.
• Recover well after surgery.
• Manage your symptoms.
• Feel more hopeful and less depressed, stressed, or worried.
• Have more energy and return to your usual activities.

Phases of Cardiac Rehab

Cardiac rehab is a program designed specifically for you and your medical needs. It includes exercise, lifestyle changes, education, and emotional support. It can help improve your health and enable you to live a more active life. Cardiac rehab can also help you return to work safely and in a timely manner.

You may start a cardiac rehab program while you are still in the hospital after having treatment for a heart attack or other heart problem, soon after leaving the hospital, or at any other time to help prevent future heart problems, improve the quality of your life, and make you healthier. Your doctor will give you an exercise prescription that gives you and your cardiac rehab team guidelines for the frequency, duration, and intensity of exercise. The prescription will be based on your medical condition and your fitness level.

How fast you recover depends on your age, your health, and whether you have other health conditions that may slow your recovery. A younger person without other health problems may improve more quickly than an older person who is in poor health. Depending on your condition and how you respond to rehab, you may stay in a certain phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase.

Cardiac rehab can have three or four phases. The number of phases depends on your program. Your doctor will determine which phase is best for you to start your program.

Inpatient program

A hospital program takes place in the hospital after you have experienced a heart attack, heart surgery, or other major heart problem. A hospital program usually includes:

• Determining how well you can care for yourself (bathing, dressing, and grooming) after your heart attack or surgery.
• Measuring your ability to exercise. Your doctor will probably want you to have an exercise test before you begin your cardiac rehab exercise program. This test will show what types of exercise are safe for you and how soon you can begin to exercise.
• Identifying which daily activities, such as lifting, you can safely do.
• Providing patient and family education about the lifestyle changes you need to make, such as eating healthy foods and quitting smoking. Changes in your diet may be difficult to make. But even small changes can help improve cholesterol levels and improve your health. For ideas that can help you get started, see:
  • Heart Disease: Eating a Heart-Healthy Diet.
• Doing light exercise, such as walking short distances several times a day and possibly beginning a weight-training program.

Outpatient programs

Cardiac rehab can include programs at home and at rehab facilities. Your rehab team will keep a close watch on how exercise affects your heart and how you are progressing, before gradually releasing you from supervision to continue cardiac rehab on your own. The healthier lifestyle you've learned—including eating a balanced diet, exercising regularly, and not smoking—can then become a way of life for you.

During this time you may also see your doctor regularly to treat other medical conditions, including high cholesterol and high blood pressure.

Cardiac rehab may include a home program, an outpatient rehab program, and a maintenance program.

These programs usually include:

• Close monitoring and supervision during the early part of your exercise program.
• Preparing you to return to work and the recreational activities you enjoyed before your heart problems. Your work or leisure activities may need to be modified.
• Providing education and counselling for you and your family to help you keep a lifestyle of healthy habits that will lower your risk of having further heart problems.
• Taking care of your emotional health. Regaining your emotional well-being and getting help for depression are important parts of cardiac rehab.
• Making a plan to help you start a safe home exercise program and participate in other unsupervised activities. For tips on walking as exercise, see:
  • Heart Disease: Walking for a Healthy Heart.

Why It Is Done

Cardiac rehab can help you recover after being in the hospital for a heart problem or heart surgery. Rehab can help improve your quality of life if you have a long-term heart problem, such as heart failure. Cardiac rehab can also help you prevent future heart problems if you are at high risk for heart disease or heart attack.

People of any age can benefit from a rehab program. But this is especially true for older adults, women, and people who are at higher risk for heart failure. Cardiac rehab can also help you return to work safely and in a timely manner.

Your doctor may suggest cardiac rehab if you have a heart problem or had a procedure or surgery. These include:

• Heart attack.
• Coronary artery disease with stable angina.
• Angioplasty.
• Bypass surgery.
• Heart failure.
• Heart valve surgery.
• Heart transplant.

Depending on your provincial guidelines, cardiac rehab may be suggested for other heart problems. These include:

• Implantable cardioverter-defibrillator (ICD) placement surgery.
• Pacemaker placement surgery.
• Peripheral arterial disease.

Not all people who have had the conditions or procedures listed above may be appropriate candidates for cardiac rehab. You may have other medical concerns that prevent your doctor from recommending cardiac rehab. But almost everyone with heart disease or risk factors for heart disease would benefit from some form of risk factor assessment, activity counselling, and health education.

Examinations and Tests

Before starting a cardiac rehabilitation (rehab) program, a thorough risk assessment will be done to find out your heart health and the types of exercises you can safely do. Testing may be done before and during cardiac rehab to help your doctor decide whether you can safely take part in a program and to monitor your progress.

Tests to find out your ability to exercise that may be done before you start cardiac rehab include:

• Resting electrocardiogram (EKG or ECG), a test that measures the electrical signals that control the rhythm of your heartbeat. The graph that shows the results is called an electrocardiogram. A resting ECG will sometimes show if more extensive testing is needed before you start an exercise program.
• Exercise electrocardiogram (ECG), a test that records the electrical activity of the heart. An exercise electrocardiogram (sometimes called a stress or treadmill test) is done during exercise to evaluate how the heart responds to exercise. Your doctor can use the test results to prescribe a safe amount of exercise for you.
• Echocardiogram (echo), a type of ultrasound test that uses high-pitched sound waves to produce an image of the heart. The sound waves are sent through a device called a transducer and are reflected off the various structures of the heart. This test shows how well your heart is pumping blood and how well your heart valves are working. Sometimes it is combined with an exercise stress test.
• Cardiac perfusion scan, a test to estimate the amount of blood reaching the heart muscle during rest and exercise. It is typically done to find out the cause of unexplained chest pain or to find out the location and amount of injured heart muscle after a heart attack.
• Ambulatory electrocardiogram (Holter monitoring test), which monitors the electrical activity of your heart while you go about your usual daily activities. Many heart problems occur only during certain activities, such as exercise, eating, sex, emotional stress, bowel movements, or even sleeping. A continuous recording is much more likely to detect any abnormal heartbeats that occur during these activities.

Other testing can help monitor your progress during cardiac rehab. Additional monitoring may include blood pressure, cholesterol, weight, and blood sugar levels.

You will be monitored closely when you first begin your cardiac rehab program. But after your exercise program is well established, you probably won't need continuous supervision. But if your doctor determines that you have special needs, he or she may want you to wear a monitoring device at home.

Risks

Cardiac rehabilitation exercise programs are safe and helpful. Exercise helps you return to your normal life. But there is a small risk of complications.^{footnote 1}

If you have a health problem that makes exercise unsafe, your rehab will not include an exercise program. These health problems include:

• Unstable angina.
• Uncontrolled high blood pressure or low blood pressure.
• Heart rhythm problems.
• Severe heart failure.
• Uncontrolled diabetes.

Even if you can't exercise or be active, you will benefit from other parts of a cardiac rehab program. For example, you can get help with quitting smoking and reducing stress. And you can get advice on how to eat a heart-healthy diet. This type of education can lower the risk of heart-related death.

Safety and your rehab team

After having a heart attack or surgery or discovering you have heart disease, you may be afraid to exercise or be active. You may worry that exercise will cause another heart attack or that you aren't strong enough for a cardiac rehab program.

It may ease your fears to know that as you begin your rehab, your doctor will monitor your activity closely and health professionals will be on hand to deal with any problems you may have. Your rehab team will tailor all of your exercises specifically for you, based on your medical condition and overall health. All cardiac rehab begins slowly at a comfortable pace and may be as gentle as walking on a treadmill.

If you are worried or afraid to be active again, talk to your doctor. Exercise and activity can greatly improve the quality of your life.

Tell your doctor and other health professionals on your rehab team about all of the medicines you are taking, especially if they cause any side effects during exercise. Medicines may also affect your ability to participate in cardiac rehab. Some prescribed medicines can change your heart rate, blood pressure, and overall ability to exercise.

Watch for symptoms

When you exercise, be sure that you are aware of signs and symptoms that mean that you should stop exercising and contact your doctor.

Your ability to identify how your body is responding to exercise and what physical conditions are normal is necessary for your rehabilitation. It is important that you monitor specific physical information to be aware not only of your improvement but also of possible complications. If you have any other physical or medical concerns such as the flu, backache, or knee pain, it is best that you put off exercising until the problem passes. You should seek medical advice if it does not.

Your rehab team might ask you to be aware of:

• How you feel.
• Your heart rate.
• Your blood pressure.

Know when to call a doctor

Call 911 or other emergency services anytime you think you may need emergency care. For example, call if:

• You have severe trouble breathing.
• You cough up pink, foamy mucus and you have trouble breathing.
• You have symptoms of a heart attack. These may include:
  • Chest pain or pressure, or a strange feeling in the chest.
  • Sweating.
  • Shortness of breath.
  • Nausea or vomiting.
  • Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
  • Light-headedness or sudden weakness.
  • A fast or irregular heartbeat.
• Stroke.
  • Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.
  • Sudden vision changes.
  • Sudden trouble speaking.
  • Sudden confusion or trouble understanding simple statements.
  • Sudden problems with walking or balance.
  • A sudden, severe headache that is different from past headaches.

  After you call 911, the operator may tell you to chew 1 adult-strength or 2 to 4 low-dose aspirin. Wait for an ambulance. Do not try to drive yourself.

• You have angina symptoms (such as chest pain or pressure) that do not go away with rest or are not getting better within 5 minutes after you take a dose of nitroglycerin.
• You have symptoms of a stroke. These may include:
  • Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.
  • Sudden vision changes.
  • Sudden trouble speaking.
  • Sudden confusion or trouble understanding simple statements.
  • Sudden problems with walking or balance.
  • A sudden, severe headache that is different from past headaches.
• You passed out (lost consciousness).

Call your doctor now or seek immediate medical help if:

• You have new or increased shortness of breath.
• You are dizzy or light-headed, or you feel like you may faint.
• You have increased swelling in your legs, ankles, or feet.

Check your weight

Your doctor may ask you to weigh yourself regularly, maybe every day. This helps you watch for sudden weight gain, which could be a sign of a problem.

Call your doctor if you notice a sudden weight gain, such as more than 1 to 1.3 kilograms in a day or 2 kilograms in a week. (Your doctor may suggest a different range of weight gain.)

Weigh yourself on the same scale with the same amount of clothing at the same time of day. The best time may be soon after you get up in the morning, but after you go to the bathroom. This way, your measurements are consistent and accurate. You may want to keep a diary of your weight.

If you have heart failure or have just had open-heart surgery, monitoring your weight is especially important. People who have heart failure must watch for a sudden weight gain, which points to fluid retention and heart failure that is getting worse. People who have had open-heart surgery must also watch for sudden weight gain/fluid retention that could mean a complication of the surgery.

How Well It Works

Cardiac rehab has many benefits. It can help you:

• Have better overall health and a better quality of life.
• Lower your risk for a heart attack or dying from heart disease.
• Recover well after surgery.
• Stay out of the hospital.
• Manage your symptoms, such as chest pain, shortness of breath, and fatigue.
• Have a heart-healthy lifestyle. This includes being active, eating healthy, losing weight, and not smoking.
• Manage other health problems, including high blood pressure and high cholesterol.
• Have more energy.
• Feel more hopeful and less depressed, stressed, or worried.
• Return to your usual activities, including work.
• Resume sexual activity safely.
• Get support from your rehab team and other patients in rehab.

What to Expect

The goal of cardiac rehabilitation (rehab) is to help you reestablish and maintain a healthy, active lifestyle after a major heart problem, such as a heart attack or heart surgery, or if you have a long-term heart condition. Rehab can help you return to work, resume recreational and other activities, and resume a normal sex life.

To keep getting the benefits of cardiac rehab, you will have to continue to exercise and follow the healthy lifestyle changes you've learned.

Exercise and lifestyle changes. Although exercise is a significant part of cardiac rehab, lifestyle changes combined with exercise may be more important than exercise alone in keeping your heart healthy. Staying with your program can give you the support you need to make these changes a permanent part of your life and may help reduce the risk of further serious heart problems.

Getting back to work. After you have a heart problem (such as a heart attack or heart surgery), cardiac rehab can help you return to work safely. How quickly you can return to work depends on how bad your heart problem is and how much physical activity your job requires. Your rehab program might include job or vocational counselling.

Resuming sex. You or your partner may be worried that you will have symptoms such as chest pain or will not have enough energy for sex. Sharing your concerns and fears about having sex is important for both partners. Both partners need to feel ready to restart having sex. Ask your doctor or a member of your rehab team when it's safe for you to have sex.

Managing stress. Stress management may lower the risk of serious heart problems, such as heart attacks. People who do not deal well with anger and frustration may have a higher risk of coronary artery disease. Learning to manage stress is often part of programs to help you make positive changes in your lifestyle.

Seeking treatment for depression.
Depression is often overlooked, especially in older adults, but commonly occurs after a serious heart problem. Depression can make it difficult for you to have the energy to perform some of the cardiac rehab programs. If you feel you suffer from symptoms of depression, make sure you seek help.