Cardiac Rehabilitation

Rationale, arbejdsmetode og erfaringer fra Bispebjerg Hospital


Foreword I

Patients

If you are fortunate enough to survive a heart attack or have experienced a bypass operation, your life changes for better and worse. This is especially true if you also find you have diabetes. You have much to overcome and many concerns with which to struggle. You can become anxious and suddenly not be able to achieve all the things you had planned and anticipated. Some of us end up in such difficulty that we have trouble returning to a normal life.

Before we encountered cardiac rehabilitation, we had both experienced individual departments and clinics that functioned pretty well based on the usual standards. We had primarily received substantial medicine. But we did not feel at all healthy, neither physically nor mentally, when we began the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital.

Getting together with other people in the same situation is clearly positive, and we were relieved immediately by being able to talk openly and honestly in unity that gave us strength. Nevertheless, what impressed us most deeply after only a few days in the 6-week intensive programme was that each of us was considered not only as people but as whole individuals. In this universe we did not have a heart there and a kidney there, a body and a soul disjointed. We actually had integrated thoughts, feelings and a body that needed to be used.

We had healthy and unhealthy habits, an inappropriate relationship with how we could and should use our bodies and especially an enormous need for more knowledge about ourselves and what was being done to and for us. Our need for motivation was key to our lives. There were mental problems and otherwise taboo sexual problems. Everything is connected, and the entire person was in focus!

Throughout the whole programme we felt that motivation was the keyword. Numerous counselling sessions and discussions, lectures and diverse activities allowed us to understand ourselves in a new and constructive way. We were actively involved the whole time, even to the extent that each patient, while consulting with the physician, could always view the monitor with the electronic record that registered the continually adapted medication and much more.

Finding a programme as well organized as this one requires an extensive search. In addition, all staff had a strongly optimistic and contagious commitment. This included the secretary, nurse, dietitian, physical therapist and physician.We are convinced that the spirit in the programme was reinforcing in the sense that the visible and positive results among the patients strengthened the enthusiasm of the cardiac rehabilitation team.

We are grateful and hope that others will continue the idea of this pioneering project in Denmark.

Peter Clemmensen
Carpenter, former trade union shop steward

Bjørn Andersen
Journalist and author


Foreword II

Institutions

There is solid documentation that cardiac rehabilitation can substantially improve the health of the more than 40,000 people who are admitted to Denmark’s hospitals each year with ischaemic heart disease.With the establishment of a comprehensive cardiac rehabilitation programme in 1999, the Department of Cardiology and Bispebjerg Hospital have implemented a reorganization of rehabilitation from traditional treatment to interprofessional, comprehensive cardiac rehabilitation services that include risk factor management and clinical assessment by a physician, exercise training, patient education, support for changing dietary habits, support for smoking cessation and psychosocial support. The services are based on current evidence and the current national guidelines.

This book describes how the Cardiac Rehabilitation Unit organizes their clinical practice, the rationale for the clinical practice and the experience of the cardiac rehabilitation team in implementing and developing the rehabilitation programme. The book focuses on clinical procedures and thus provides several specific action plans and tools that can be used in clinical practice.

We hope that this book can inspire health care personnel who work with people with heart disease so that the systematic, comprehensive rehabilitation services are not merely offered to a few people but may be provided in the future to all of Denmark’s heart patients who need these services.

This book is the result of the hard work, commitment and perseverance of many people for more than three years (Annex 3). The project manager, Ann-Dorthe Olsen Zwisler, has been the prime mover since the project idea arose in May 1997. Her efforts have had invaluable significance for the fact that Bispebjerg Hospital today has well-functioning comprehensive cardiac rehabilitation services.

The following people have read and commented on the manuscript: Joep Perk, Chief Physician, Oskarshamn Hospital, Sweden and former Chair of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology; Carsten Hendriksen, Chief Physician, Unit for Coordination and Rehabilitation, Centre for Internal Medicine, Bispebjerg Hospital and Associate Professor, Institute of Preventive Medicine, Copenhagen; Birgitte Fogde, Rehabilitation Nurse, Department of Cardiology, Rigshospitalet (National Hospital), Copenhagen; and Ulla Ischiel Træden, freelance medical consultant specializing in dietary intervention. Barbara Ciechanowska has helped in production and reference management.

The reorganization project has received financial support from the Pharmacists’ Foundation, research funds of the Copenhagen Hospital Corporation and the Danish Heart Foundation and numerous external and internal foundations (Annex 2). The Ministry of the Interior and Health, Denmark provided financial support for the book.

Lars Iversen
Former consultant, Unit of Preventive Medicine and Health Promotion
Bispebjerg Hospital
Head, Division of Health Services, Quality Assurance and Health Development
Ribe County

Bjarne Sigurd
Chief Physician
Department of Cardiology
Bispebjerg Hospital

Mette Madsen
Deputy Director
National Institute of Public Health


October 2003


1. RATIONALE

Chapter 1

Introduction

Ann-Dorthe Zwisler

Cardiac rehabilitation today targets people with ischaemic heart disease, congestive heart failure and people with a high risk of developing ischaemic heart disease (1).

The short-term goals of cardiac rehabilitation are to stabilize heart disease, to limit the physical and mental effects of heart disease, to improve the functioning of the people with heart disease and to improve their quality of life. The long-term goals are to reduce patients’ long-term risk of heart disease, to stop the progression of heart disease and to reduce morbidity and mortality (1).

According to current evidence, these goals can best be realized through comprehensive cardiac rehabilitation programmes based on exercise training, patient education, lifestyle intervention, risk factor management and clinical assessment, psychosocial support and optimizing the pharmaceutical treatment of symptoms. Pharmaceutical treatment comprises an important part of overall rehabilitation (1).


1.1 Health Benefits

Studies (2–6) have shown that comprehensive cardiac rehabilitation can substantially improve the health of people with ischaemic heart disease.

The results of health economics studies (7–10) further show that comprehensive cardiac rehabilitation is cost-effective. Chapters 5–11 document the individual components of cardiac rehabilitation.


1.2 Guidelines And Recommendations

In 1997, the Danish Heart Foundation and the Danish Society of Cardiology published clinical guidelines for cardiac rehabilitation in Denmark (11). These guidelines closely follow the current international recommendations (1;12;13). The role of cardiac rehabilitation in the treatment of people with ischaemic heart disease has subsequently been emphasized in Denmark among professionals (14–16) and among politicians and administrators (17–21). Nevertheless, hospital-based comprehensive cardiac rehabilitation still needs to be expanded in Denmark (22;23).

Health benefits of cardiac rehabilitation
31% reduction in total mortality
16–36% reduction in the number of admissions
Reduction in symptoms of heart disease
Long-term changes in lifestyle (smoking, diet and exercise)
Improvement of the health-related quality of life
Improved physical functioning


1.3 From idea to project

In 1997, few hospitals in Denmark offered cardiac rehabilitation services that complied with the newly published guidelines (24;25).The heads of the Department of Cardiology at Bispebjerg Hospital appointed an interprofessional working group in spring 1997 (Annex 1) to assess whether the rehabilitation services in the Department complied with the guidelines. The working group indicated that the existing rehabilitation services needed to be reorganized and prepared a local report on this reorganization (26). The heads of the Department, the management of Bispebjerg Hospital and external partners reacted positively to the report. Evaluating the reorganization was given high priority, since Denmark has little experience with cardiac rehabilitation. A three-year project (described at www.CardiacRehabilitation.dk) was initiated with support from foundations and research funds (Annex 2).


1.4 Guidance for the reader

This book is a practical manual on organizing and developing a cardiac rehabilitation programme. The book describes how the Cardiac Rehabilitation Unit currently organizes clinical practice, the rationale on which the efforts are based and the experience of staff in developing and implementing the programme. The experience is based on treating 389 patients who received comprehensive cardiac rehabilitation, most the full programme.

The target group for this book is health professionals and health planners in the fields of heart health or rehabilitation. In addition, the book is suitable for medical and other health degree programmes.

The book is divided into three sections: rationale, methods and experience. Chapter 2, which covers the key concepts in the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital, introduces the components of cardiac rehabilitation described in the second section. The third section describes the experience with the methods. Chapter 11 on type 2 diabetes mellitus is very extensive, since the Cardiac Rehabilitation Unit has especially focused on this area as part of a PhD study. 1 We have attempted to use the latest knowledge in this field and mostly refer to the most recent relevant reviews and original research. Each chapter is designed so that it can be read independently, and the chapters may therefore overlap. Each chapter has a reference list.

The cardiac rehabilitation team (Annex 4) prepared the book collectively. Individual contributors wrote most of the individual chapters; Ann-Dorthe Olsen Zwisler wrote the sections on evidence in Chapters 4–11. The editors edited the text for consistency. The material used in teaching, interview guides, descriptions of functions and other purposes is available (in Danish) at www.CardiacRehabilitation.dk to inspire other people in clinical practice and administration. In addition, the comprehensive cardiac rehabilitation programme is described in more detail in English at:

www.CardiacRehabilitation.dk.

High-risk patients are defined as patients at high risk for developing ischaemic heart disease. The field of rehabilitation uses several terms for the person who needs rehabilitation, including patient, user and client. We have chosen to use the word patient because cardiac rehabilitation in this context is part of an overall programme for hospital patients.We also use the word patient for people at high risk of developing ischaemic heart disease. These people have all been admitted to a department of cardiology because of symptoms that caused the admission.

The health professionals involved are called professionals or practitioners here. The term cardiac rehabilitation team includes all the staff of the Cardiac Rehabilitation Unit, and the clinical team covers solely practitioners.

The book uses the most commonly known words and abbreviations used within cardiology. Annex 6 is a glossary of words and abbreviations used within cardiology. Reference books within cardiology and medical dictionaries may also be useful. The book uses the present tense although it refers to a project that ended in January 2004. The comprehensive cardiac rehabilitation programme at Bispebjerg Hospital is now permanent.

The project and its process of development have been described (27), and the results of the evaluation are being published in scientific journals.


References

(1) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(2) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(3) Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease.N Engl J Med 2001; 345(12): 892–902.

(4) McAlister FA, Lawson FM,Teo KK,Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323: 957–962.

(5) Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316(7142): 1434–1437.

(6) Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003; 123(6): 2104–2111.

(7) Brown A,Taylor R, Noorani H, Stone J, Skidmore B. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systemic clinical and economic review. 3. Ottawa, Canadian Coordinating Office for Health Technology Assessment, 2003.

(8) Lowensteyn I, Coupal L, Zowall H, Grover SA. The cost-effectiveness of exercise training for the primary and secondary prevention of cardiovascular disease. J Cardiopulm Rehabil 2000; 20(3): 147–155.

(9) Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997; 17(4): 222–231.

(10) Oldridge N, Furlong W, Feeny D, Torrance G, Guyatt G, Crowe J et al. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol 1993; 72(2): 154–161.

(11) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(12) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(13) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(14) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(15) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(16) Larsen ML, Sjøl A, Videbæk J. Hjerterehabilitering på sygehuse [Hospital-based cardiac rehabilitation]. Copenhagen, National Network of Health Promoting Hospitals in Denmark and Danish Society of Cardiology, 2003.

(17) Government of Denmark. Government Programme on Public Health and Health Promotion, 1999–2008. Copenhagen, Ministry of Health, 1999.

(18) Government of Denmark. Healthy throughout life – the targets and strategies for public health policy of the Government of Denmark, 2002–2010. Copenhagen, Ministry of the Interior and Health, 2002.

(19) National Association of Local Authorities in Denmark, Danish Regions and Ministry of Finance. Udfordringer og muligheder – den kommunale økonomi frem mod 2010 [Challenges and opportunities – local government finances towards 2010]. Copenhagen, Schultz Information, 2002.

(20) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity handbook on prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(21) Cardiac Follow-up Group, National Board of Health. Det fremtidige behov for revaskulariserende behandling af iskæmisk hjertesygdom – herunder PCI-behandling [The future need for revascularization treatment of ischaemic heart disease – including percutaneous coronary intervention]. Copenhagen, National Board of Health, 2003.

(22) Ischiel Træden U, Olsen Zwisler AD, Møller L, Tønnesen H. Forebyggelse på danske sygehuse. En kortlægning [Disease prevention and health promotion at hospitals in Denmark. A survey]. Copenhagen, Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital and National Network of Health Promoting Hospitals in Denmark, 2003.

(23) Zwisler ADO, Traeden UI, Videbaek J, Madsen M. Implementing cardiac rehabilitation services in Denmark – room for expansion. Presented at the 19th Nordic Congress of Cardiology, 4–6 June 2003, Odense, Denmark.

(24) Danish Heart Foundation. Kardial rehabilitering i Danmark 1994 [Cardiac rehabilitation in Denmark, 1994]. Copenhagen, Danish Heart Foundation, 1994 (Hjertenyt 1994).

(25) Brinksby L. A questionnaire study on cardiac rehabilitation at Danish hospitals. IV Nordic Conference on Cardiac Rehabilitation, June 1996, Copenhagen, Denmark.

(26) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(27) Zwisler ADO. DANREHAB-studiet. Efterbehandlingstilbud til patienter udskrevet fra en hjerteafdeling. Status [The DANREHAB study. Rehabilitation services for patients discharged from a department of cardiology]. Copenhagen, Bispebjerg Hospital and National Institute of Public Health, 2002.


1. RATIONALE

Chapter 2

Basic Principles

Ann-Dorthe Olsen Zwisler & Lone Schou


2.1 Introduction

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit at Bispebjerg Hospital has been organized using several basic principles that are based on the current guidelines (1–3) and established by an interprofessional working group (4).

Basic principles of comprehensive cardiac rehabilitation
  • Broad concept of cardiac rehabilitation
  • Broad target group
  • Comprehensive cardiac rehabilitation services
  • Individually tailored programme
  • Involvement of family members
  • Performing tasks using an interprofessional approach
  • Patient-centred health communication
  • Systematic clinical assessment and referral

This chapter defines and explains the basic principles. The chapter concludes by outlining legislation and ethical aspects relevant to cardiac rehabilitation.


2.2 Basic Principles

2.2.1 Broad concept of cardiac rehabilitation

An international expert group appointed by the World Health Organization (5) defined cardiac rehabilitation as “the sum of activity required to ensure cardiac patients the best possible physical, mental and social conditions so that they may, by their own effort, regain as normal as possible a place in the community and lead an active life”. Efforts to prevent heart disease can be divided into primary, secondary and tertiary prevention. Primary prevention means preventing disease from arising at all. Secondary prevention means identifying patients at high risk of developing ischaemic heart disease and identifying symptoms and disease at early stages to reduce the course of disease and contribute to improving the prognosis. Tertiary prevention means preventing remission of disease and preventing chronic conditions, including reduced functioning as a result of disease (6).

Activities targeting patients with known heart disease therefore include secondary and tertiary prevention. The concept of tertiary prevention and WHO’s definition of cardiac rehabilitation are very similar.

Since both secondary and tertiary prevention are core services in cardiac rehabilitation, the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital has aimed towards a concept of cardiac rehabilitation that covers both rehabilitation and disease prevention. We thus wanted to establish that the cardiac rehabilitation programme is a broadly founded rehabilitation programme that is considerably more extensive and comprehensive than previous cardiac rehabilitation programmes, which often concentrated on individual components such as physical rehabilitation (exercise training) and patient education.


2.2.2 Broad target group

The effects of cardiac rehabilitation have especially been documented among young men with myocardial infarction (7), but the results from recent studies show that these effects can be transferred to a broader target group.

Diagnostic groups
Ischaemic heart disease: Cardiac rehabilitation is recommended for all patients who have manifest ischaemic heart disease: patients with myocardial infarction, patients who have undergone percutaneous coronary intervention, patients who have undergone coronary artery bypass grafting and patients with stable ischaemic heart disease who have not yet been offered comprehensive rehabilitation (1;8–11).

Heart surgery: Patients who have undergone other heart surgery than coronary artery bypass grafting and percutaneous coronary intervention, such as the implantation of an implantable cardioverter defibrillator (12;13), heart valve surgery (14) and heart transplantation (15) also have documented benefits from cardiac rehabilitation organized based on the special conditions of the basic disease and intervention performed (11).

Congestive heart failure: Good evidence exists that physical exercise is a well-indicated treatment for patients with congestive heart failure whose symptoms are well controlled (16;17), and the clinical guidelines on cardiac rehabilitation recommend that patients with congestive heart failure be offered comprehensive cardiac rehabilitation based on the same principles as patients with ischaemic heart disease (10;11).

High-risk patients: Attention on the importance of preventing the development of heart disease among high-risk patients has increased in recent years. High-risk patients are considered a target group for cardiac rehabilitation emphasizing lifestyle intervention and risk factor management (10).

Groups unrelated to diagnosis
Women: Several studies (18–20) have shown that women obtain the same benefits from cardiac rehabilitation as men, and guidelines from Denmark (1) and elsewhere (8–10) emphasize that women should also participate in cardiac rehabilitation programmes. Despite these recommendations, studies (18;21–24) indicate that women participate half as often as men in cardiac rehabilitation programmes. One reason could be that fewer women are referred to cardiac rehabilitation (25;26) and another that women are more often older than men when they heart disease becomes manifest (27).

Elderly people: Evidence (28;29) indicates that elderly patients benefit as much as younger patients from cardiac rehabilitation. Despite the existing documentation for the effectiveness of cardiac rehabilitation, studies (25;26) show that fewer older than younger cardiac patients are referred to cardiac rehabilitation programmes, and elderly people are more likely to decline cardiac rehabilitation services (22;30). Some hospital departments in Denmark have a maximum age for participating in cardiac rehabilitation, typically 70 years (31).

Ethnic minorities: Knowledge is limited on the effectiveness of cardiac rehabilitation in Denmark among patients with an ethnic background other than Danish (32). Despite this lack of knowledge, this project could not investigate this important topic because money was lacking for simultaneous interpretation.

Based on the existing evidence and the clinical guidelines, the services offered by the Cardiac Rehabilitation Unit target men and women of all ages who speak Danish and have ischaemic heart disease, congestive heart failure or a high risk of developing ischaemic heart disease.

Target groups of the comprehensive cardiac rehabilitation programme
  • Patients with ischaemic heart disease
  • Patients with congestive heart failure
  • Patients with a high risk of developing ischaemic heart disease

Patients who cannot transport themselves are offered transport to and from the Cardiac Rehabilitation Unit.


2.2.3. Comprehensive cardiac rehabilitation services

The cardiac rehabilitation programme has three phases: during admission (phase I), hospital-based outpatient cardiac rehabilitation (phase II) and the late maintenance and follow-up phase (phase III) (33). 1 In recent years attention has increasingly focused on the fact that patients are especially vulnerable during the transitions between phases because coordination may be lacking between phases, actors and efforts, with the risk of losing the health benefits achieved (34).

The Cardiac Rehabilitation Unit offers a phase II hospital-based programme. According to current guidelines (1;35;36), outpatient cardiac rehabilitation includes comprehensive cardiac rehabilitation programmes involving exercise training, patient education, lifestyle intervention, risk factor management, psychosocial support and optimizing the pharmaceutical treatment of symptoms.Nevertheless, the recommendations do not prescribe how these elements should be weighted or composed in detail. A successful phase 2 cardiac rehabilitation programme requires optimum clinical assessment and acute treatment.

Based on current evidence, the Cardiac Rehabilitation Unit has seven components and a supplementary module for patients with type 2 diabetes.

Core components of the comprehensive cardiac rehabilitation programme
  • Individually tailored rehabilitation programme
  • Patient education
  • FExercise training
  • Support for changing diet
  • Support for smoking cessation
  • Psychosocial support, including a 24-hour helpline
  • Systematic risk factor management and clinical assessment
  • A supplementary module for patients with diabetes

Cardiac rehabilitation programme
1 week after referral:
Individually tailored programme
6-week programme:
Intensive cardiac rehabilitation
3, 6 and 12 months:
Management and clinical assessment

Knowledge is lacking on the relationship between the length of phase II cardiac rehabilitation and the resulting effects (10). The length of phase II programmes varies greatly in Europe: from 1 to 46 weeks (33;35); the length of the programmes included in a metaanalysis of the effects varied from 1 week to 30 months (7). Although this aspect has not been sufficiently studied, the most recent European position paper (10) indicates a minimum length of 8–12 weeks.

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit lasts 12 months. The programme starts with a brief period in which the individual programme is tailored followed by intensive cardiac rehabilitation for 6 weeks. When the intensive programme ends, the patient attends planned clinical follow-up assessment at the Cardiac Rehabilitation Unit after 3, 6 and 12 months.Then the patients are referred to their general practitioners or continue under the supervision of a department of cardiology if the course of disease is complicated.

The individual components and the efforts of each group of professionals need to be coordinated for the comprehensive cardiac rehabilitation programme to succeed. The Cardiac Rehabilitation Unit ensures this by organizing clinical practice, communicating with patients and exchanging information between professions.


2.2.4 Individually tailored programme

The patient is the central actor in the cardiac rehabilitation programme, since involving patients is a prerequisite for success. The Cardiac Rehabilitation Unit tailors the programme to the needs and resources of each patient based on individual discussions between the patients and health professionals.


2.2.5 Involvement of family members

The patient’s family members (primarily spouses) play an important role in cardiac rehabilitation at Bispebjerg Hospital and are involved as resource people in the overall rehabilitation. Studies indicate that patients with good family support are more likely to maintain participation in cardiac rehabilitation and changes in lifestyle than patients without such support (36). In addition, family members often feel powerless and anxious in connection with the illness of close family and have an independent need for support in coping with the early phase of acute illness in their family (37–41).


2.2.6 The current guidelines

(1‚8–10) unanimously emphasize that hospital-based cardiac rehabilitation efforts should be based on an interprofessional approach. In Europe, the practitioners involved are divided into a core team comprising the practitioners with whom the patient has daily contact and a peripheral team that can be involved under special circumstances. The clinical team in the Cardiac Rehabilitation Unit comprises the staff groups that already were part of the existing rehabilitation programme in the Department of Cardiology. The composition complies with the newest recommendations for Europe, which, however, do not indicate the form of cooperation and the responsibility and role of each team member in the cardiac rehabilitation programme.

Health professionals in the Cardiac Rehabilitation Unit
Core team

Physicians
Nurses
Physical therapists
Clinical dietitians
Secretaries

Peripheral team

Social workers
Liaison psychiatrists


2.2.7 Patient-centred health communication

Studies have shown that communication between patients and health personnel can influence satisfaction, quality of life and health (42;43) and compliance (44–47). In accordance with the most recent recommendations in Denmark for communication in the health care system (48), the Cardiac Rehabilitation Unit emphasizes a patient-centred form of communication. This means that the patient’s behaviour, thoughts, feelings and general well-being are taken into account along with biological and paraclinical aspects of illness and treatment.


2.2.8 Systematic clinical assessment and referral

Although services may be available in some areas, experience in many countries (33;35) indicates that few patients who need cardiac rehabilitation are referred. The Cardiac Rehabilitation Unit emphasizes that all individual patients should be assessed systematically to determine the need for cardiac rehabilitation. This assessment is based on information from the patient records on diagnoses and the results of tests and examinations, including risk factors, and counselling the patients on their needs and resources. The Unit emphasizes to the patient that cardiac rehabilitation is a service just like all other treatment and that cardiac rehabilitation is considered and recommended as part of overall treatment.

Because of the special requirements of carrying out a randomized clinical trial,2 a nurse within the Unit (which was a project with temporary status at that time) conducted the assessment and referral from the Department of Cardiology during the project period.


2.3 Legislation

In contrast to such places as Belgium (37), Denmark has no specific legislation on cardiac rehabilitation. The Hospitals Act of 1995, the general legislation on hospitals in Denmark, describes the obligations of hospitals in disease prevention, including cardiac rehabilitation (51). The Act on Patients’ Legal Rights of 1998 stipulates that health personnel must inform patients about their state of health and treatment opportunities, including rehabilitation opportunities. Information on rehabilitation opportunities must be provided even if the hospital providing the information does not offer rehabilitation. The Hospital System Act of 2001 strengthened the obligation of hospitals to prepare rehabilitation plans. Patients have the right to have an individual rehabilitation plan prepared in connection with discharge if the physician considers that the patient needs one. The ethical rules for doctors (§ 2 on physicians’ precision and conscientiousness) say that physicians are obligated to contribute to preventing disease and promoting health. In addition, the Hippocratic oath obligates physicians to seek new knowledge to benefit patients, including knowledge on preventing disease and rehabilitation.


2.3.1 Evidence-based treatment

The Cardiac Rehabilitation Unit strongly emphasizes monitoring the continually updated clinical guidelines on the treatment of patients with heart disease and a high risk of developing heart disease, including guidelines on cardiac rehabilitation (Chapter 4). Clinical guidelines are developed to support practitioners in composing the best possible evidence-based treatment for patients based on the existing knowledge in each field. The treatment recommendations in the clinical guidelines are not legally mandated but are increasingly included in legal assessments in connection with patient complaints (50).


2.4 Ethical Considerations

Medical ethics has four traditional principles: justice, respect for patients’ autonomy, beneficence and non-maleficence (51). Cardiac rehabilitation, like all other forms of treatment, includes these ethical considerations. This section outlines the significance and the weighting of these four principles, focusing on the complexity of the basic principles for cardiac rehabilitation activities.

The Cardiac Rehabilitation Unit maintains the basic principles of the Department of Cardiology for social justice in treatment: age, gender and social status do not influence treatment. The Unit also emphasizes tailoring the treatment to the needs and resources of each patient.

The patients’ motivation and own efforts are decisive in achieving the treatment goals, and respect for the patients’ self-determination is very important in cardiac rehabilitation. On the other hand, cardiac rehabilitation activities are based on the obligation of health professionals to disseminate and use knowledge on the relationships between disease, lifestyles, level of functioning and treatment opportunities. The programme strongly emphasizes the fact that patients are ultimately responsible for their own health.

Cardiac rehabilitation at Bispebjerg Hospital gives high priority to the safety of patients, similar to the rest of Denmark’s health care system. Nevertheless, in efforts to prevent disease, situations may arise in which health services inadvertently cause people to feel more ill than they are. This applies especially to high-risk patients, but patients who have been told that they are healthy after an invasive intervention may also experience an inadvertent feeling of being ill in connection with cardiac rehabilitation.


References

(1) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(2) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(4) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(5) Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD: report on two WHO consultations, Udine, Italy, 28–30 April 1992, Tours, France, 9 July 1992. Copenhagen, WHO Regional Offfice for Europe, 1993 (http://whqlibdoc.who.int/euro/-1993/ EUR_ICP_CVD_125.pdf, accessed 22 March 2004).

(6) Kamper Jørgensen F, Almind G. Det forebyggende sundhedsarbejde. Forebyggelsesbegreber og forebyggelsesprogrammer [Disease-preventive health activities. Concepts and programmes within disease prevention]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 17–51.

(7) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(8) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(9) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(10) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(11) Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003; 123(6): 2104–2111.

(12) Lewin RJ, Frizelle DJ, Kaye GC. A rehabilitative approach to patients with internal cardioverterdefibrillators. Heart 2001; 85(4): 371–372.

(13) Sears SF Jr, Conti JB. Quality of life and psychological functioning of icd patients. Heart 2002; 87(5): 488–493.

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1. RATIONALE

Chapter 3

Lifestyle Intervention

Jeannette Larsen & Ann-Dorthe Olsen Zwisler


3.1 Introduction

Health behaviour is often used synonymously with lifestyle, and aspects of lifestyle such as smoking, dietary and exercise habits are strongly related to health, life expectancy and heart disease (1;2).

Lifestyle intervention, comprising systematic education in techniques to change health behaviour, is essential for implementing changes in lifestyle and is an important element in preventing heart disease and cardiac rehabilitation (3–5).

The Cardiac Rehabilitation Unit intervenes in patients’ lifestyles to motivate and support them in changing their lifestyles long term to improve their heart health. This intervention is based on knowledge about the links between heart disease and smoking, dietary and exercise habits.


3.2 Theoretical Basis

There are several theories on how health behaviour is established; different theories have dominated in different eras. Nevertheless, no theory so far has been able to explain fully how lifestyle can be changed in the long term (1), and documentation for the effect of the individual theories on long-term changes in lifestyle is scarce even though these theories are used frequently (6).

The clinical practice in the Cardiac Rehabilitation Unit is based on components from several theories and accounts for the fact that lifestyles change in a complex interaction between behaviour, knowledge and attitudes depending on cognitive, emotional and intellectual abilities and skills, motivation, environment and other factors (7).

The Cardiac Rehabilitation Unit has focused on the stages of change model for lifestyle intervention. This model comprises the basis for many disease prevention services at hospitals in Denmark (8–11). The Unit also uses parts of the health belief model, the self-efficacy theory of Albert Bandura and the principles of action competence. This section outlines the main aspects of these theories, focusing on the elements significant for clinical practice in relation to patients with heart disease and patients with a high risk of heart disease. Due & Holstein (1) and Glanz et al. (12) explore these theories in more detail.

3.2.1 The stages of change model

Psychologists James O. Prochaska and Carlo C. DiClemente developed the stages of change model in the 1980s based on a series of observations of people who had undergone a process that changed their behaviour such as smoking cessation or stopping alcohol consumption.

This model is based on the fact that successful change in behaviour seldom occurs spontaneously. Many people cycle between various stages, and some reach the final stage that signifies long-term change.To support patients in changing their lifestyles, practitioners must be able to identify the current stage of the patient. This allows the practitioners to target the intervention by either using motivational or advisory techniques or by such methods as changing focus from investigating justification for change to making specific plans for change.

Illustration: Stages of change

The strategy is that practitioners should approach patients differently according to their current stage. The purpose is to motivate the patients to move beyond their current stage; this model is therefore also called the cycle of motivation or the process of change.

A systematic review of studies that used the stages of change model (13) could not document clear effects.

Stages
Precontemplation: Patients deny that they have a problem. They have no intention of changing their behaviour, which they do not consider to be a problem. Most patients want to avoid information on the harmful effects of their behaviour.Negative experience from previous attempts to change behaviour may make them apathetic.

The objective is to achieve dialogue with these patients.

Contemplation: Patients are aware that their behaviour comprises a risk to health. They begin to have conflicted feelings about their lifestyles, since they are aware of several of the risks associated with the behaviour, but they are also satisfied with the benefits the behaviour provides. Thus, they are uncertain as to whether they want to change their behaviour. For many people, this ambivalence becomes a permanent state in which they continually consider changing their behaviour but do not mange to realize the changes.

The objective is to support these patients and to clarify the extent of their motivation.

Preparation: Patients are closer to clarifying their desires and intend to change behaviour in the near future. They have become even more aware of their habits, have often designed strategies and made plans with the aim of breaking their habits and have started to change behaviour in some cases. These patients seek knowledge focusing on the benefits resulting from a change in behaviour.

The objective is to guide the patient in the practical preparation and planning of the programme.

Action: Patients are changing their health behaviour. Altering habits and lifestyle is important in their lives, and they are initially very focused on complying with the planned strategy.The strategy will still need to be adjusted, however: perhaps more time needs to be spent exercising, and patients may have to learn how to tackle situations in which they risk relapse. Many patients are surprised that getting used to their new lifestyle can take many months.

The objective is to guide the patient in how to carry out the plan in practice and prevent relapse.

Maintenance: The new behaviour is beginning to be integrated in the patients’ daily lives, and practitioners must support the patients in focusing on the apparent advantages of the new lifestyle. Practitioners must tell patients that achieving lasting changes in health behaviour is a long-term process during which they must continue to be aware of high-risk situations and the planned strategies still need to be integrated into daily life to avoid relapse.

The objective is to encourage and to help the patients in preventing relapse and to focus on the advantages.

Relapse: Patients have not maintained their new lifestyles, and many are frustrated. Some feel guilty and may not attend the planned meetings to avoid confrontation. All patients need acceptance and understanding. Experience shows that most of the patients who attempt to change their lifestyle cycle through the various stages of the model several times before they achieve long-term change.

Motivation
Motivation is one of the key concepts in the stages of change model. Internal and external motivation are often distinguished. Internal motivation requires that people who are going to change their lifestyle be autonomous, determining themselves whether they will change their lifestyle, and requires that people experience that they have the opportunity to influence their state of health. This experience contributes to the commitment that is decisive in changing lifestyle. External motivation is associated with the changes in lifestyle imposed by the environment. An example is a job at a workplace at which smoking or drinking alcohol is prohibited or immediate rewards such as the extra money smokers suddenly have available when they stop smoking (14).


3.2.2 The health belief model

Psychologists Godfrey Hochbaum and Irwin Rosenstock developed the health belief model in the 1950s, and since then it has been further developed and modified. The model assumes that the relationship between the experienced threat of illness and the advantages and/or disadvantages associated with changing one’s health behaviour determine whether people choose to change behaviour. The decision results from the desire to become healthy or to avoid illness and the expectation that changing health behaviour can prevent or cure illness.

The extent to which people consider their health threatened depends on how aware they are that their behaviour comprises a risk to health and whether the risk of developing a given disease increases. People’s decision to change health behaviour may also arise from changes in their life situation, such as changing employment, illness or other factors or may be based on other people’s experience in changing behaviour.

This theory has been used to explain why the rate of smoking cessation seems to be very high among patients with heart disease (15;16).

Illustration: Health-Belief Model


3.2.3 Bandura’s self-efficacy theory

Psychologist Albert Bandura developed the concept of self-efficacy in the 1980s. It is based on individuals believing that they can change their behaviour and having the self-efficacy to change it. Bandura’s self-efficacy theory is the most well-documented theory within heart health. The theory has proved to be suitable to explain why some people manage to change habits that promote heart health in the long term (17–19). The following figure illustrates the relationship between situationally specific selfconfidence and the effect of changing behaviour.

Situationally specific self-confidence means that people believe that they can carry out a specific change in behaviour. The expectation of effect means that people know which change or changes in behaviour can result in achieving a desired goal. Thus, there is a difference between people knowing that they can lose weight by adopting a low-fat diet and believing that they can lose weight. If people repeatedly attempt to lose weight unsuccessfully through a low-fat diet, this will result in low situationally specific self-confidence and no long-term change in behaviour.

Four factors influence situationally specific self-confidence: prompting by an authority, observing other people in a group context, successful testing and biofeedback.

Biofeedback is a key concept in Bandura’s theory as a means of strengthening people’s situationally specific self-confidence. The evaluation of the achievement of goals by using physiological or biological markers is fed back to strengthen patients’ belief that barriers can be overcome and new behaviour can be established.


3.2.4 Action competence

Tone Gabrielsen (21) has described the concept of action competence. Changing lifestyle aims at developing situationally specific action competence in relation to the fields in which the competence will be used.The aim is to unify knowledge and action. Action competence includes:

  • knowledge about the problem
  • an attitude towards the problem
  • the ability to act to solve the problem

The task of the interprofessional clinical team is to motivate patients to adopt attitudes based on their newly acquired knowledge and experience and especially to demonstrate new ways of converting the new knowledge into action. Successfully disseminating health knowledge requires that practitioners ensure that the knowledge disseminated and how it is disseminated are relevant to each patient. One way to ensure this is by presenting patients with knowledge that is individually tailored and related to their daily lives (21).


3.2.5 Relationships between the theories used

The health belief model and Bandura’s self-efficacy theory are psychological theories in which health behaviour is considered to result from psychological processes. The stages of change model is considered a planning model; its purpose is to guide people in the field of lifestyle intervention in choosing appropriate methods but does not seek to explain why people do what they do (1). The theories complement one another and have common characteristics in several areas (22).

The following figure outlines the stages in which the psychological theories and the cross-cutting concept of action competence support the intervention strategy in the stages of change model.

Illustration: Stages of change model


3.3 Cross-Cutting Methods

The Cardiac Rehabilitation Unit uses various clinical methods, and the composition is based on the patients’ motivation, needs and resources.The methods used are described in Chapters 5–10 on the components of patient education, exercise training, support for changing diet, support for smoking cessation, psychosocial support and risk factor management and clinical assessment. This section describes the cross-cutting clinical methods: motivational interviewing or counselling, health communication, prompting by an authority, biofeedback and evaluation, group activities and practical testing.


3.3.1 Motivational interviewing

Psychologists William R. Miller and Stephen Rollnick developed motivational interviewing (or counselling) in the 1990s. This is used in health promotion and disease prevention initiatives in which health personnel attempt to motivate people to change their behaviour based on the stages of change model. Motivational interviewing mainly targets people who are motivated to change behaviour (action and maintenance stages) (23;24).

The technique of motivational interviewing is a form of guidance that places patients in the centre. Instead of directing patients towards a predetermined goal, patientcentred health communication starts with the situation and resources of patients. The practitioner and the patient jointly prepare a strategy that optimally promotes the patient’s action competence. This ensures that patients can process the knowledge they encounter and make decisions on a qualified basis.

The practitioner begins the interview by investigating what patients already know. Patients who need knowledge are offered further information. This information must be based on facts and exclude the practitioner’s assessment. Patients are informed about the effects of various forms of health behaviour. Information presented orally may be supplemented by written material.

The purpose of motivational interviewing is not necessarily to get patients to change their behaviour but more to tailor advice and guidance to each individual. The startingpoint is that the motivation for change arises from personal clarity and liberation from an ambivalent attitude towards change. Health personnel can help patients to achieve clarity and perhaps change by using a motivational interviewing technique in a nonjudgemental atmosphere.

Health-promoting counselling

A form of health-promoting counselling was developed at Bispebjerg Hospital in the late 1990s. It is based on the principles of motivational interviewing but specifically targets people who are not currently motivated to change their lifestyle (precontemplation, contemplation and preparation stages) (9;10).

Health-promoting counselling focuses on risks related to heart disease, the links between arteriosclerosis and lifestyle, the seriousness of the disease and the effects of inappropriate lifestyles, the health benefits of changing lifestyle and the opportunities to achieve appropriate health behaviour.

Practitioners attempt to strengthen patients’ situationally specific self-confidence by such means as mentioning positive experience from previous changes in lifestyle. Biofeedback may also be used to emphasize the effects of inappropriate lifestyles. The task of the practitioner is to clarify how patients can be motivated to change their lifestyle and what the current barriers to change are.


3.3.2 Health communication

Health communication is defined here as all communication on disease, illness, disease prevention and health promotion involving a health professional and a patient (25). Health communication is key in intervening in patients’ lifestyle and is an integral part of the theoretical basis of the comprehensive cardiac rehabilitation programme. Lifestyle intervention also integrates the fact that knowledge cannot function in isolation (26;27) but is part of a complex interaction with other factors.

Structured health communication takes place in the structured services for patient education, group activities and individual counselling. The daily clinical practice emphasizes communicating knowledge in a neutral, factual and nonjudgemental tone. The communication is tailored to the motivation, needs and resources of each patient. The Unit attempts to ensure that the various practitioners provide uniform information to avoid confusion and uncertainty about the message among patients. Nonverbal health communication is also consciously promoted in the form of a smokefree environment, bowls of fruit and water instead of sweetened drinks. The effect of practitioners’ health behaviour on patients has been documented in smoking cessation and other areas (28–31).


3.3.3 Prompting by an authority

The Cardiac Rehabilitation Unit consistently ensures that physicians as authorities emphasize to patients how serious heart disease is and inform about the opportunities to prevent and avoid progression of heart disease by changing lifestyle. The importance of the physician prompting changes in lifestyle is based on the health belief model and the self-efficacy theory and is especially well documented in smoking cessation (32–34). In addition, patients surveyed indicated that the physician’s advice has been decisive in their decision to change lifestyle (35).


3.3.4 Biofeedback

The Cardiac Rehabilitation Unit evaluates whether goals have been achieved by using physiological and biological markers in all areas. This evaluation is fed back to reinforce the patients’ belief that barriers can be overcome and new behaviour can be established, corresponding to strengthening situationally specific self-confidence in the self-efficacy theory.

Examples of how the Unit uses biofeedback include measuring serum cholesterol levels in dietary intervention,weighing patients as part of a weight-loss programme, measuring carbon monoxide concentrations in expired air and pulmonary functioning as part of smoking cessation and repeatedly testing aerobic functioning and monitoring heart rate in connection with exercise training.


3.3.5 Group activities

The Cardiac Rehabilitation Unit emphasizes social interaction between patients, and many of the rehabilitation components are carried out as group intervention, such as smoking cessation, exercise training and cooking. Group activities as part of lifestyle intervention have especially been documented to influence smoking cessation (36).


3.3.6 Practical testing

Cardiac rehabilitation at Bispebjerg Hospital emphasizes giving patients the opportunity to test changing their lifestyle in practice. Patients who cook experience that food that promotes heart health can taste good and that very little fat is needed. The exercise training component emphasizes transferring the exercise directly into daily life.

This cross-cutting method is based on several theories. Practical testing contributes to strengthening the situationally specific self-confidence from the self-efficacy theory, positively influencing long-term changes in lifestyle. Practical testing is also a tool for increasing patients’ action competence within a specific area and can give patients experience on which they can draw in planning and implementing change in lifestyle in accordance with the stages of change model.


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(36) Kamper-Jørgensen L, Gry Poulsen J. Forebyggelse gennem gruppeaktiviteter [Preventing disease through group activities]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 312–321.


2. METHODS


Chapter 4

Individually Tailored Rehabilitation

Marianne Frederiksen & Pernille Kriegsbaum

[see illustration]


4.1 Introduction

One main principle of cardiac rehabilitation is that treatment should be individually tailored for each patient (1–4). This principle is considered to be a key element in the future organization of cardiac rehabilitation (5), and modern cardiology emphasizes this as the organizational focus of treatment (6). Previous assessments of the achievement of goals in European countries have shown that the traditional arrangement of rehabilitation has been inadequate to achieve the goals set (7;8), and recent studies on cardiac rehabilitation (9;10) have shown that individually tailored programmes achieve goals better and are cost-effective.

The Cardiac Rehabilitation Unit at Bispebjerg Hospital tailors patients’ rehabilitation programmes based on individual consultation with a physician, a clinical dietitian, a physical therapist and a nurse followed by an interprofessional conference that establishes the final goals of treatment based on the needs and resources of each patient. This chapter describes the individual consultations and the interprofessional conferences.


4.2 Mmethods

4.2.1 Principles

The programme is individually tailored and the individual consultation is performed based on several consistent principles.

Patient-centred communication
The professionals attempt to carry out the consultation based on the principles of equality, empathy and responsiveness. The dialogue is based on the individual patients and attempts as much as possible to identify the patients’ needs and resources. The professionals ensure that patients understand the information provided, and oral information is supplemented with relevant written information to the extent patients desire this. The clinical team tries to disseminate uniform information to avoid confusion and uncertainty about the messages among patients.

Information
The clinical team generally tailors the amount of information to the patients’ needs and resources. Lack of knowledge and uncertainty on treatment and illness can result in anxiety, whereas patients can stay calm if they feel well informed. Conversely, too much information may upset patients. Many patients prefer to have oral information supplemented with written information that they can review at home. Nevertheless, some patients have difficulty reading and would therefore mainly benefit from material with images, including film and video. They may benefit from seeing a film focusing on their current situation. The Cardiac Rehabilitation Unit finds that patients increasingly use the Internet to search for information. The task of the clinical team is to refer to patient-friendly material on the Web that is in accordance with the information disseminated in the programme.

Continuity in the treatment programme
The programme emphasizes ensuring that patients experience a coherent treatment programme. At the first appointment, patients are informed about the programme, the time frame and the order of the various activities in the comprehensive cardiac rehabilitation programme. Patients are regularly informed when changes are made.

Responsibility and division of labour
The roles and responsibilities of the clinical team members are an important part of the programme. The professionals briefly describe their background and role during the patient’s programme at the Cardiac Rehabilitation Unit the first time each patient meets each professional.

The nurse is the key staff member in each patient’s individual programme. The nurse is also responsible for coordinating the Unit’s interprofessional approach.

The nurse and physician review many of the same items in the individual consultation; the physician especially focuses on the patients’ history and course of illness and the nurse more on the patients’ psychosocial well-being.

Documentation and quality assurance
The Cardiac Rehabilitation Unit uses joint electronic patient records to coordinate and optimize the interprofessional approach.1 The treatment activities and quality assurance of the treatment are documented through structured record notations and systematic data registration. As part of the individual consultations, the goals of treatment, treatment plan and any changes are registered so that this information is available at the subsequent consultations and the interprofessional conferences.

Heart-health orientation binder
A heart-health orientation binder published by the Danish Heart Foundation is given to the patients. Patients are encouraged to bring the heart-health orientation binder to individual consultations. All written material provided by the Unit is designed in a format that fits the binder.

Preparation for individual consultation
The staff members are prepared for the planned individual consultations in the cardiac rehabilitation programme so that the patients experience presence and commitment. Time is set aside for preparation immediately before the consultations so that all professionals are reminded of the patient’s illness history, lifestyle and psychosocial factors, test results, biochemical data, pharmaceutical treatment, treatment goals and treatment plan.

Appointment and time used
Patients referred to the programme are ideally appointed to the first consultation with a physician 1 week after referral. After the physician, the patient consults the physical therapist and the dietitian. The consultation with the nurse is the last in the series of introductory individual consultations.

The initial consultations are allocated 60 minutes, including preparation, discussion, record-keeping and administration. The patients are informed at the start of the consultations on their purpose and time frame.


4.2.2 Administration of individual programmes

The secretary coordinates the four individual consultations and the start of group sessions in the intensive 6-week programme.

Illustration of: Administration of individual programmes

1 week after referral
Individually tailored programme:
Consultation with physician
Consultation with physical therapist
Aerobic functioning test
Consultation with dietitian
Consultation with nurse
Interprofessional conferences

6-week programme
Intensive cardiac rehabilitation:
Individual consultations if needed

3, 6 and 12 months
Management and clinical assessment

Notifying the patient: The Unit sends a welcoming letter to the patient in connection with the placement of the patient in the physician’s schedule. The letter includes the time of the consultations with the physician, physical therapist, dietitian and nurse. A welcoming letter is included that describes the treatment programme and a guide for various clinical tests and examinations (the welcoming letter, brochures and appointment card are available in Danish at www.CardiacRehabilitation.dk). Family members (especially spouses) are invited to participate in all individual consultations.

Group sessions: PPatients who will be attending group sessions are notified of the start of group sessions when five to eight patients are ready. The patients’ desires for starting time are taken into account. Patients attend planned activities of 2–5 hours per day twice a week for 6 weeks.

The Unit sends the patient an appointment card with an overview of appointments and activities. If individual follow-up appointments are needed, these are coordinated with the other appointments to minimize the number of trips to the Unit.

Administration: The secretary ensures that the patients are entered into the electronic administrative system (the joint electronic patient records). Group sessions are administered in an electronic patient database (the DANREHAB database) developed as an administrative tool to manage patient appointments, the creation of groups and the dissemination of letters and evaluation forms. The information is maintained and updated regularly. The secretary ensures that the necessary papers, including patient records and material related to assessment and referral, is present and updated at the first appointment.


4.2.3 Individual consultation with a physician

Purpose
The purpose of the initial individual consultation is to assess patients’ overall health based on their diagnoses, severity of illness, symptoms, risk profile, lifestyle, physical functioning and psychosocial well-being and to organize an individually tailored rehabilitation programme based on individual treatment goals.

The consultation
The physician prepares an assessment report based on the patient’s hospital records that comprise the basis for the consultation. The consultation is structured based on a specific interview guide (available in Danish at www.CardiacRehabilitation.dk).

Summary of illness history and course of illness. The physician and the patient review the patient’s current illness history that resulted in the referral to the comprehensive cardiac rehabilitation programme. This review is based on the assessment report, and patients can ask questions and provide additional information.

Test results: The patient is informed about the tests performed and their purpose. Medical terms often need to be explained. A metaphor is used to describe technical terms such as ejection fraction. “Imagine that the heart is like a pump in the shape of a balloon and is filled with 100 ml of water. Every time you squeeze, 60 ml of water is ejected [ejection fraction 60%]. This is about how much blood the heart pumps out. If you squeeze the balloon less, only 40 ml is ejected [ejection fraction 40%], and this means that the heart has lost some of its ability to pump.”

Other diseases and disorders: The physician systematically gathers information on other diseases and disorders that can influence the rehabilitation programme to assist in individual tailoring of programmes. The presence of arthritis or rheumatism or other musculoskeletal disorders may affect the organization of the exercise training. The physician informs the patient about the links between heart disease and related diseases. Such diseases as stroke before myocardial infarction or intermittent claudication are related both to one another and to the risk factors for cardiovascular disease.

Risk profile: The patient’s overall risk profile for cardiovascular disease is reviewed using the interview guide based on the available information. If information is missing, this is collected. The links between heart disease and the classical risk factors are reviewed briefly. Many patients learn for the first time that serum cholesterol is associated with smoking, overweight and physical inactivity, and many patients believe that high blood pressure is not related to heart disease.

The metabolic syndrome: The metabolic syndrome comprises several risk factors for cardiovascular diseases, the key ones being overweight, elevated blood pressure and high serum cholesterol. This syndrome has several definitions, but the Cardiac Rehabilitation Unit diagnoses based on WHO recommendations, and the syndrome diagnosis is used as a concept for improving the ability to trace and stratify by risk the patients with the highest risk, who often (but not always) have type 2 diabetes mellitus or impaired glucose tolerance (11;12).

Physical and mental well-being since discharge: Patients are asked how they are doing, such that the patient has the opportunity to describe minor health problems. Patients are then asked to assess their overall health. The physician asks about other cardiovascular problems, such as angina pectoris, breathlessness, ankle oedema, dizziness and palpitation. The links between heart disease and these various problems are explained when needed. Patients are asked about any symptoms of anxiety, mood swings and/or difficulty in sleeping to determine whether the patient has latent depression.

Social situation: The physician asks about previous or current employment, domestic activities and leisure pursuits, friends and family and determines whether the patient has given up any activities. Patients are asked about publicly subsidized services (such as home help or a personal alarm), sickness benefit and pension information. The patient is informed about the opportunity to consult a social worker. Finally, patients with driving licences are informed about the rules for driving among people with cardiovascular disease based on guidelines prepared by the Danish Society of Cardiology (13).

Sick leave: The physician determines the need for any sick leave and its duration at the first session. The sick leave should be as short as possible and account for cardiovascular status and the physical and mental demands of the employment. Most patients with myocardial infarction are on sick leave for 3–4 weeks after discharge. Some patients with light work that has low physical demands can return to work after 1–2 weeks.

Pharmaceutical treatment: The patient’s pharmaceutical treatment is reviewed, including natural medicine. The physician ensures that the patient receives and is complying with prophylactic medicine (Chapter 10). Many patients have difficulty in managing the numerous pharmaceutical products, and the cost of the user charges may be a problem. The patients are informed about rules for public subsidies, the purpose of the treatment and, if possible, the duration of the treatment. If necessary, the use of nitroglycerin is explained.

A physical examination: A cardiological examination is performed with inspection of the thorax and any surgical scars, stethoscopy of the heart, lungs, carotid and inguinal blood vessels, blood pressure measurement, inspection and investigation of the pulse on the lower extremities. The patient is weighed.

The physical examination is placed at the end of the consultation since the patient and physician usually build trust during the consultation. The physician summarizes such topics as overweight, elevated blood pressure and physical activity, and such topics as sex life and anxiety are also discussed.

Establishing treatment goals: Optimum treatment goals are established based on the information gathered and considering the patient’s diagnosis within the areas of symptomatic and prophylactic pharmaceutical treatment, risk factor management, lifestyle and level of functioning.The physician and patient discuss the treatment goals.

The following table presents the guidelines for ideal treatment goals based on Denmark’s current guidelines for each area. If a patient’s situation applies to several areas, such as having both ischaemic heart disease and type 2 diabetes, the most restrictive treatment goals apply.

Ideal treatment goals in the comprehensive cardiac rehabilitation programme
  CHF
- type 2 diabetes
(20;21)
IHD
- type 2 diabetes
(22-27)
Type 2 diabetes
micro-albuminuria
(12;28-30)
Type 2 diabetes
micro-albuminuria
(12;28-30)
High risk
- type 2 diabetes
(25-27)
Symptomatic treatment No angina
NYHA classes I–II
No angina
NYHA classes I–II
Fasting blood glucose
Hg A1c < 6.5%

Blood pressure (mmHg) <140/90 <130/80 <120/75 <140/90
Serum cholesterol

Total (mmol/l)

<4,5

<4,5

<5,0

LDL (mmol/l)

<2,6

<2,6

<3,0

HDL (mmol/l)

>1,0

>1,2

>1,0

Triglycerides (mmol/l)

<2,0

<1,7

<2,0

Weight

BMI

<25 kg/m2

<25 kg/m2

<25 kg/m2

Waist male/female <94 cm/<80 cm <102 cm/<88 cm <102 cm/<88 cm
Lifestyle

Physical activity

30 minutes
per day.

30 minutes
per day.

[see note]

30 minutes
per day.

[see note]

Dietary habits

Heart-healthy diet

Type 2 diabetes diet

Heart-healthy diet

Smoking Nonsmoker Nonsmoker Nonsmoker
Level of functioning

Physical Maximally optimized Maximally optimized Maximally optimized
Psychological Maximally optimized Maximally optimized Maximally optimized
Social Maximally optimized Maximally optimized Maximally optimized
CHF = congestive heart failure
IHD = ischaemic heart disease
NYHA = New York Heart Association classification system
Hb A1c = glycosylated haemoglobin A
LDL = low-density lipoproteins
HDL = high-density lipoproteins
BMI = body mass index

The guidelines on treatment goals are based on guidelines from Denmark and elsewhere. The Department of Cardiology has prepared local guidelines on treatment that summarize the current guidelines in Denmark and elsewhere (available in Danish at www.klinik-y.dk).

The values for ideal treatment of elevated blood pressure and elevated serum cholesterol have changed in recent years (14–19), which has resulted in more intensive treatment of patients with heart disease and type 2 diabetes and of patients with a high risk of heart disease.

Treatment plan: The consultation ends by establishing a treatment plan that considers patients’ experience, needs, resources and motivation. The physician and the patient complete the plans for treatment and results in the heart-health orientation binder.

The physician emphasizes to patients the significance of and effects of lifestyle intervention, and the extent of their motivation for intervention is determined in the initial consultations with the physical therapist, dietitian and nurse, who manage this part of the treatment. The physician specifies in the treatment and results plan whether risk factors should solely be managed using lifestyle intervention: for example, treating slightly elevated blood pressure by exercise training alone.

The physician decides whether pharmaceutical treatment needs to be further assessed or initiated or changed. Finally, the physician reviews the absolute and relative contraindications for carrying out the aerobic functioning test and participating in exercise training and decides whether the test should be carried out with normal or extended precautionary procedures (these procedures are available in Danish at www.CardiacRehabilitation.dk).

Contraindications for exercise training or aerobic functioning test (32;34)
  • Acute ischaemic heart disease stabilized for less than 5 days
  • Resting apnoea
  • Pericarditis, myocarditis or endocarditis
  • Symptomatic aortic stenosis
  • Severe hypertension
  • Fever
  • Thrombophlebitis
  • Class IV of the New York Heart Association classification system


4.2.4 Individual consultation with a physical therapist

A key aspect of the programme is optimizing patients’ physical functioning and ensuring that they are active in daily life to prevent future heart problems. The clinical team must therefore have extensive knowledge of this area.

The patient has an individual consultation with a physical therapist. This consultation is immediately after the initial consultation with a physician and includes an aerobic functioning test. The physical therapist prepares by focusing special attention on any contraindications for exercise training and whether patients receive pharmaceutical treatment that can influence exercise training.

Purpose
The purpose of the initial consultation is to jointly plan the exercise training programme based on the patient’s needs, resources, experience and motivation to be physically active in daily life and the opportunities to implement exercise training in the activities of daily living, including exercise training at work.The physical therapist strives to get the patients to set the goals for their physical rehabilitation, which are not set in stone but are regularly adjusted jointly by patients and the physical therapist. The physical therapist supports patients in setting realistic goals, guides the patients towards achieving these goals and apply any corrective measures necessary.

Physical activity levels
  1. Nearly sedentary: <2 hours per week
  2. Light physical activity 2–4 hours per week
  3. Modeate physical activity >4 hours per week
  4. Strenuous physical activity >4 hours per week
Note: The recommendation on physical activity changed during the study period from 4 hours of moderate physical activity a week to >30 minutes per day (31–33).

Initial consultation
The initial consultation with the physical therapist is carried out based on patient records and is structured based on an interview guide (available in Danish at www.CardiacRehabilitation.dk).

Determining the level of physical activity: The consultation is used to quantify the patients’ daily and weekly level of activity based on self-report and to place them in one of the four groups above. The patients describe their daily physical activity.

Problems related to physical activity: Patients are asked whether they have musculoskeletal symptoms from physical activity.They are also asked about any difficulty in breathing, whether they are anxious about exercise and the thoughts they have in relation to this anxiety.

Experience with physical activity: Patients’ experience with physical activity is determined with the aim of focusing on positive experience and avoiding reinforcing negative experience. Any specific exercises that are not carried out are reviewed and noted.

Patients’ goals for physical activity: Patients are encouraged to set their own goals for exercise training in the 6-week exercise training programme and in their activities of daily living. Examples of patients’ goals for activities of daily living include getting to Tivoli without help or cycling to work instead of driving.

Test of aerobic functioning: All patients take a test of aerobic functioning. The test is used to stratify patients in terms of risk and also has a health education aim for the patients who are anxious about activity and physical effort. The test is further carried out to assess patients’ aerobic capacity to assist in establishing individual exercise training programmes and a basis for biofeedback related to exercise training and in evaluating exercise training.

Patients carry out a maximum symptom-limited aerobic functioning test on an exercise cycle. If the test cannot be performed because of contraindications or because the patient cannot cycle, the patient walks for 6 minutes. Both tests are performed based on a set procedure that ensures patient safety (available in Danish at www.CardiacRehabilitation.dk). The procedure is based on the guidelines for clinical exercise testing in relation to ischaemic heart disease of the Danish Society of Cardiology (34).

Setting treatment goals: The treatment goals are set together with the patient based on the consultation and the aerobic functioning test. It is decisive that the patients define their own goals for exercise training, both in the six-week programme and in activities of daily living, and this is therefore a key aspect of the consultation.

The overall goal for physical activity in daily life is light physical activity 30 minutes per day in accordance with the guidelines of the National Board of Health. The goal is to get all patients up to this level regardless of their starting-point. Patients who have the potential can set a more extensive goal.

An individually tailored exercise training programme is set based on the initial consultation and the aerobic functioning test, including the level of exercise training based on heart rate response and effort achieved during the test (the procedure is described in Chapter 6).


4.2.5 Individual consultation with a clinical dietitian

A heart-healthy diet is a cornerstone of the comprehensive cardiac rehabilitation programme. The clinical team must therefore have extensive knowledge of patients’ dietary habits and the clinical dietitian must therefore consult individually with all patients.

Purpose
The purpose of the consultation is to determine each patient’s current dietary habits and individual dietary problems and to arrange an individually tailored programme of dietary change based on individually established treatment goals.

The initial consultation: The initial consultation with the dietitian is carried out based on patient records and is structured based on an interview guide (available in Danish at www.CardiacRehabilitation.dk).

Determining dietary habits and examining nutritional status. The dietitian gathers information on the patient’s dietary habits by obtaining a detailed dietary history and by examining nutritional status, including registration of weight and waist circumference.

Medicine and diet: The patient’s medicine is reviewed to determine whether any pharmaceuticals can influence weight or interact with foodstuffs. For example, antidepressants can cause weight gain and antiplatelet drugs may interact with foodstuffs rich in vitamin K1 (Chapter 7).

Review of the principles of a heart-healthy diet: The principles of a heart-healthy diet include reducing fat intake, especially saturated fat and trans-fatty acids, increasing intake of fatty fish, eating 500–600 grams of vegetables and fruit per day and reducing salt intake. The review focuses on the areas in which the patient needs to change dietary habits.

Agreement on dietary change: Based on the information gathered and the patient’s motivation, the dietitian and patient enter into a written agreement on dietary change and/or weight loss, which the patient places in the heart-health orientation binder (the agreement form for weight loss is available in Danish at www.CardiacRehabilitation.dk).

The dietitian determines whether each patient needs an individually tailored dietary rehabilitation programme with the dietitian to supplement group sessions. Individual programmes are relevant if the patient is overweight, has type 2 diabetes, is quitting smoking, has recently starting pharmaceutical treatment known to cause weight gain or has a risk of undernutrition (assessed through body mass index, progressive weight loss and food intake (35)).


4.2.6 Individual consultation with a nurse

The nurse’s coordinating role requires the nurse to have a comprehensive overview of each patient’s course of illness and treatment, health resources, motivation for changing lifestyle and psychosocial situation. Each patient therefore has an individual consultation with a nurse as part of organizing the individually tailored programme.

This consultation, which is the last of the four initial consultations with the clinical team, takes place within the first week of the intensive programme. An early consultation ensures that the patient does not brood over unanswered questions and is the basis for optimum coordination and planning of the intensive programme.

Purpose
The purpose of the consultation is that the nurse acquires a comprehensive sense of patients, including their current resources and needs, insight into the course of illness and treatment and motivation to change lifestyle in accordance with the recommendations. Patients are encouraged to describe their course of illness so far, and the nurse supports the patients in setting goals for both the short term and long term, depending on the current problems.

The initial consultation
The nurse uses patient records to determine patients’ diagnoses, risk factors, course of illness and treatment, planned examinations and tests and any pharmaceutical treatment and gets a sense of lifestyle and goals based on the other individual consultations.

An interview guide (available in Danish at www.CardiacRehabilitation.dk) ensures that the nurse achieves the agreed goals for the consultation. The guide is applied flexibly, since the consultation is based on patients’ needs.

Patients’ descriptions of the previous course of illness: Experience shows that patients and professionals can weight various aspects differently. Allowing patients to recount their course of illness gives the nurse a solid basis to understand patients, their course of illness and the subjective impressions experienced.

Patients’ descriptions of the situation since discharge or completion of treatment: The nurse asks about patients’ current physical, mental and social situation. How has it been to come home and start daily life again? How have family members reacted?

Patients’ physical, mental and social resources: The nurse mainly focuses on mental and social resources. The nurse asks about patients’ private life, work, networks (including contact with primary health care), leisure activities, experience with previous bouts of illness and mental well-being.

Patients’ health resources: Patients are encouraged to describe their strengths. What are they good at? How do they cope with adversity? Which characteristics do they use to cope? Most of these patients are not used to describing themselves and therefore need support in expressing their strengths.

Current physical, mental and social problems: The nurse helps patients in assessing their current physical, mental and social problems. Patients’ mental status is assessed in relation to the natural reaction to crises (in accordance with Cullberg’s (36) theory of the four phases of a crisis: shock, reaction, adaptation and reorientation), anxiety and depression.

Patients’ smoking history: Patients’ smoking habits are determined. The nurse asks smokers how many years they have smoked, their current consumption and whether they have tried to quit.

Patients’ motivation to carry out the recommended changes in lifestyle: Each patient enters into an agreement with the nurse on whether the patient will attempt to change several lifestyle facets at once or one at a time.

Goal-setting and initiatives: Patients are encouraged to formulate short-term and long-term goals for change based on the problems and their motivation to change their lifestyle. The goals are used to agree on an action plan, including any referral to psychiatrists, social workers and/or alcohol treatment professionals.

Patients’ expectations towards the rehabilitation programme: Patients are encouraged to describe their expectations towards the rehabilitation programme, and the nurse and patient discuss the potential to meet these expectations.

Patients’ follow-up by other hospital departments: To ensure optimum coordination, the nurse investigates whether other hospital departments are following up patients.

Patients’ wishes about family members participating. Patients are encouraged to ask their family members (especially spouses) to participate in the programme, but the clinical team respects the wishes of patients who want to participate alone.

Pharmaceutical treatment: The nurse reviews the current pharmaceutical treatment with patients. Can they tolerate the medicine? Do they remember to take it? Can they afford the co-payments?

Heart-health orientation binder: At the end of the consultation, the nurse gives the heart-health orientation binder, which contains relevant material, to the patients who did not receive it during admission. The nurse may also give patients other written material if they can benefit.

Need for follow-up consultation with the nurse: Follow-up consultation can be arranged if planned initiatives need to be coordinated and followed up or planned goals need to be evaluated, including any new goals and action plans. Follow-up consultation will further be relevant for patients motivated to participate in smoking cessation counselling or who need to have a family member attend a review of the programme. Patients referred to a psychiatrist or alcoholism treatment should have follow-up consultation with the nurse at which they can jointly assess the situation based on any new treatment initiatives.


4.2.6 Interprofessional conference

After the individual consultations, the weekly interprofessional conference discusses the patients. This conference is mandatory for all professionals involved, who prepare for the conference so that they can present patients’ cases, discuss based on the perspectives of each profession and determine the final goals of treatment.

The clinical team has joint interprofessional responsibility for conducting the conference at a professionally qualified level and within the established time frame. The project manager ensures that the meeting is held in relation to the agreed framework, and the secretary is responsible for preparing the list of patients so that the professionals can prepare. The nurse is responsible for presenting the patients and tying up loose ends. The other professionals are responsible for supplementing the discussion from their professional perspective.

Purpose
The purpose of the interprofessional conference is to ensure that each patient has an interprofessionally coordinated and individually tailored rehabilitation programme and to determine the interprofessionally coordinated treatment goals adapted to each patient’s motivation and resources.

The conference
The conference takes 1 hour and is based on the joint electronic patient record for each patient. The conference has a standard agenda. The secretary records decisions made in the patient record.

The nurse reviews all new patients, summarizing their illness history and the state of diagnosis, assessment, prognosis and review of risk factors and current pharmaceutical treatment. Each patient’s psychosocial situation is summarized and resources and barriers are reviewed. The interprofessional treatment goals are adjusted based on the information available, and the final treatment plan is determined. Then specific problems among current patients are discussed. The problems are placed on the agenda before the conference takes place. The problems requiring interprofessional initiatives are presented briefly and discussed. The conference ends by reviewing and coordinating the work tasks of the coming week.


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(21) Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22(17): 1527–1560.

(22) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(23) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(24) Bertrand ME, Simoons ML, Fox KA,Wallentin LC, Hamm CW, McFadden E et al. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2002; 23(23): 1809–1840.

(25). Forebyggelse af iskæmisk hjertekarsygdom i almen praksis [Prevention of ischaemic heart disease in general practice]. 2nd edn. Copenhagen, Danish College of General Practitioners, 2002.

(26) Færgeman O, Christensen B, Steen Hansen H, Jensen GH, Melchior TM, Nordestgaard BG et al. Sekundær og primær forebyggelse af koronar hjertesygdom med særligt henblik på dyslipidæmi [Secondary and primary prevention of coronary heart disease with a special focus on dyslipidaemia]. Copenhagen, Danish Society of Cardiology, 2000 (www.dadlnet.dk/klaringsrapporter/ 2000-07/2000-07_0.htm, accessed 22 March 2004).

(27) Abildgaard Jacobsen I, Bang LE, Borrild NJ, Feldt-Rasmussen BF, Steen Hansen H, Ibsen H et al. Hypertensio arterialis [Arterial hypertension]. Copenhagen, Danish Hypertension Society, 1999 (www.dadlnet.dk/klaringsrapporter/1999-09/1999-09-0.htm, accessed 22 March 2004).

(28) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(29) European Diabetes Policy Group. A desktop guide to type 2 diabetes mellitus. Diabet Med 1999; 16: 716–730.

(30) American Diabetes Association. Clinical practice recommendations 2001. Diabetes Care 2001; 24(suppl 1): S33–S63.

(31) Fysisk aktivitet og sundhed [Physical activity and health]. Copenhagen, National Board of Health, 2001.

(32) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity – manual on disease prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(33) Andersen LB. Physical spare time activity. Physical activity and prevention of cardiovascular diseases. Copenhagen, Danish Heart Foundation, 1999.

(34) Saunamaki K, Egstrup K, Krusell L, Mickley H, Nielsen JR, Schnohr P.Vejledende retningslinjer for klinisk arbejdstest i relation til iskæmisk hjertesygdom [Guidelines for clinical exercise testing in relation to ischaemic heart disease]. Copenhagen, Danish Society of Cardiology, 2002.

(35) Ernæringsrigtigt sygehus. Definition og strategi for implementering [Healthy nutrition at hospitals. Definition and strategy for implementation]. Copenhagen, National Network of Health Promoting Hospitals in Denmark, 2003.

(36) Cullberg J. Dynamisk psykiatri [Dynamic psychiatry]. Copenhagen, Hans Reitzels Forlag, 1989.


2. METHODS

Chapter 5

Patient Education

Lone Kjems Brunse

[see illustration]

5.1 Introduction

Patient education is defined as systematic communication of health knowledge and guidance to patients and their families. It is a cornerstone of cardiac rehabilitation.

Patient education in the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital includes group education, individual education and training of practical skills. This chapter describes the principles of the patient education, the heart-health meetings, which are arranged as a structured educational programme encompassing six meetings, and the supplementary instruction in cardiac resuscitation.

Patient education

1 week after referral:
Individually tailored programme

6-week programme
Intensive cardiac rehabilitation:
Heart-health meetings
Individual education
Supplementary instruction in cardiac resuscitation

3, 6 and 12 months
Management and clinical assessment


5.2 Documentation

Evidence On The Effects Of Patient Education

Knowledge comprises an important aspect of lifestyle intervention but cannot stand alone (Chapter 3) (1). Two comparative studies on patient education for patients with heart disease (2;3) show that patient education is essential to give patients a qualified basis for making decisions and to increase their knowledge, but it is not sufficient to change lifestyle significantly. The quality of patient education depends on planning and on the use of principles especially related to social theories of learning: relevance to patients’ needs and resources, opportunity for individualization, feedback, reinforcement and facilitating behaviour change through skills and resources (4). Patient education should be combined with psychosocial support and lifestyle intervention to result in change in health behaviour. Similarly, knowledge of the disease and how people react to it are key components of psychosocial support (Chapter 9) but are not sufficient to improve psychosocial well-being (5).

Studies have shown that patients with heart disease seek knowledge on disease, treatment options and prognosis (6) and what they can do to prevent the disease or its progression (7;8). Health personnel in Denmark are obligated by law to inform and advise patients on these matters. According to the Act on Patients’ Legal Rights of 1998 (9), health personnel in Denmark must inform patients about their state of health and treatment opportunities, including opportunities to prevent disease, and the potential effects of not initiating treatment.

There is a consensus in Denmark that patient education should be part of comprehensive cardiac rehabilitation (10–12) and the rehabilitation of patients with type 2 diabetes who have a high risk of heart disease (13). Nevertheless, Denmark has no detailed guidelines for the content, form and extent of the education.


5.3 Purpose

The purposes of the patient education in the comprehensive cardiac rehabilitation programme are to provide patients with basic knowledge on their illness and how they can contribute to preventing or hindering the progression of the disease and to advise patients on how to master their disease.


5.4 Methods

5.4.1 Principles

Patient education in the comprehensive cardiac rehabilitation programme is based on several cross-cutting principles described in this section.

Adult education
The intervention, which aims towards strengthening patients’ ability to learn, is based on the principles of educating adults. This means that patients should be stimulated to define their needs and what types of knowledge they want.The educational process is determined by patients’ expressed desires and self-identified needs (14). Patient education in the comprehensive cardiac rehabilitation programme is based on patients exchanging experience, viewing their life situation and experience as a valuable resource and considering each patient’s readiness for learning.

Barriers to learning
Known barriers to learning are minimized when the programme of patient education is arranged, either in groups or individually. Before patients can be receptive to education, any mental problems must be tackled, patients’ pain must be treated optimally and their physical state must allow them to concentrate. Patients with special needs receive special attention, such as patients with impaired vision or hearing and patients not born in Denmark.

Group sessions
Patient education is mainly organized as group sessions. The educational sessions were inspired by a course developed by the Danish Heart Foundation and Sundhedshøjskolen (Health School) Diget (15) and adapted to the comprehensive cardiac rehabilitation programme. Patients are also offered a supplementary course in cardiac resuscitation.

The patients have education sessions with the professionals they know from the individual consultations, which creates continuity in the programme.This means that the patient, spouse or other family member and professional build trust during the sixweek programme. The group sessions have no more than eight patients plus any family members.

The instructor presides over the meeting and encourages patients to participate in constructive debate that allows questions and the exchange of knowledge and experience. For example, one patient described how he experienced the week after a bypass operation, and another patient described the warning signs he got before myocardial infarction. This stimulates the exchange of ideas among the other patients.

To create a secure atmosphere, the patients present themselves briefly and an agreement is made about the rules the group will follow. Finally, the instructor clarifies the purpose of the education by reviewing the topics to be discussed and then discusses patients’ expectations. The instructor tells the group that everyone has to maintain confidentiality and that each individual decides what information to relate to the group.

Der lægges vægt på, at alle skal kunne følge med. Det har vist sig, at mange patienter, som har talt med deres læge om angina pectoris gennem mange år, ikke præcist ved, hvad betegnelsen betyder. Fagsprog i undervisningen bliver derfor holdt på et minimum, men langsomt introduceres patienterne til ordvalg og forkortelser som angina pectoris, AMI, PCI osv., da patienterne før eller siden vil støde på ordene [se note].

Everyone has to be able to follow the group sessions. Many patients who have talked with their physician about angina pectoris for many years still do not know exactly what this means. Technical language is therefore minimized in the sessions, but words and abbreviations such as angina pectoris, acute myocardial infarction and percutaneous coronary intervention are gradually introduced since patients sooner or later will encounter these words.

Since the groups are randomly created across age, gender and course of illness, not all patients consider the content of the course to be equally relevant to them. The instructor attempts to adapt the set education programmes to the situation of each patient. The instructor regularly assesses which topics are most appropriately discussed in individual counselling.

Group effects: It is important for groups to keep attendance reasonably constant. High attendance stimulates both patients and instructors. The patients are therefore requested to notify the instructor if they are going to be absent. This request has turned out to have an inherent effect of increasing attendance.

Individual education
Patients who do not wish to participate in group education sessions or are considered to need a supplement to group education are offered individual education sessions. For example, patients in crisis and patients with a complicated course of illness would benefit from extra guidance, perhaps together with family members. This also applies to patients who do not speak Danish well, are hearing impaired, mentally unstable or for whom the group sessions are interrupted because of admission or illness. The relevant professional conducts the education and bases the sessions on the patient’s situation. Several professions are often involved, such as combining counselling with a physical therapist and a dietitian in a weight-loss programme.

Instructional aids
Education sessions use slide presentations in PowerPoint (Microsoft Office), flipover charts, a whiteboard and various models of the heart and the coronary arteries. The dietitian uses food packaging and blind tasting so that several senses are activated in the learning process. The education computer of the Cardiac Rehabilitation Unit is linked to the Internet, and relevant web sites are used as needed in education sessions. Further, the Unit has various video films on heart disease and treatment that patients can watch or borrow and watch at home.

Heart-health meetings
Meeting Topic Professional responsible
1 Development of cardiovascular disease Physician and nurse
2 Mental reactions associated with (the risk of)
cardiovascular disease and hospital admission
Nurse
3 Living with (the risk of) cardiovascular disease
– including pharmaceutical treatment
Nurse
4 A heart-healthy diet in daily life Dietitian
5 Physical activity in daily life Physical therapist
6 Changing lifestyle – what about daily life? Nurse


5.4.2 Heart-health meetings

Six heart-health meetings of 1.0–1.5 hours are held. Each meeting begins by briefly reviewing the agenda and the type of meeting, and the patients are informed that they can ask any questions they have during the meetings. Each meeting has a special education programme (available in Danish at www.CardiacRehabilitation.dk) with which the entire clinical team is familiar. Each professional takes responsibility for preparing and developing his or her own educational materials.


1. Heart-health meeting


Development of cardiovascular disease




Physician and nurse

Purpose
The purpose of the meeting is to give patients and family members insight into the factors that contribute to cardiovascular disease and related risk factors in accordance with the recommendations of the Danish Society of Cardiology.

The meeting
The patients are encouraged to introduce themselves by name and age and to describe very briefly their course of illness. Then patients get a nametag to place on their clothes. The introductions are arranged such that each patient can decide whether to participate. The patients are seeing one another for the first time, and some have never attended such courses before.

The physician starts by describing the physiological background for developing cardiovascular disease and indicates that arteriosclerosis is a universal phenomenon. Thus, the discussion is relevant to all patients even if they do not yet have signs of illness. Risk factors related to previous and present lifestyle are reviewed and discussed together with when and why pharmaceutical treatment is advantageous. Finally, the nurse explains the programme of heart-health meetings and gives the patients a written overview of the meetings (available in Danish at www.CardiacRehabilitation.dk) to put in their heart-health orientation binder. The nurse informs patients about the supplementary course on cardiac resuscitation and encourages them to participate.


2. Heart-health meeting


Mental reactions associated with (the risk of)
cardiovascular disease and hospital admission




Nurse

Purpose
The purpose of this meeting is to give patients and family members insight into various types of mental reactions to hospital admission and cardiovascular disease. The meeting allows patients and family members to exchange experience based on their current desires and needs.

The meeting
The nurse explains that the education will focus on emotional reactions that may arise in connection with illness and hospital admission. The nurse emphasizes that there can be more than one way to tackle this situation, and not everyone experiences these emotional reactions.

The nurse defines the concept of crisis and reviews the phases of the crisis in relation to symptoms and duration (Chapter 4). Anxiety is explained, since anxiety can be a natural result of heart disease. This can include anxiety related to the future, falling asleep, physical activity, including resuming sexual activity, and other matters. Patients should understand that these reactions are quite normal. The nurse informs patients about the symptoms of depression and the importance of taking these symptoms seriously and seeking help when necessary. The nurse explains that spouses often experience the same phases as patients.

The patients are encouraged to exchange experience on how to cope with stress, crisis, anxiety, depression or other problems. Many patients really need to express how they have experienced illness, whereas others prefer to take action to cope with their problems.

The nurse adjusts the content of the meeting according to the composition of the group in terms of course of illness and present situation. Not everyone wants to share their feelings and thoughts with others in the group, and this wish is respected. If the nurse considers that some patients need to discuss their course of illness subsequently they are offered individual consultations. Similar, the nurse is aware that the meeting can promote a process of reflection that some patients may need to discuss later in the programme.


3. Heart-health meeting


Living with (the risk of) cardiovascular disease
– including pharmaceutical treatment




Nurse

Purpose
This meeting educates and guides patients in their symptoms and taking appropriate action based on these symptoms. The meeting also discusses pharmaceutical treatment and reviews selected risk factors in detail.

The meeting
Following up the theoretical explanation of cardiovascular disease at the first meeting, the nurse explains how individuals can cope with heart disease in daily life. Such symptoms as angina pectoris, breathlessness, impotence and intermittent claudication are explained. What should patients do when these symptoms arise? When should they seek health care professionals? Which procedures should they follow in daily life? The nurse ensures that everyone knows the effects and side effects of using nitroglycerin and other pharmaceuticals. If most of the patients in the group do not yet have heart disease, the nurse emphasizes risk factors for cardiovascular disease. The nurse attempts to include patient’s risk profiles as examples. When are blood pressure or serum cholesterol too high? What roles do smoking or overweight play?


4. Heart-health meeting


A heart-healthy diet in daily life




Dietitian

Purpose
This meeting gives patients tools to make conscious choices in purchasing situations. The focus is on the fat content of food, especially “hidden” fat and saturated fat. The taste and quality of food is discussed as well as traditions and habits.

The meeting
The dietitian encourages patients to suggest topics based on current problems. Based on the fat content of food, the dietitian explains how to read a food product label and the different between the percentage of fat in the food and the percentage of total energy deriving from fat. The meeting then discusses many common foods and the recommendations for the maximum percentage of energy intake from fat. The fat content of cheeses, processed meat and fish products and various cuts of meat is reviewed. The fat and sugar content of the currently available low-fat and low-sugar products is reviewed. The dietitian hands out material for help in shopping (a purchasing guide from the Becel® Programme, the Danish Heart Foundation or the Danish Diabetes Association and a fat-o-meter from the Federation of Danish Pig Producers and Slaughterhouses) and presents ideas on heart-healthy sandwiches (from the Becel® Programme). Patients’ potential rejection of low-fat margarine (versus butter and full-fat butter–oil blends) and low-fat cheese are discussed based on blind tasting.

The educational methods include slide shows, dialogue, blind tasting and demonstration of product packages. The dietitian includes as many senses as possible to strengthen the learning process. Patients are allowed to ask questions so that they can compare with their previous experience in such areas as shopping, cooking and following a specific diet.


5. Heart-health meeting


Physical activity in daily life




Physical therapist

Purpose
This meeting ensures that patients receive theoretical knowledge on physical activity with the aim of preventing heart disease. The educational process, similar to exercise training, is intended to encourage patients to adopt a more physically active lifestyle.

The meeting
The physical therapist emphasizes that everyone is expected to participate in the discussion and that all questions on physical activity are relevant. The physical therapist then explains the overall principles of exercise training in an attempt to promote discussion on exercise training and what it means to each person. Patients’ experience is incorporated in the meeting, and patients have the opportunity to draw parallels with the supervised exercise training.

Patients have an opportunity to express how they have experienced the previous 5 weeks of exercise training and can discuss the perspectives for the future. Numerous questions emerge during the meeting.Why should people be physically active? What physical activities are necessary? What intensity is sufficient? How can physical activity be implemented in everyday life? How can people maintain an appropriate level of physical activity in the future?


6. Heart-health meeting


LChanging lifestyle – what about daily life?




Nurse

Purpose
This meeting gives each patient the opportunity to evaluate the programme and their own efforts and to set new goals for changing and maintaining lifestyle based on their current situation.

The meeting
The meeting is based on the patients’ experience and thoughts. Each patient is encouraged to describe their individual programme and tell about changes they have initiated. Then the patients can discuss their thoughts.Will maintaining the changes after the intensive programme is over be difficult? What plans does each patient have for the future? The nurse considers the fact that everyone may not wish to describe their own efforts. Nevertheless, habits related to physical activity, diet and smoking are less taboo that such topics as crisis, anxiety and depression for most people.

The nurse informs patients about local activities and how these can support individual patients in changing lifestyle (included in Danish in the activity folder described in Chapter 9). These can include events held by the Danish Heart Foundation, events related to physical activity or smoking cessation and especially meetings that strengthen community with other people. The information is adapted to the group and the current needs of each patient..

Finally, the nurse informs patients about their relationship with the comprehensive cardiac rehabilitation programme in the following year, including clinical assessment by the physician and opportunities for individual follow-up among the various professionals in the clinical team.


5.4.3 Supplementary instruction in cardiac resuscitation

Studies show that both patients with heart disease and their close family members are interested in receiving instruction in cardiac resuscitation (16). Patients who have been resuscitated and family members who have witnessed cardiac arrest are especially interested in such instruction (17). Nevertheless, we found that very few family members actively seek instruction in cardiac resuscitation. Denmark’s departments of cardiology have not traditionally offered patients’ family members instruction in cardiac resuscitation even though patients with heart disease have an increased risk of cardiac arrest and about 70% of all cases of cardiac arrest occur at home (18).

The comprehensive cardiac rehabilitation programme developed a three-hour course in cardiac resuscitation for patients and family members to supplement the intensive programme. The instructional material was prepared in accordance with the international guidelines on basic life support for adults (19) and the recommendations of the Danish Heart Foundation (20). The group sessions have no more than eight people. Patients and family members are informed about and offered the course in cardiac resuscitation at the first heart-health meeting. The nurse teaches the course.

Course in cardiac resuscitation
Nurse

Purpose
The course teaches family members and patients about the causes of cardiac arrest, how to determine whether cardiac arrest is occurring and training in practical skills in cardiac resuscitation.

The course
The course is simple and includes only the absolutely crucial elements, to ensure that the participants remember the essentials. The goal is to get participants to feel ready to help in cardiac resuscitation and feel certain that they cannot do anything inappropriate. The participants can train at their own pace. Some participants are not strong enough to practise cardiac massage or to give artificial respiration; others have difficulty practising on the floor. The course considers individual needs.

Introduction (15 min.): Each participant is encouraged to describe his or her expectations on and reasons for taking the course. The nurse asks everyone whether they have witnessed cardiac arrest whether they have experienced cardiac arrest or have helped in cardiac resuscitation. This can help the nurse in considering individual needs in the course.

Theory (40 min.): The nurse explains the known causes of cardiac arrest. The participants are then shown how to determine whether cardiac arrest is occurring and how to treat it and how and when one should call for help. The nurse briefly reviews fainting (syncope), which looks similar to cardiac arrest, the recovery position and the chain of survival.

The chain of survival has four links: getting help early, early cardiac massage, early defibrillation and early advanced cardiac resuscitation. The family members learn to take action in the first two links. The nurse emphasizes that all four links are essential for optimum resuscitation.

Illustration of The Chain of Survival


Practical exercises (100 min.): The participants perform practical exercises in a large room with space for pairs of participants to practise. The exercises comprise:

  • Determining whether cardiac arrest is occurring;
  • Calling for help; and
  • Resuscitation (artificial respiration and cardiac massage)

The nurse demonstrates these techniques on a mannequin, and then the participants individually try to perform them. Each person has a mannequin available. The stepwise demonstration clarifies many questions during the course and participants learn much by observing one another. After the demonstration the participants pair off to practise determining whether cardiac arrest is occurring, calling for help and cardiac massage.The nurse supervises the participants and ensures that all participants practise all aspects.

Conclusion (10 min.): The conclusion includes discussion and answering questions arising during the course. All participants get a brochure on cardiac resuscitation (20), and the nurse explains the importance of participants regularly repeating the theoretical and practical skills.


References

(1) Froelicher ES. Multifactorial cardiac rehabilitation: education, counseling, and behavioral interventions. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. New York, Dekker, 1999: 187–191.

(2) Godin G. The effectiveness of interventions in modifying behavioral risk factors of individuals with coronary heart disease. J Cardiopulm Rehabil 1989; 9: 923–936.

(3) Cowan MJ. Cardiovascular nursing research. Annu Rev Nurs Res 1990; 8: 3–33.

(4) Mullen PD, Mains DA, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns 1992; 19(2): 143–162.

(5) Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol 1999; 18(5): 506–519.

(6) Danish Regions, Copenhagen Hospital Corporation and Ministry of Health. Patienternes vurdering af landets sygehuse [Patients’ assessment of Denmark’s hospitals]. Glostup, Copenhagen County, 2000.

(7) Campbell N, Grimshaw J, Ritchie L, Rawles J. Cardiac rehabilitation: the agenda set by postmyocardial infarction patients. Health Educ J 1994; (53): 409–420.

(8) Duryee R.The efficacy of inpatient education after myocardial infarction. Heart Lung 1992; 21(3): 217–225.

(9) Lov nr. 482 om patienters retstilling [Act No. 482 of 1 July 1998 on Patients’ Legal Rights]. Copenhagen, Ministry of the Interior and Health, 1998.

(10) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(11) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(12) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(13) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(14) Maunsbach M. “One thing is something theoretical … quite another is practice!” Aspects of compliance and non-compliance among patients with type 2 diabetes. Dissertation. Aarhus, Department of General Practice, University of Aarhus, 1997.

(15) Rødkær C, Bergfors V, Hvid U. Kursus for hjerteramte familier, 7 døgns internatkursus. Sundhedshøjskolen Diget [Course for families of people with heart disease, 7-day course at Health School Diget]. Copenhagen, Eget forlag, 1990.

(16) Platz E, Scheatzle MD, Pepe PE, Dearwater SR. Attitudes towards CPR training and performance in family members of patients with heart disease. Resuscitation 2000; 47(3): 273–280.

(17) Kliegel A, Scheinecker W, Sterz F, Eisenburger P, Holzer M, Laggner AN. The attitudes of cardiac arrest survivors and their family members towards CPR courses. Resuscitation 2000; 47(2): 147–154.

(18) Årsberetning 2000 [Annual report, 2000]. Copenhagen, Danish Heart Foundation, 2001.

(19) Handley AJ, Becker LB, Allen M, Van Drenth A, Kramer EB, Montgomery WH. Single rescuer adult basic life support. An advisory statement from the Basic Life Support Working Group of the International Liaison Committee on Resuscitation (ILCOR). Resuscitation 1997; 34(2): 101–108.

(20) Hjertestop – din hjælp er livsvigtig [Cardiac arrest – your help is vital]. Copenhagen, Danish Heart Foundation, 2001.


2. METHODS

Chapter 6

Exercise Training

Thomas Hvass Villadsen & John Kristensen

[see illustration]

6.1 Introduction

Exercise training comprises the largest portion of time spent in the 6-week cardiac rehabilitation programme at Bispebjerg Hospital. This chapter describes the principles of the exercise training, how the supervised exercise training is carried out and the followup consultations with a physical therapist. Exercise training includes an introductory discussion with a physical therapist, a test of aerobic functioning and theoretical patient education (Chapters 4 and 5).

Illustration of Exercise training

1 week after referral
Individually tailored programme:
Consultation with a physical therapist
Test of aerobic functioning

6-week programme
Intensive cardiac rehabilitation:
Supervised exercise training
Theoretical education
Open group sessions

3, 6 and 12 months
Management and clinical assessment:
Consultation with physical therapist
Test of aerobic functioning


6.2 Documentation

Physical inactivity – a risk factor among people with healthy hearts
Evidence (1;2) shows that physical inactivity is an important risk factor for heart disease among both men and women. Studies show an association between low aerobic capacity and the risk of death and heart disease. Evidence (3–5) further indicates that increasing physical activity reduces this risk.

Exercise training and survival among patients with heart disease
Several meta-analyses (6–10) show that exercise training among patients with known ischaemic heart disease reduces the mortality from heart disease. Mortality from heart disease declines by an estimated 31% and all-cause mortality by 27% compared with patients with heart disease not undergoing exercise training (8). A small study (11) demonstrated reduced mortality and hospital admissions among patients with congestive heart failure undergoing exercise training, but this needs to be confirmed.

Improving physical functioning and compliance
People with heart disease have poorer physical functioning than people with healthy hearts; this applies to men and women and to young and old people (12). The poorer functioning can be attributed to reduced aerobic capacity and to the anxiety about exercising after an acute cardiac event. Strong evidence (5) indicates that exercise training improves the physical capacity for work among people with healthy hearts and heart disease. Although supervised exercise training increases people’s aerobic capacity, this does not necessarily ensure a high level of physical activity in the long term. Patient compliance with both supervised and unsupervised exercise training is quite low: in one trial (13), only about half were more physically active after one year than they were before rehabilitation, and this dropped to 13% after three years. Knowledge of how to optimally organize exercise training to sustain the effect over a long time period is inadequate.

Mental functioning
Physical activity as part of comprehensive cardiac rehabilitation improves the quality of life of patients with heart disease (8;14), and Studies indicate that the effect of exercise training supplements the pharmaceutical treatment of mild and moderately severe depression (15).

Modifiable risk factors
Basic research on the effects of exercise training shows that exercise training substantially reduces blood pressure and increases serum high-density lipoproteins. Large intervention studies (8;16) could not reproduce this effect, however. Exercise training improves the regulation of blood sugar among people with diabetes (17), and lifestyle intervention including exercise training reduces the risk of developing type 2 diabetes among people with impaired glucose tolerance (18–20). Exercise training alone has limited effects on weight loss (21); adding dietary intervention to exercise training increases the effect.

There is a consensus in Denmark and elsewhere that exercise training is an important aspect of the overall rehabilitation of patients with chronic congestive heart failure (22), patients with ischaemic heart disease (23–25) and patients at high risk of ischaemic heart disease (5;26). According to the Hospital System Act of 2001, hospitals in Denmark are legally obligated to offer a rehabilitation plan to patients who have a medically justified need.


6.3 Purpose

The purposes of exercise training in the comprehensive cardiac rehabilitation programme are to teach patients about the relationship between physical activity and heart disease, to increase patients’ aerobic capacity and to test their mental and physical reactions in realistic exercise situations with the aim of getting patients physically active in daily life.


6.4 Methods

6.4.1 Principles

The supervised exercise training in the comprehensive cardiac rehabilitation programme is structured based on several principles described in this section.

Six weeks of supervised exercise training
Current European recommendations (27) say that supervised exercise training should last 8–12 weeks, but the length of supervised exercise training varies substantially between cardiac centres and countries (28). The comprehensive cardiac rehabilitation programme offers all patients 6 weeks of supervised exercise training, which can be extended if needed. The need for further supervised exercise training is assessed based on an aerobic functioning test and an evaluation consultation.

Individual exercise training level
Strong evidence indicates that patients with heart disease can improve their aerobic capacity. Effective exercise improves cardiovascular capacity or strength. An exercise training session is optimally 90 minutes long. Of this, at least 30 minutes should be at 60–70% of the maximum heart rate for each patient. This is equivalent to the patient exercising hard but still being able to converse (22;29–31).

The intensity of exercise among patients with heart disease is recommended to be 60–80% of the maximum heart rate (30). The comprehensive cardiac rehabilitation programme determines the patients’ theoretical maximum heart rate by carrying out a symptom-limited aerobic functioning test on a stationary cycle (Chapter 4). If such a test cannot be performed, the theoretical maximum heart rate is determined based on the formula: estimated theoretical maximum heart rate = 208 – (0.7 × age). This formula has been validated in a population including a large group of elderly people (32). The comprehensive cardiac rehabilitation programme sets the maximum recommended heart rate at 70–80% of the theoretical maximum obtained through a test of aerobic functioning or estimation.

Calculated theoretical maximum heart rate for a 65-year-old
Estimated theoretical maximum heart rate: = 208 – (0.7 × 65) = 162 beats per minute
Exercise training: = 30 minutes at 60–70% of 162 beats per minute = 97–113 beats per minute

The maximum heart rate to be attained in exercise training is reduced individually for patients who have strain-induced angina pectoris, arrhythmia, an implantable cardioverter defibrillator, heart transplantation, congestive heart failure (NYHA class III) or obesity and patients who get very little exercise.

The exercise training programme for these patients is planned based on a precautionary principle. Exercise training is induced at about 50% of the theoretical maximum heart rate (under the maximum conversational level) with short intervals, frequent breaks and slow progression (22).

The comprehensive cardiac rehabilitation programme uses heart rate monitoring and the guideline of a conversational maximum to simultaneously assess patient’s individual exercise intensity. The exercise heart rate is established based on these principles depending on the results of the aerobic functioning test, the variation in the patient’s heart rate and the clinical assessment by the physical therapist of the patient’s level of aerobic functioning.

Activity in daily life
The National Board of Health recommends at least 30 minutes of moderate physical activity daily for adults (4;5), and the exercise training in the comprehensive cardiac rehabilitation programme is based on this principle. According to the recommendation, all forms of physical activity in the activities of daily living are included, even less intensive physical activities that do not influence maximum oxygen uptake substantially but are still considered to promote health. An example of moderate activity is rapid walking in which the respiration frequency is elevated but conversation is possible. Accumulated activity in daily life is just as health-promoting as continuous activity and perhaps even more so based on a behavioural perspective.

Exercise training can improve general cardiovascular (aerobic) capacity or muscle strength. The physical capacity of many patients with heart disease is so low that almost any type of physical activity will influence both aerobic capacity and muscle strength (31;35). Exercise training in the comprehensive cardiac rehabilitation programme is mainly group sessions and based on everyday activities such as walking, climbing stairs and cycling. No special clothes and equipment are necessary.The exercise training is performed both outdoors and indoors.

Normal walking insufficiently challenges the cardiovascular system among welltreated patients with heart disease but without congestive heart failure, and especially patients with a high risk of heart disease. The comprehensive cardiac rehabilitation programme therefore also uses walking-sticks for outdoor walking (see the model photograph in Chapter 9). The walking-stick activates the upper extremities, which ensures exercise for the entire body. Exercise balls, balance boards and aerobic elastics for light muscular strength training are also used.

The exercise training is intended to be easy to perform, to be easy to implement in daily life and to make the body feel good. The specific exercises are chosen based on the extent to which the exercises are relevant to each patient. Easier, less expensive and more relevant exercises are more likely to make patients choose to be more physically active in daily life in the maintenance phase after the 6-week intensive exercise training programme.

Exercise training is individually tailored, considering diagnosis, individual differences in physical capacity, motivation for exercise, musculoskeletal strengths and weaknesses and the patient’s daily life. Patients receive individual feedback, and individual patients are supported in fulfilling their specific desires. The physical therapist emphasizes involving patients from the first session as co-planners of their exercise training. The physical therapist can easily identify the patients who lack motivation to begin exercise training by either allowing each patient to choose the type of exercise training or making a collective agreement on the exercise training each day.

During the entire programme, the patients are encouraged to exercise at home between the two weekly exercise training sessions in accordance with the recommendations on daily exercise of the National Board of Health (4;33).

Voluntary effort and breaks when needed
Exercise training in the comprehensive cardiac rehabilitation programme is based on the principle of voluntary effort and taking breaks when needed; experience shows that patients are more motivated to exercise if they know that they can take breaks than if the exercise training is very strict. Further, the breaks ensure that patients do not overexert themselves and exceed their capacity.

Warming up and cooling down
Before exercising, the patients warm up for at least 10 minutes. After exercising, the patients cool down either by gradually reducing the strain on the stationary cycle, through relaxation (visualization, breathing exercises or meditative exercises) or by stretching muscles. This avoids sudden cardiovascular strain, which can be manifested as angina pectoris, changes in blood pressure, peripheral tiredness and, occasionally, arrhythmia.

Individual evaluation and feedback
For each patient, the heart rate data from each day’s exercise training is registered, and the patients rate their perceived exertion based on the Borg Scale from 6 to 20, the subjective sense of exercise training on a scale from 1 to 5 and any angina on the Borg Angina Scale from 1 to 10 (the evaluation scales used for individual evaluation are available in Danish at www.CardiacRehabilitation.dk). The physical therapist also registers any extraordinary events in connection with exercise training (such as falls or dizziness). Based on the patients’ ratings and the heart rate data for that day, the physical therapist and the patient discuss how exercise training went and adjust and adapt the exercise training when necessary. The effect of exercise training is assessed at the three-month and 12-month follow-up consultations, at which a test of aerobic functioning is conducted (Chapter 4).

Exercise training for patients with congestive heart failure
Exercise training for patients with symptoms of congestive heart failure (NYHA classes II and III) follows the same principles as for other patients with heart disease. Patients must be undergoing pharmaceutical treatment and must not have symptoms at rest (NYHA class VI), which contraindicates exercise training. In accordance with the European recommendations (22) and the principle of precaution, the exercise programme is set with a lower intensity of exercise, typically 50% of the theoretical maximum heart rate.The exercise training also has briefer intervals, many breaks and gradual progression based on the progress in exercising of each patient. Patients with congestive heart failure exercise together with the other patients and also have a heart rate monitor. Patients with congestive heart failure typically exercise longer than 6 weeks in the comprehensive cardiac rehabilitation programme.

Exercise training of patients with type 2 diabetes
The exercise training of patients with type 2 diabetes follows the same principles as exercise training for other patients with heart disease but considers any diabetes selfcare and regulation. Unregulated diabetes is a relative contraindication for exercise training. The patients are informed that exercise training reduces any insulin dose required, and measuring their blood sugar before and after exercise training has great psychological significance and increases the patients’ motivation for exercise training.


6.4.2 SSupervised exercise training

Group exercise training
Group exercise training comprises 12 exercise sessions of 1.5 hours. The exercise training changes from considerable supervision to self-managed exercise training during the 6 weeks.

Week 1
First session: The physical therapist informs the patients of the purpose and principles of exercise training in the comprehensive cardiac rehabilitation programme, the roles of the physical therapist and the patients and the use of various exercise facilities. Questions are clarified and the practical exercise training can begin. Through the initial individual consultation, the aerobic functioning test and the patient record, the physical therapist is thoroughly oriented about the patient’s illness history, lifestyle and psychosocial state and biochemical data and pharmaceutical treatment, which can influence the level of physical activity.

The patients are instructed on general procedures for exercise training at the Cardiac Rehabilitation Unit and at home.

General procedures for exercise training for patients with heart disease
  • Patients should only exercise when they feel healthy. Patients should not exercise until 2 days after any symptoms of fever, influenza or the common cold disappear.
  • Patients should not exercise intensively after a large meal but should wait at least 2 hours.
  • Patients should drink plenty of water before, during and after exercise.
  • Patients should not drink alcohol before exercising.
  • Exercise should be adapted to the weather. Special consideration should be taken in both very hot and very cold weather.
  • Patients who develop angina pectoris, headache, dizziness, breathlessness or dyspnoea, muscle cramps or palpitation should stop exercising immediately.
  • Patients should walk more slowly in hilly terrain.
  • Patients should be dressed appropriately, use proper footwear and protect the head against cold and wind.

Patients are instructed to be very attentive to signs of excessive intensity.

Clinical signs of excessive exercise intensity
  • Patients who have trouble sustaining the exercise intensity at the end of the session should reduce the pace since it is important that exercise end with a feeling of physical energy.
  • Patients who have difficulty in conversing during exercise should slow down.
  • Dizziness or dyspnoea can result from insufficient cooling off.
  • Patients who are chronically tired should take more breaks and reduce the duration of exercise.
  • Patients who get excessive aerobic exercise can get insomnia. The exercise level should be reduced so that symptoms disappear. An appropriate exercise programme should promote a good sleeping pattern.
  • Joint pain can be a sign of excessive strain. Patients should stop the activity or reduce the intensity.

Finally, patients are encouraged to always ensure gradual progression: they are told that they should take one break too many instead of one too few. Patients are advised that the body must have time to recuperate. Appropriate exercise allows recuperation within 24 hours. If exercise requires longer recuperation, the intensity is excessive.

The first exercise is usually ball training in a room, which is used to test patients’ motor skills, breathlessness, any exertion-caused angina pectoris and functional capacity and the patient’s ability to cooperate and take initiatives.The physical therapist informs and supervises when needed based on the impression of the individual patient and the group. This exercise brings the patients together and supports a positive process of group dynamics. Then the physical therapist introduces stationary cycles and perhaps step benches (simulated stair-climbing), which are each performed for a maximum of 5–10 minutes. The step benches are used to prepare patients for actual stairclimbing and for patients who need specific training in climbing stairs.

Second session: In the second session, the physical therapist introduces heart rate monitors, and the optimum exercising heart rate is determined based on the aerobic functioning test. The physical therapist tests the patients’ ability to climb stairs and to use a step bench. All patients start slowly, since climbing stairs is a relatively strenuous activity. At the end, the individual patients evaluate the group exercise training that day.

Week 2
During the second week, the patients have the opportunity to try the facilities and the physical therapist has had time to get an impression of each patient. More specific initiatives and individual tasks can therefore be tackled. The physical therapist still has a managing function and serves more as a instructor than as a supervisor, depending on how well the group works together. The exercise sessions become longer; the time spent exercising, the intensity and the choice of activities are optimized continually. However, the physical therapist does not yet attempt to get patients to exercise strenuously for a total of 30 minutes.

Week 3
The physical therapist manages the exercise training less in the third week.The physical therapist has taken on a more supportive function, and patients can consult the physical therapist when they need to. The physical therapist attempts to get the patients to fully use the exercise time, reach the agreed intensity, choose exercises and reach the effective exercise time in accordance with the planned goals.

Weeks 4-6
The exercise facilities of the Cardiac Rehabilitation Unit now function as a heart fitness centre in which the patients exercise with considerable autonomy. The patients have begun to acquire a routine in exercising, and most can feel the physical progress. Patients who have difficulty with exercise training get extra support to become optimally active.

Exercising in the community environment (phase III cardiac rehabilitation): Patients are encouraged to continue the daily physical activity at the same level after they end the 6-week supervised exercise training programme at the Cardiac Rehabilitation Unit. The physical therapist presents suitable exercise opportunities in the local area in the theoretical education (Chapter 5) and though the activity folder (Chapter 9). Nevertheless, appropriate exercise opportunities of this type are very scarce in the community environment. Finally, the patients are reminded about the activities of the Danish Heart Foundation in local areas, which are advertised in local newspapers, the newsletter of the Foundation (HjerteNyt) and at the web site of the Foundation (www.hjerteforening.dk).

Exercise training in open groups
The cardiac rehabilitation programme allows patients to participate in open groups. These groups are mainly for patients who need extra supervised exercise training, which is assessed at the follow-up evaluation consultation with the physical therapist. Patients eligible for the open groups include patients in individual programmes, patients with special needs and patients who have participated well either individually or in a group but have not achieved the expected physical or mental progress. This exercise training follows the general principles and is evaluated after another 6 weeks. The interprofessional conference decides who will participate in an open group.

Exercise training in an individual programme

Patients who have problems participating under normal conditions in the group sessions are offered individual guidance and exercise training. In practice, patients who receive individual exercise training are treated precisely the same as group participants except that the aspect of group dynamics is lacking.


6.4.3 Individual follow-up consultation

After 6 weeks of exercise training
The purpose of the second individual consultation with the physical therapist is to assess, through discussion and an aerobic functioning test, whether patients have achieved their overall goals. Another aim is to make the transition from intensive exercise training to normal daily activities as flexible and effective as possible. The physical therapist assesses whether patients need help in remaining physically active after the treatment period and whether they might benefit from further supervised exercise training.

After 12 months
Patients have been responsible for their own exercise for about 9 months. The third and final aerobic functioning test shows whether patients have been able to realize the goals agreed with the physical therapist. The physical therapist discusses the patients’ physical activity level in daily life based on their assessment of their situation and the aerobic functioning test. Patients who believe that they have achieved their goals and for whom the aerobic functioning test supports this have successfully changed their exercise habits. If this is not the case, patients should ideally be referred to a supervised programme in primary health care, although this is not currently possible within the public health care system in the local area surrounding Bispebjerg Hospital.


References

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(2) Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med 2000; 160(11): 1621–1628.

(3) Schnohr P, Scharling H, Jensen JS. Changes in leisure-time physical activity and risk of death: an observational study of 7,000 men and women. Am J Epidemiol 2003; 158(7): 639–644.

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(5) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity – manual on disease prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(6) Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA 1988; 19; 260(7): 945–950.

(7) O’Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS, Jr. et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80(2): 234–244.

(8) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(9) Brown A,Taylor R, Noorani H, Stone J, Skidmore B. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systemic clinical and economic review. Ottawa, Canadian Coordinating Office for Health Technology Assessment, 2003.

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(11) Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation 1999; 99(9): 1173–1182.

(12) Pinsky JL, Jette AM, Branch LG, Kannel WB, Feinleib M. The Framingham Disability Study: relationship of various coronary heart disease manifestations to disability in older persons living in the community. Am J Public Health 1990; 80(11): 1363–1367.

(13) Dorn J, Naughton J, Imamura D, Trevisan M. Correlates of compliance in a randomized exercise trial in myocardial infarction patients. Med Sci Sports Exerc 2001; 33(7): 1081–1089.

(14) Lloyd-Williams F, Mair FS, Leitner M. Exercise training and heart failure: a systematic review of current evidence. Br J Gen Pract 2002; 52(474): 47–55.

(15) Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001; 322(7289): 763–767.

(16) Smith KL, Wenger NK. Benefits of exercise training. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999.

(17) Boule NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001; 286(10): 1218–1227.

(18) Pan XR, Li GW, Hu YH,Wang JX, Yang WY, An ZX et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance.The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20(4): 537–544.

(19) Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344(18): 1343–1350.

(20) Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM,Walker EA et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346 (6): 393–403.

(21) Ross R, Janssen I. Physical activity, total and regional obesity: dose-response considerations. Med Sci Sports Exerc 2001; 33(6 Suppl): S521–S527.

(22) Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22(2): 125–135.

(23) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(24) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(25) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(26) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(27) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

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(31) Meyer K. Exercise training in heart failure: recommendations based on current research. Med Sci Sports Exerc 2001; 33(4): 525–531.

(32) Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001; 37(1): 153–156.

(33) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity – manual on disease prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(34) Andersen LB. Physical spare time activity. Physical activity and prevention of cardiovascular diseases. Copenhagen, Danish Heart Foundation, 1999.

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2. METHODS

Chapter 7

Support For Dietary Change

Inger Bols Jeppesen

[see illustration]

7.1 Introduction

The relationship between diet and cardiovascular disease has received increasing attention in recent years. Cardiac rehabilitation at Bispebjerg Hospital includes support for changing patients’ diet: individual counselling with a dietitian, practical cooking classes, theoretical education and individual programmes for special problems. This chapter describes the principles of providing support for changing patients’ diet, practical cooking classes, theoretical education and individual programmes for special problems. Chapter 4 describes the individual counselling with a dietitian, and Chapter 5 describes theoretical education in diet-related problems.

Illustration of Support for dietary change

1 week after referral
Individually tailored programme:
Counselling with a dietitian

6-week programme
Intensive cardiac rehabilitation:
Individually tailored programmes
Cooking classes
Theoretical education

3, 6 and 12 months
Management and clinical assessment:
Counselling with a dietitian if needed


7.2 Documentation

Evidence (1) indicates that dietary change aimed at reducing serum cholesterol can reduce the risk of myocardial infarction and reduce mortality from heart disease among patients with known ischaemic heart disease. Fatty fish and omega-3 fatty acids (2–4) and a Mediterranean diet 1 (3;5–7) reduce mortality and reinfarction.

The Danish Nutrition Council reviewed the evidence and concluded in 1996 (8;9) that heart-healthy dietary habits can reduce the risk of myocardial infarction and reduce mortality among patients with ischaemic heart disease, even though the dietary change may not necessarily be reflected in traditional risk factors such as serum cholesterol, blood pressure and weight.

Based on the evidence, guidelines in Denmark (10–12) recommend that all patients with ischaemic heart disease be motivated to eat a heart-healthy diet regardless of their serum cholesterol concentration. The effect on patients at high risk of ischaemic heart disease would probably be the same, but there is no evidence to support this.


7.3 Purpose

The purpose of dietary counselling in the comprehensive cardiac rehabilitation programme is that patients learn about the relationships between diet and heart disease and get tools to convert this knowledge into practical action that can result in longterm change in diet.


7.3 Methods

7.3.1 Principles

Dietary counselling in the comprehensive cardiac rehabilitation programme follows the overall recommendations for a heart-healthy diet: less fat and minimal saturated fat and trans-fatty acids, more high-fat fish and more vegetables and fruit (8). Patients’ motivation to change their diet differs in these various areas (13), and one study (14) indicates that patients with heart disease are more motivated to reduce fat intake and perform better at achieving this than at increasing intake of vegetables and fruit. This section reviews the principles and evidence for this heart-healthy diet.

Less fat
Dietary studies (2;4;6;7;15–19) have investigated the effects of reducing fat intake either isolated or as part of a Mediterranean diet.1 Based on the results, patients with heart disease are currently recommended to reduce their fat intake to 30% of total energy. This recommended reduction applies especially applies to saturated fat (sources including meat from land animals and dairy products) and trans-fatty acids (sources including hydrogenated vegetable fat), such that a maximum of 10% of total energy comes from these sources.

More fish
Based on studies that have increased fish intake to a level of 2–3 times per week (2;3;6), the intake of high-fat fish currently recommended is about 300 grams per week, corresponding to 7 grams of omega-3 polyunsaturated fatty acids per day. Patients who cannot or will not eat fish are recommended a daily supplement of fish oil, although the omega-3 content varies considerably in various fish oil products.

More vegetables and fruit
Studies that advised people to have a high intake of vegetables and fruit (3–7) found a protective effect on the incidence of heart disease. Daily intake of 500–600 grams of vegetables and fruit is recommended based on these studies.

Other dietary factors
In addition to a heart-healthy diet, patients are counselled on salt and alcohol intake. Salt intake is recommended to be less than 5000 mg of NaCl per day, equivalent to 1980 mg of elemental sodium. Patients are informed that liquorice has substantial salt. Alcohol is recommended to be avoided if serum triglyceride levels are excessive. Otherwise the programme advises the maximum weekly limits of 14 standard drinks per week for women and 21 for men recommended by the National Board of Health. Patients who desire to lose weight may need to reduce alcohol intake because alcohol provides substantial energy.

Cholesterol-rich foodstuffs
There is no consensus on the significance of high cholesterol intake from food. Nevertheless, meta-analyses show an association between dietary intake of cholesterol and blood cholesterol (20). The European recommendation (21) is a maximum of 300 mg of cholesterol intake per day, which is in accordance with other dietary recommendations that suggest reducing the amounts of high-fat meat and meat products, high-fat dairy products and butter and butter-oil mixtures. Food that contains animal fat is the most important source of dietary cholesterol and is therefore restricted. The amount of dietary cholesterol obtained from a normal intake of cholesterol-rich foods (eggs, organ meats and shrimp) therefore has little influence on heart health, and the general patient education does not focus on cholesterol intake.


7.4.2 Practical cooking classes

Group education comprises three cooking sessions of 2.5 hours. The three classes focus on heart-healthy and tasty recipes and emphasize that patients should be able recognize the food and find it easy to prepare.

The heart-healthy diet in the comprehensive cardiac rehabilitation programme
Session Topic Special materials Examples of dishes
1 High-fat fish,
vegetables and soup
Board
Food models
Foodstuffs
Food models
Foodstuffs
Salmon cakes
Herring with vegetable garnish
Grilled mackerel
Stir-fried vegetables
Stewed root vegetables
Stewed spinach
Fish soup
Beef vegetable soup
2 High-fat fish,
sauces and gravies,
vegetables and desserts
300 g of fruit
300 g of vegetables
Plates for serving
Salmon quiche
Fried herring with parsley gravy
Fish lasagna
Baked vegetables
Ratatouille
Potatoes au gratin
Chocolate apple cake
Baked peaches with meringue
3 Meat dishes,
sauces and gravies,
vegetables and desserts
Written quiz to test patients’ knowledge Meat balls and potato salad
Stewed cabbage
Meatballs in curry sauce with vegetables
Tenderloin with gravy
Casseroles with meat and vegetables
Lasagna
Mashed potatoes with root vegetables
Salads with mixed, chopped raw vegetables
Old-fashioned apple cake
Carrot cake
Rhubarb cake
Christmas dinner
Easter dishes

Patients work in teams of 2–3 and prepare 3–4 new dishes in each session. Before each session, the dietitian finds the recipes and ingredients for each group. Patients can save time if they do not have to find all the ingredients themselves in a kitchen with which they are not familiar. The dietitian briefly explains each recipe, focusing on why these recipes are especially appropriate to a heart-healthy diet.

Patients bring very different levels of skill to the class. This challenge is often met by establishing groups in which at least one person usually has some experience in cooking. A few patients cannot read. In such cases, the dietitian reads the recipe aloud or describes what is to happen to solve this problem in the cooking classes.

Each session is prepared based on the main themes of a heart-healthy diet. In the first two sessions, the dietitian introduces the principles of a heart-healthy diet for 30 minutes each. The kitchen is a suitable room for instruction, since various foods are present and can thus be shown to the patients. Then the patients work on cooking the dishes in a friendly and relaxed atmosphere.

The comprehensive cardiac rehabilitation programme use recipes from the Becel® Programme, the Danish Heart Foundation, the Danish Diabetes Association and its own recipes.2 Patients suggest recipes, which are then adapted so they comply with the principles of a heart-healthy diet.

Each cooking class ends with everyone sitting down to dinner. Patients’ spouses are invited to participate in the cooking and the meal afterwards. The meal is an informal forum at which many patients express thoughts and concerns they have in relation to their illness.The comprehensive cardiac rehabilitation programme therefore gives priority to ensuring that all professionals participate in the meal. The patients participate in setting and clearing the table and washing the dishes.


7.4.3 Individual programmes with the dietitian

Individual programmes are planned for patients with special needs who are motivated to change their dietary habits as follow-up to the initial consultation (see Chapter 4). The comprehensive cardiac rehabilitation programme has structured individual programmes for patients who are overweight, have type 2 diabetes or have a risk of undernutrition.

PPatients are offered dietary counselling, regular follow-up with adjustment of diet and inspiration and support to maintain the changes in diet. Patients in individual programmes are offered several counselling sessions throughout the 12 months they are in the comprehensive cardiac rehabilitation programme.

Individual weight-loss programmes
All patients whose body mass index (BMI) exceeds 25 or waist circumference exceeds the ideal treatment goals (listed in Chapter 4) are offered an individual weight-loss programme with the dietitian. Counselling and guiding overweight patients in the comprehensive cardiac rehabilitation programme is a very extensive process, however, since they are being recommended to change behaviour in several ways: increasing physical activity, changing their diet qualitatively and quantitatively and often reducing alcohol intake and quitting smoking. Further, each aspect of changing diet is considered as a separate change in behaviour.Thus, eating more vegetables and fruit, eating more fish and eating less saturated fat comprise several different changes to the patients (13;14).

An important aspect of the interprofessional approach is therefore to determine the lifestyle aspects in which the patients are most motivated and in which order the changes should be made. It is important to focus on the fact that weight loss of 10–20% can improve the blood sugar level, insulin sensitivity and the blood lipid profile sufficiently to reduce mortality from ischaemic heart disease. The dietitian can therefore agree with the patient on a realistic goal for moderate weight loss that can be achieved within a reasonable time period instead of working towards an ideal weight. The problem of obesity among many patients with BMI exceeding 35 may dominate their entire existence, and the opportunity to obtain help from a psychologist should be considered (22).

Most individual weight-loss programmes include seven counselling sessions.Week 1 comprises individual counselling for 60 minutes to agree on changing diet and to prepare an individual diet plan.Week 3 includes individual counselling and weighing (30 minutes).Weeks 5 and 8 include individual counselling and weighing and inspiration for cooking (15 minutes). At 3, 6 and 12 months, follow-up comprises individual counselling and weighing (15 minutes).

The dietitian prepares a diet plan for patients who require one. The energy used is calculated using basal metabolism based on age, gender and weight multiplied by an activity factor 3 (8). The recommended energy consumption is about 3000 kJ/day less, which produces an expected weight loss of about 0.65 kg per week. Obese patients (BMI exceeding 30) can plan a larger energy deficit (reduction corresponding to 4000 kJ/day) and a greater weight loss of about 1 kg per week. The recommended protein intake is at least 0.8 grams per kilogram of body weight.

Many patients who follow the recommendations on exercise training gain weight or remain stable in the first 2–3 weeks despite good compliance with dietary recommendations, mostly as a result of increased blood volume and muscular oedema.Weight loss is therefore not the sole focus; the patients’ waist circumference is also in focus, being measured at the initial consultation with the dietitian, at the weighing after 8 weeks and at follow-up consultations at 3, 6 and 12 months. Patients with good dietary compliance can expect to lose at least 4 kg at the 3-month control despite increased muscle mass (9).

Individual programmes for patients with type 2 diabetes
Patients with type 2 diabetes (without nephropathic complications) or impaired glucose tolerance who fulfil current criteria (23) are offered an individual programme with the dietitian as part of the total rehabilitation programme to normalize blood glucose, blood lipids, blood pressure and weight and prevent late complications. In practice, 85% of these patients also fulfil the criteria for being offered an individual weight-loss programme. Patients with newly discovered type 2 diabetes, impaired glucose tolerance or poorly regulated known type 2 diabetes are offered a further 30-minute individual consultation when the programme starts regardless of whether they need to or want to lose weight. The dietitian assesses compliance based on changes in haemoglobin A1c, blood lipids, waist circumference and weight.

The recommended diet for patients with type 2 diabetes is similar to the recommendations for a heart-healthy diet (24). In addition, patients with type 2 diabetes are recommended to have a regular pattern of meals with five or six total to reduce the degree of hyperglycaemia or hypoglycaemia between meals. This recommendation applies especially to pharmaceutically treated type 2 diabetes. Further, patients with type 2 diabetes are recommended to restrict intake of added sugar to 25 grams per day, evenly distributed among all meals.

Individual programmes for patients at risk of undernutrition
Patients who fulfil the inclusion criteria for treatment for undernutrition (instructions for screening such patients are available in Danish at www.CardiacRehabilitation.dk) are offered individually dietary treatment to help them gain weight or prevent further weight loss (12). Patients with congestive heart failure are typically in this group, as their appetite may be reduced because of illness and pharmaceutical treatment.

The diet of patients with heart disease being treated for undernutrition should ideally be based on the recommendations for a heart-healthy diet. Nevertheless, fat intake may need to be increased and vegetables and fruit reduced to ensure sufficient energy intake. Increased fat intake should mostly comprise monounsaturated and polyunsaturated fatty acids. Fruit intake may be maintained through fruit compote, stewed fruit, juice and other forms. The protein required varies from 1.0 to 1.5 grams per kilogram of body weight depending on the nutritional state and the underlying illness.

Patients at high risk of undernutrition may have to ignore the principles of a hearthealthy diet or any diet modified to account for diabetes for a period (13;14).

A heart-healthy diet and antiplatelet treatment
Some patients in the comprehensive cardiac rehabilitation programme are receiving antiplatelet treatment because of atrial fibrillation or after heart valve surgery. Many vegetables have a high concentration of vitamin K1, which can influence this treatment in combination with other factors.We find that many patients in antiplatelet treatment are incorrectly informed about the ideal choice and quantity of vegetables. The programme therefore emphasizes giving patients in antiplatelet treatment reliable and uniform guidance.

Vegetables with moderate to high concentration (>50 µg/100 g) of vitamin K1
Vegetable Vitamin K1 µg per 100 g
of vegetable (range)
Vegetable Vitamin K1 µg per 100 g
of vegetable (range)
Spinach, fresh 560 (480-640) Red cabbage 149
Spinach, frozen 340 Head lettuce 130
Broccoli 260 Iceberg lettuce 112
Kale 250 Celery root 100
Brussels sprouts 250 Peas 70
Cauliflower 210 (140-280) White cabbage 59
Spring (green) cabbage 170

Source: Saxholdt (25).

There is no consensus on the influence vegetables rich in vitamin K1 have on antiplatelet treatment. In practice, the current recommendation is a maximum of 250 µg of dietary vitamin K1 per day but, most importantly, a fairly constant intake each day. The main sources of vitamin K1 include dried beans, liver, eggs and certain vegetables, especially the cabbage family. Virtually no other foodstuffs contain significant amounts of vitamin K1.

The dietitian emphasizes to patients at the individual consultation that antiplatelet treatment does not mean that they cannot eat vegetables with vitamin K1 but that the maximum intake of these vegetables is about 100 grams per day (see table). For most people this will not be restrictive. All other vegetables are unrestricted, and patients in antiplatelet treatment should eat 600 grams of vegetables and fruit daily just like other patients with heart disease or a high risk of heart disease. Patients being treated with antiplatelet drugs must get the impression that they can still eat many vegetables.

Some herbs contain considerable vitamin K1. Nevertheless, they are usually eaten in such small quantities that this does not influence the total intake of vitamin K1. Dried beans, chick peas and the like also have a high content of vitamin K1.Vegetarians and some patients of non-Danish ethnic background may therefore have difficulty in maintaining vitamin K1 intake at 250 µg per day. In these cases, professionals should consider whether pharmaceutical treatment can be adapted more closely to each patient’s dietary habits.


Referencesr

(1) Katerndahl DA, Lawler WR. Variability in meta-analytic results concerning the value of cholesterol reduction in coronary heart disease: a meta-meta-analysis. Am J Epidemiol 1999; 149(5): 429–441.

(2) Burr ML, Fehily AM, Gilbert JF, Rogers S, Holliday RM, Sweetnam PM et al. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet 1989; 2(8666): 757–761.

(3) de Lorgeril M, Renaud S, Mamelle N, Salen P, Martin JL, Monjaud I et al. Mediterranean alphalinolenic acid–rich diet in secondary prevention of coronary heart disease. Lancet 1994; 343(8911): 1454–1459.

(4) Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990; 336(8708): 129–133.

(5) de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999; 99(6): 779–785.

(6) Singh RB, Rastogi SS,Verma R, Laxmi B, Singh R, Ghosh S et al. Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: results of one year follow up. BMJ 1992; 304(6833): 1015–1019.

(7) Singh RB, Dubnov G, Niaz MA, Ghosh S, Singh R, Rastogi SS et al. Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial. Lancet 2002; 360(9344): 1455–1461.

(8) Stender S, Astrup A, Dyerberg J, Færgeman O, Godtfredsen J, Vestager L et al. Kostens betydning for patienter med åreforkalkning i hjertet [The significance of diet for patients with coronary arteriosclerosis]. Søborg, Danish Nutrition Council, 1996; (10): 3–64.

(9) Stender S, Astrup AV, Dyerberg J, Faergeman O, Godtfredsen J, Lind EM et al. [Significance of food for patients with ischaemic heart disease.] Ugeskr Laeger 1996; 158(48): 6885–6891.

(10) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(11) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(12) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(13) Frame CJ, Green CG, Herr DG, Myers JE, Taylor ML. The stages of change for dietary fat and fruit and vegetable intake of patients at the outset of a cardiac rehabilitation program. Am J Health Promot 2001; 15(6): 405–413.

(14) Frame CJ, Green CG, Herr DG, Taylor ML. A 2-year stage of change evaluation of dietary fat and fruit and vegetable intake behaviors of cardiac rehabilitation patients. Am J Health Promot 2003; 17(6): 361–368.

(15) Leren P. The Oslo diet-heart study. Eleven-year report. Circulation 1970; 42(5): 935–942.

(16) Woodhill JM, Palmer AJ, Leelarthaepin B, McGilchrist C, Blacket RB. Low fat, low cholesterol diet in secondary prevention of coronary heart disease. Adv Exp Med Biol 1978; 109: 317–330.

(17) Schuler G, Hambrecht R, Schlierf G, Niebauer J, Hauer K, Neumann J et al. Regular physical exercise and low-fat diet. Effects on progression of coronary artery disease. Circulation 1992; 86(1): 1–11.

(18) Watts GF, Lewis B, Brunt JN, Lewis ES, Coltart DJ, Smith LD et al. Effects on coronary artery disease of lipidlowering diet, or diet plus cholestyramine, in the St Thomas’ Atherosclerosis Regression Study (STARS). Lancet 1992; 339(8793): 563–569.

(19) Watts GF, Jackson P, Burke V, Lewis B. Dietary fatty acids and progression of coronary artery disease in men. Am J Clin Nutr 1996; 64(2): 202–209.

(20) Howell WH, McNamara DJ, Tosca MA, Smith BT, Gaines JA. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: a meta-analysis. Am J Clin Nutr 1997; 65(6): 1747–1764.

(21) Prevention of coronary heart disease in clinical practice. Recommendations of the Second Joint Task Force of European and other Societies on coronary prevention. Eur Heart J 1998; 19(10): 1434–1503.

(22) Heitmann BL, Richelsen B, Hansen GL, Hølund U. Overvægt og fedme [Overweight and obesity]. Copenhagen, National Board of Health, 1999.

(23) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(24) Diætbehandling ved type 2 diabetes, voksne. Rammeplaner [Dietary treatment of adults with type 2 diabetes. Framework plans]. Copenhagen, Association of Danish Clinical Dietitians, 2001.

(25) Saxholdt E. Indholdet af K1-vitamin i levnedsmidler [Content of vitamin K1 in foods]. Copenhagen, Danish Veterinary and Food Administration, 1993.


2. METHODS

Chapter 8

Support For Smoking Cessation

Jeannette Larsen

[see illustration]

8.1 Introduction

Smoking cessation is considered an important element in both primary and secondary prevention of cardiovascular disease.The Cardiac Rehabilitation Unit supports smoking cessation through individual counselling with a nurse, smoking cessation counselling in groups and individual cessation programmes.


8.2 Evidence On The Effects Of Smoking Cessation

Tobacco smoking is the most important modifiable risk factor for ischaemic heart disease (1–3). Several studies (4–6) have calculated that smoking causes at least 25–30% of cases of acute myocardial infarction in Denmark, and 80% among young people

Illustration of Support for smoking cessation

1 week after referral
Individually tailored programme:
Counselling with a nurse

6-week programme
Intensive cardiac rehabilitation:
Individual cessation programme
Group cessation counselling
Nicotine replacement therapy

3, 6 and 12 months
Management and clinical assessment:
Follow-up counselling needed


Among people who have had an acute myocardial infarction, smokers have higher mortality than nonsmokers. A meta-analysis (7) estimated a 20% mortality rate among patients who have an acute myocardial infarction and continue to smoke.

These findings have never been confirmed in randomized clinical trials. The evidence is so convincing, however, that guidelines in Denmark recommend that patients with heart disease (8–10) and patients at high risk of heart disease stop smoking (11).

Many smokers who have had an acute myocardial infarction stop smoking spontaneously, but most start to smoke again shortly after admission (12;13).

Strong evidence shows that structured counselling by physicians (14), smoking cessation counsellors (15) and nurses (16) influences the rate of cessation. Support and counselling begun during admission and followed up at least one month after admission produces significantly higher cessation rates (17). Intensive counselling during admission without follow-up after admission did not seem to have any additional effect, however (18). Both individual counselling (15) and group education (19) increase the potential for sustaining cessation (20). Clear evidence indicates that nicotine replacement therapy combined with structured counselling is effective for heavy smokers, independent of the intensity of the counselling and the external setting (21). Evidence (22) also shows that bupropion, an antidepressant, has a positive effect. Nevertheless, experience is lacking in the use of bupropion among patients with heart disease, and it is therefore not routinely recommended for them.


8.3 Purpose

The purpose of smoking cessation services in the comprehensive cardiac rehabilitation programme is to support patients in quitting smoking and maintaining this.


8.4 Methods

8.4.1 Principles

Smoking cessation services are composed based on existing knowledge about activities that positively influence the cessation rate and based on a scheme developed by the Danish Council on Tobacco and the Danish Cancer Society that targets the general population. This scheme has been adapted and developed further to tackle the complex situation of the patients admitted to a hospital (23).


8.4.2 Individual smoking cessation counselling

The nurse records a smoking assessment for all patients who smoke or quit within the past 6 months at the individual consultation. The smoking assessment includes the smoking history and an assessment of the patients’ motivation for smoking cessation. The smoking assessment is recorded on a form for registering current data (available in Danish at www.CardiacRehabilitation.dk).

Patients’ smoking history
The consultation clarifies the patient’s previous experience with smoking cessation, smoking experience and present smoking profile and consumption. Patients are tested using the Fagerström Test for Nicotine Dependence (available in Danish at www.CardiacRehabilitation.dk and in English from many sources) to determine dependence and the dosage of nicotine required.

Assessment of motivation
Based on the cycle of motivation (described in Chapter 3), the nurse tries to determine patients’ motivation to quit smoking to initiate further activities if indicated. Patients are asked to state whether they have plans to quit smoking or have quit recently, and they are placed in one of the six stages in the cycle of motivation. The steps to be taken are arranged based on this placement. This section describes only the patients who are considering quitting or have begun to quit.

Patients who want to attend the group smoking cessation counselling during the intensive part of the comprehensive cardiac rehabilitation programme can agree with the nurse at the initial consultation about reducing smoking and start immediately. Patients who start to reduce smoking after the initial consultation can reduce consumption during the 10 days that elapse before the actual smoking cessation is planned.

Patients considering quitting (contemplation): The nurse’s tasks include supporting patients in overcoming their ambivalent attitudes towards quitting; informing patients about the effects of smoking and the significance of quitting on their disease and treatment; and determining whether patients want to reduce their consumption before quitting. The nurse explains nicotine replacement therapy to patients who want to cut down and supplies products.

Patients with plans to quit (preparation): The nurse’s tasks include helping patients in planning quitting; assessing whether patients should have individual support in quitting or participate in group cessation counselling; supporting patients in setting a date for quitting; and determining whether patients want to reduce smoking before quitting.

Patients in a cessation programme (action and maintenance): The nurse’s tasks include allowing patients to describe their progress in quitting; supporting patients with information on the health advantages of quitting, especially in relation to cardiovascular disease; continuing to inform about and offer nicotine replacement therapy; assessing whether patients have abstinence, including measuring the carbon monoxide concentration in expired air; and assessing the need for further follow-up.

Patients who have resumed smoking (relapse): Not all patients can quit permanently. Patients who have failed in quitting need acceptance and understanding and are therefore offered individual consultation to liberate them from guilt and help them to focus on the experience they have acquired in attempting to quit, since patients need to draw on their experience in new attempts to quit. Patients are informed to expect relapse in quitting smoking.

Nicotine replacement therapy
In the individual consultation, the nurse reviews the various forms of nicotine replacement therapy with patients. The nurse gives them two or three products, depending on their needs, a supply lasting 6 weeks. Spouses who want to quit smoking can receive nicotine replacement products for 1 week. Patients are instructed thoroughly in using nicotine replacement therapy so they do not increase the daily intake of nicotine. Patients and the professional agree on how much nicotine (lozenges, sublingual tablets, inhalers, chewing gum and patches) the patient may consume, and this is recorded in the smoking cessation form (available in Danish at www.CardiacRehabilitation.dk).The nurse monitors the patient at the next consultation, either at the first group counselling session or at the next individual smoking counselling. Symptoms of abstinence and overdose are corrected.

Carbon monoxide measurement
All patients have their concentration of carbon monoxide in expired air measured in accordance with current instructions (available in Danish at www.CardiacRehabilitation.dk). The carbon monoxide concentration is measured regularly among patients who are quitting to allow the patient to see that this parameter declines as a result of quitting.


8.4.3 Smoking cessation counselling in groups

The nurse informs patients about the group smoking cessation counselling during the initial consultation and at the first heart-health meeting and emphasizes that patients’ motivation is decisive to the success of this counselling. The group counselling is also open to the patient’s spouse or cohabitant.

The counselling is arranged as a programme of five sessions of 1.0–1.5 hours depending on the number of participants. Group counselling programmes start regularly so that patients can start as soon as they are motivated to quit. The sessions have the following themes: the patients’ smoking history, the motivation to quit, information on addiction and maintaining cessation. Nurses who are qualified smoking cessation counsellors conduct the sessions, which are structured around the following topics and relevant slides that are viewed at each session.:

Group smoking cessation programme
Session Topic
1 Smoking history and ambivalence towards quitting
2 Nicotine addiction, abstinence and nicotine replacement therapy
3 High-risk situations, relaxation and distraction
4 Health benefits of quitting and the problems of weight gain
5 Maintenance and evaluation


Session 1
Smoking history and ambivalence towards quitting

The patients and smoking cessation counsellor introduce themselves and review the patients’ smoking history. Based on the cycle of motivation, the participants discuss ambivalence towards quitting, focusing on why each patient wishes to quit now. Experience from any previous attempts to quit is discussed. The counsellor reviews the relationship between smoking and heart disease and other tobacco-related disease as well as the short-term health benefits. The participants discuss why quitting is so difficult, including both physical and mental addiction. Patients’ carbon monoxide concentrations in expired air are measured at the end of the session, and the group may decide to agree on a common quitting date while considering individual needs.


Session 2
Nicotine addiction, abstinence and nicotine replacement therapy

The participants say whether they have succeeded in reducing tobacco consumption. Nicotine addiction, abstinence and nicotine replacement therapy are discussed. The results of the Fagerström Test for Nicotine Dependence are used to determine the dosage of nicotine replacement therapy. The counsellor demonstrates the various nicotine replacement products and gives the participants samples. Patients’ carbon monoxide concentrations in expired air are measured and the group agrees on a common quitting date.


Session 3
High-risk situations, relaxation and distraction

The participants evaluate their attempt to quit and are encouraged to maintain cessation. The participants who have not quit are supported in their decision to quit, and a new date for quitting is set. The participants discuss situations with a high risk of resuming smoking, such as parties and after meals and learn distraction techniques and relaxation exercises. The counsellor emphasizes the health benefits again, and nicotine replacement therapy is evaluated for each participant. Patients’ carbon monoxide concentrations in expired air are measured.


Session 4
Health benefits of quitting and the problems of weight gain

The participants discuss the health benefits after about 12 days of nonsmoking. They discuss individual weight gain and change in dietary habits, and some participants may plan a meeting with the dietitian. Patients’ carbon monoxide concentrations in expired air are measured, and the counsellor gives patients more nicotine replacement products.


Session 5
Maintenance and evaluation

The participants evaluate the cessation efforts and discuss ways of maintaining cessation. The counsellor informs about the necessity of gradually reducing nicotine replacement.The counsellor hands out certificates of participation (available in Danish at www.CardiacRehabilitation.dk) and commemorative pins.


8.4.4 Individual support for smoking cessation

Patients who do not want to participate in the group smoking cessation are offered individual support for smoking cessation with a nurse and attend the same programme as group participants but with reduced time. After the 6-week intensive programme, the physician asks patients about their current smoking habits at the planned followup consultations and offers patients a counselling session with the nurse.


References

(1) Schnohr P, Jensen JS, Scharling H, Nordestgaard BG. Coronary heart disease risk factors ranked by importance for the individual and community.A 21 year follow-up of 12 000 men and women from The Copenhagen City Heart Study. Eur Heart J 2002; 23(8): 620–626.

(2) Shaper AG, Pocock SJ, Walker M, Phillips AN, Whitehead TP, Macfarlane PW. Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study. J Epidemiol Community Health 1985; 39(3): 197–209.

(3) Kawachi I, Colditz GA, Stampfer MJ,Willett WC, Manson JE, Rosner B et al. Smoking cessation in relation to total mortality rates in women. A prospective cohort study. Ann Intern Med 1993; 119(10): 992–1000.

(4) Kirchhoff M, Schroll M, Hagerup L, Larsen S. [Smoking habits and risk of coronary heart disease, especially risk associated with low daily tobacco consumption.] Ugeskr Laeger 1993; 155(10): 718–721.

(5) Hein HO, Suadicani P, Gyntelberg F. Ischaemic heart disease incidence by social class and form of smoking: the Copenhagen Male Study – 17 years’ follow-up. J Intern Med 1992; 231(5): 477–483.

(6) Nyboe J, Jensen G, Appleyard M, Schnohr P. Smoking and the risk of first acute myocardial infarction. Am Heart J 1991; 122(2): 438–447.

(7) Wilson K, Gibson N,Willan A, Cook D. Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med 2000; 160(7): 939–944.

(8) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(9) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(10) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(11) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(12) The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 1996; 275(16): 1270–1280.

(13) Miller NH, Smith PM, DeBusk RF, Sobel DS, Taylor CB. Smoking cessation in hospitalized patients. Results of a randomized trial. Arch Intern Med 1997; 157(4): 409–415.

(14) Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995; 155(18): 1933–1941.

(15) Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 2002; (3): CD001292.

(16) Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2001; (3): CD001188.

(17) Rigotti NA, Munafo MR, Murphy MF, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2003; (1): CD001837.

(18) Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and by-pass surgery: randomised controlled trial. BMJ 2002; 324(7329): 87–89.

(19) Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2002; (3):CD001007.

(20) Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000; 321(7257): 355–358.

(21) Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2002; (4): CD000146.

(22) Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2003; (2): CD000031.

(23) Mundt K, Fugleholm AM, Hedegaard AM, Jepsen JM. Rygeophør på sygehus. Fakta, metoder og anbefalinger [Hospital-based smoking cessation. Facts, methods and recommendations]. Copenhagen, Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital and National Network of Health Promoting Hospitals in Denmark, 2001.


2. METHODS

Chapter 9

Psychosocial Support

Lone Kjems Brunse & Morten Birket-Smith

[see illustration]

9.1 Introduction

The psychosocial support offered by the Cardiac Rehabilitation Unit is not a delimited component of rehabilitation but is part of the overall services. In addition to the structured, individual counselling, psychosocial support plays a key role in the informal discussions between patients and practitioners and between patients, such as in exercise training, where social interaction is essential. Effective pharmaceutical treatment of symptoms can similarly be considered part of psychosocial support, since this is important in treating any depression or anxiety that develops in association with heart disease.

Illustration of Psychosocial Support

1 week after referral
Individually tailored programme:
Counselling with a nurse
Screening for anxiety and depression

6-week programme
Intensive cardiac rehabilitation:
Patient education
Therapeutic counselling
Counselling with a social worker if needed
Treatment of anxiety and depression

3, 6 and 12 months
Management and clinical assessment:
Follow-up counselling if needed


This chapter describes the structured psychosocial intervention carried out by the Cardiac Rehabilitation Unit, which includes therapeutic counselling, group intervention, treatment of anxiety and depression, a 24-hour helpline and social support. The chapter provides specific proposals for action to provide psychosocial support in practice.


9.2 Evidence On The Effects Of Psychosocial Support

Anxiety and depression
Patients with myocardial infarction can experience crises, but the fact that heart disease increases the risk of depressive and anxiety disorders and that not treating them can complicate the course of disease and produce new heart problems and death is less well known.

About 11–25% of patients with ischaemic heart disease have depressive disorder. A further 30% develop mild depressive episodes, and 9% of outpatients with heart disease and 10–50% of patients with acute coronary syndrome have anxiety disorder (1–6). A few more recent epidemiological studies (7–10) even indicate that mental factors can increase the risk of ischaemic heart disease, and studies (11–13) have shown that depression and anxiety are underdiagnosed in heart disease.

Depression and anxiety complicate the course of heart disease. Developing depression not only influences the patients’ subjective health but also adversely affects the results of treatment and reduces survival in some cases. Among patients with ischaemic heart disease, those with untreated depression have 3–4 times as much morbidity and mortality as those without depression (2). Similarly, among patients who have had coronary artery bypass grafting, those with moderate to severe depression have excess mortality compared with those with no depression (14).

Studies indicate that the effect of exercise training supplements the pharmaceutical treatment of mild and moderately severe depression. Exercise training is not recommended as the sole treatment but should be used to supplement pharmaceutical treatment (15;16). Knowledge on how to master illness is an important aspect of psychosocial support, but knowledge cannot stand alone (17).

Patients with ischaemic heart disease treated for anxiety and depression tolerate treatment well, have less depression and seems to have fewer complications related to heart disease (18–21). A study of 2481 people who had myocardial infarction (22) showed that treating depression did not influence survival.

Social network
Studies (23–26) have shown that people who live alone and lack a social network have a higher risk of ischaemic heart disease and death. Other studies (27–29) show that social isolation is associated with reduced survival and health for patients with cardiovascular diseases. No study has shown that intervening in the lives of socially isolated people with heart disease can improve health and survival. Nevertheless, studies have shown that intervening in the lives of socially isolated people with heart disease increases the quality of life (30;31) and mental well-being (32). In addition, depression can reinforce social isolation (33).

Continuing employment
About 20–25% of patients with myocardial infarction in Denmark are employed at admission. Many are concerned about whether they can resume employment. A study of employment prospects after myocardial infarction in Denmark (34) showed that the short-term employment prospects were good: about 90% of the employed patients had resumed working within the first six months. Studies (34–36) indicate that patients’ age, educational level, socioeconomic status, psychosocial well-being and self-confidence that they could return to work are more important for continuing employment than their physical functioning (34–36). Continuing employment is an important goal of cardiac rehabilitation (37). Nevertheless, the extent to which cardiac rehabilitation has an effect is still uncertain, since this area has been little studied (34;35).

Recommendations
There is a consensus on cardiac rehabilitation in Denmark that psychosocial support should be a component of comprehensive cardiac rehabilitation (37–39).


9.3 Purposes

The purposes of psychosocial support in the comprehensive cardiac rehabilitation programme are to guide patients in mastering their illness and reactions to their illness; to identify and treat mental disorders such as depression and anxiety; and to strengthen patients’ social skills and guide patients in social matters, including supporting patients in continuing to work.


9.4 Methods

9.4.1 Therapeutic counselling

Many people who get a life-threatening disease get into a state of crisis. Nearly everyone who gets heart disease is in crisis at some point during the course of illness. The crisis can be catalysed by a combination of several factors. In addition to pain and impaired physical functioning, they have to find a new role both for their personal lives and work lives. Most patients are very anxious that a new acute heart event will take place.

The crisis can be divided into four phases: shock, reaction, adaptation and reorientation (40–42). The course and outcome of the crisis depend on patients’ physical, mental and social resources. Two crises are seldom identical and do not follow a set pattern but alternate between various phases.

The nurse is especially attentive to patients’ psychosocial well-being in the comprehensive cardiac rehabilitation programme. At the initial consultation, the nurse asks patients how they experience their role as patients, how they live with their illness in daily life and how the illness has influenced their relationships with their surroundings. This allows patients to express how they feel about the events, and the nurse can assess whether the patient is in crisis. The assessment is based on the nurse’s professional knowledge of the phases of crisis and their content and duration.

Patient’s family members, especially spouses or cohabitants, are also influenced by the situation, and some spouses react more strongly that the patients themselves. Several patients report that their spouses are unnecessarily worried in daily life and are insecure when patients have to perform simple tasks they previously performed without problems. These spouses are therefore asked to participate in patient education and in the individual consultations. Nevertheless, patients should have an opportunity to cope with their new role before spouses are involved. Spouses should be involved in accordance with the situation of each patient.

This section describes several techniques that can be used in counselling patients (43):

Let patients describe the situation: Therapeutic counselling is based on letting patients describe the course of illness and treatment. This ensures that the nurse gets a detailed sense of how patients experience their own situation. For example, if professionals are uncertain whether a patient’s palpitation is caused by arrhythmia or anxiety, the patient’s description can determine the nature of the problems. The nurse further determines whether a patient has understood the relationship between disease and the treatment initiated, both pharmaceutical and non-pharmaceutical.

Most patients need to discuss the same topics many times as part of adapting to the situation. Lack of knowledge and uncertainty about what has happened may result in anxiety. Professionals should therefore carefully balance the amount of information provided with the patients’ resources.

Repeat the last few words the patient says: Among patients who are not used to expressing their feelings or seem inhibited, the professional can encourage patients to continue their story by repeating the last few words they said. This gives patients the sense that the professional considers what they are saying important. The professional may conclude by summarizing the main topics discussed, which is subsequently recorded in the joint electric patient record, to ensure that the patient remembers the main content of the discussion.

Allow natural pauses in the conversation: Professionals may be tempted to fill in the small pauses in the conversation with conclusions or new questions. This may make patients feel that they are not permitted to finish talking or that the professional is not listening to what they are saying. If pauses are a natural part of the conversation, the patient will make new associations and have new thoughts and will relax and open up. Many patients have difficulty in abandoning their defence mechanisms for fear of collapsing: they attempt to suppress their anger, doubt, guilt feelings and insecurity. Patients’ defence mechanisms can include both exaggerating and downplaying the disease.The professional can help patients in abandoning their defensiveness and viewing their situation in an appropriate perspective by showing them that the professional has lots of time and is listening to what they are feeling and thinking.

Do not necessarily answer questions during the consultation: Anxious patients usually ask many questions since they want to be comforted that their symptoms are not lifethreatening. Patients who say that they wake up at night with palpitation expect the professional to respond in the hope that the explanation is physiological. If the professional suspects that the problem is mental, the professional should be cautious in answering the patients’ questions, since the professional risks preventing patients from recognizing their own problems. Patients asked for a possible explanation often say that they speculate considerably about their disease at night. If patients recognize by themselves that the symptoms are mental, this helps them in adapting to the situation. For patients who seem helpless and desperate, professionals may tend to give advice, but the best help may be to avoid giving advice. Patients in shock may need to have professionals take over, but later the professional can easily delegate more responsibility to patients.


9.4.2 Group intervention

The comprehensive cardiac rehabilitation programme emphasizes social interaction between patients, and many of the components of the programme are carried out as group intervention, such as smoking cessation, exercise training and patient education.

People in the same life situation sharing experience reveals and de-individualizes their problems and they begin to understand their own and other people’s problems in a larger context. In such a process with group dynamics, the group members use one another’s experience, and patients who have been through the same events often have greater trust in other such patients than a professional. The process of group dynamics focuses on social interaction and human resources. The professional is responsible for taking advantage of the group’s overall resources so that each individual achieves the greatest possible support and insight. Such serious topics as anxiety about death and anxiety about life often arise.The comprehensive cardiac rehabilitation programme emphasizes that professionals should not exceed their competencies and thus do not practise group therapy (44).


9.4.3 A 24-hour helpline

The comprehensive cardiac rehabilitation programme offers patients telephone counselling 24 hours per day. When the Unit is open, the secretary answers the telephone and assesses, together with the patient, the professional the patient would benefit by consulting. When the Unit is not open, personnel in the inpatient ward of the Department of Cardiology answer the telephone. Patients can get answers to acute questions. All contacts are registered and referred to the Cardiac Rehabilitation Unit, and the staff there follow up (the registration form is available in Danish at www.CardiacRehabilitation.dk).

In practice, the helpline is little used and therefore requires few resources, but patients express that they feel more secure knowing that they can contact the Department of Cardiology at any time.


9.4.4 Treatment of anxiety and depression

Appropriately treating anxiety and depressive disorders requires knowing how to identify them and some knowledge of classification and diagnostic criteria. There are so many possible diagnoses each with diagnostic criteria that they cannot all be known and used clinically. In most contexts, professionals can manage if they know the three levels of severity of depression and a few anxiety diagnoses such as panic disorder, generalized anxiety disorder, phobic anxiety disorders and hypochondriacal disorder.

Screening for anxiety and depression. The nurse in the Cardiac Rehabilitation Unit screens each patient for anxiety and depression using the Hospital Anxiety and Depression Scale (45;46). Patients who answer any of the questions in either category affirmatively may have depression and are referred to psychiatric assessment. Patients are informed that, because they have heart disease, they are especially vulnerable to developing depression and anxiety and that untreated depressive or anxiety disorders may exacerbate heart disease. Professionals respect the wishes of patients who do not want to consult a psychiatrist.

Determining the cause of anxiety or depression may be difficult in some cases. Causes can include the somatic illness or treatment, special mental vulnerability or previous depressive or anxiety disorders. Thus, several causative factors may be involved in any depression and anxiety associated with heart disease.

The Cardiac Rehabilitation Unit treats patients with mild depression or anxiety based on the following principles and refers patients with severe depression to psychiatric treatment.

The comprehensive cardiac rehabilitation programme focuses primarily on treating the underlying somatic illness among patients with depression or anxiety. Improving patients’ somatic state will spontaneously reduce depression and anxiety.

If the depression or anxiety is suspected of being caused by or exacerbated by pharmaceutical treatment, the programme switches patients to another type of treatment that does not promote these disorders if possible.

Depression and anxiety associated with heart disease are treated based on the same principles as any other depressive or anxiety disorder (47). Antidepressants with a low risk of interaction with somatic treatment are chosen. Older tricyclic antidepressants are not used because they have a high risk of cardiovascular complications (48).


9.4.5 Social support

The comprehensive cardiac rehabilitation programme emphasizes determining patients’ need for social support in the individual consultation with the nurse. The social worker from the Department of Cardiology participates in the weekly interprofessional conference (Chapter 4) at which any social problems among patients are presented. The social worker advises the clinical team on the subsidy and other social schemes available to each patient, and the team assesses whether the social worker can contribute further with individual counselling and follow-up.

Social network
The patient education in the comprehensive cardiac rehabilitation programme informs patients about the significance of a social network. The nurse or social worker informs patients about specific activities in the local area related to maintaining lifestyle changes, meet other people in the same situation, discuss illness history and establish a personal network. Information is adapted individually to each patient’s resources, desires and needs.

Local activities: The nurse and social worker in the comprehensive cardiac rehabilitation programme have visited selected activity locations in the Bispebjerg area and prepared an activity folder containing text on and photographs of fitness centres, community centres and daytime programmes. The material in this folder provides information on the user interface, price, waiting lists and heart-friendly activities in each location (selected activities from the folder are available in Danish at www.CardiacRehabilitation.dk). The activity folder is kept in the waiting room so that both patients and family members can keep up to date on local activities. The nurse and social worker take responsibility for updating the folder.

Finances
Patients with heart disease may experience financial strain because of co-payments for medicine and a potential reduction in income for those whose employment situation changes. Patients whose finances worsen may have difficulty in remaining optimistic, especially those who have had a complicated course of disease. Patients in the comprehensive cardiac rehabilitation programme are informed that Denmark’s social welfare legislation may potentially provide financial support for the co-payments for medicine used to treat heart disease (the rules for public subsidies for medicine in Denmark are available in Danish at www.CardiacRehabilitation.dk). In some cases, patients can get an individual consultation with the social worker. The social worker advises patients on various subsidy schemes, including private insurance, such as lump-sum payments from insurance policies for critical illness.

Maintaining employment
The comprehensive cardiac rehabilitation programme supports employed patients in maintaining employment either full time with optional social support schemes or part time. The social worker can offer to participate in visiting patients’ employers or contact patients’ social case workers in their municipality and suggest such measures as maintaining current employment, publicly subsidized employment for people with permanently reduced working capacity (flex job), vocational rehabilitation or partial old-age pension. Patients are supported and encouraged in maintaining employment through consultation with the social worker and indirectly through the comprehensive cardiac rehabilitation programme.


References

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(2) Ladwig KH, Kieser M, Konig J, Breithardt G, Borggrefe M. Affective disorders and survival after acute myocardial infarction. Results from the post-infarction late potential study. Eur Heart J 1991; 12(9): 959–964.

(3) Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993; 270(15): 1819–1825.

(4) Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation 1995; 91(4): 999–1005.

(5) Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry 1998; 20(1): 29–43

(6) Carney RM, Rich MW, Tevelde A, Saini J, Clark K, Jaffe AS. Major depressive disorder in coronary artery disease. Am J Cardiol 1987; 60(16): 1273–1275.

(7) Epløv LF, Jørgensen T, Birket-Smith M, Segal S, Johansen C, Mortensen EL. Psychic vulnerability as a risk factor for ischaemic heart disease. Presented at the 24th European Conference on Psychosomatic Research, 19–22 June 2002, Lisbon, Portugal.

(8) Barefoot JC, Schroll M. Symptoms of depression, acute myocardial infarction, and total mortality in a community sample. Circulation 1996; 93(11): 1976–1980.

(9) Aromaa A, Raitasalo R, Reunanen A, Impivaara O, Heliovaara M, Knekt P et al. Depression and cardiovascular diseases. Acta Psychiatr Scand Suppl 1994; 377: 77–82.

(10) Kubzansky LD, Kawachi I. Going to the heart of the matter: do negative emotions cause coronary heart disease? J Psychosom Res 2000; 48(4–5): 323–337.

(11) Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med 1990; 150(5): 1083–1088.

(12) Freedland KE, Lustman PJ, Carney RM, Hong BA. Underdiagnosis of depression in patients with coronary artery disease: the role of nonspecific symptoms. Int J Psychiatry Med 1992; 22(3): 221–229.

(13) Hirschfeld RM, Keller MB, Panico S, Arons BS, Barlow D, Davidoff F et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 1997; 277(4): 333–340.

(14) Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB et al. Depression as a risk factor for mortality after coronary artery by-pass surgery. Lancet 2003; 362(9384): 604–609.

(15) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity – manual on disease prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(16) Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001; 322(7289): 763–767.

(17) Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeduational programs for coronary heart disease patients. Health Psychol 1999; 18(5): 506–519.

(18) Shapiro PA, Lesperance F, Frasure-Smith N, O’Connor CM, Baker B, Jiang JW et al. An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction (the SADHAT Trial). Sertraline Anti-Depressant Heart Attack Trial. Am Heart J 1999; 137(6): 1100–1106.

(19) Glassman AH, O’Connor CM, Califf RM, Swedberg K, Schwartz P, Bigger JT Jr et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002; 288(6): 701–709.

(20) Strik JJ, Honig A, Lousberg R, Lousberg AH CE, Tuynman-Qua HG, Kuipers PM et al. Efficacy and safety of fluoxetine in the treatment of patients with major depression after first myocardial infarction: findings from a double-blind placebo-controlled trial. Psychosom Med 2000; 62: 783–789.

(21) McFarlane A, Kamath MV, Fallen EL, Malcolm V, Cherian F, Norman G. Effect of sertraline on the recovery rate of cardiac autonomic function in depressed patients after acute myocardial infarction. Am Heart J 2001; 142(4): 617–623.

(22) Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003; 289(23): 3106–3116.

(23) Case RB, Moss AJ, Case N, McDermott M, Eberly S. Living alone after myocardial infarction. Impact on prognosis. JAMA 1992; 267(4): 515–519.

(24) Ell K, Dunkel-Schetter C. Social support and adjustment to myocardial infarction, angioplasty, and coronary artery by-pass surgery. In: Shumaker SA, Czajkowski SM, ed. Social support and cardiovascular disease. New York, Plenum Press, 1994; 301–331.

(25) Gorkin L, Schron EB, Brooks MM, Wiklund I, Kellen J, Verter J et al. Psychosocial predictors of mortality in the Cardiac Arrhythmia Suppression Trial-1 (CAST-1). Am J Cardiol 1993; 71(4): 263–267.

(26) Ruberman W,Weinblatt E, Goldberg JD, Chaudhary BS. Psychosocial influences on mortality after myocardial infarction. N Engl J Med 1984; 311(9): 552–559.

(27) Ahern DK, Gorkin L, Anderson JL, Tierney C, Hallstrom A, Ewart C et al. Biobehavioral variables and mortality or cardiac arrest in the Cardiac Arrhythmia Pilot Study (CAPS). Am J Cardiol 1990; 66(1): 59–62.

(28) Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly. Ann Intern Med 1992; 117(12): 1003–1009.

(29) Williams RB, Barefoot JC, Califf RM, Haney TL, Saunders WB, Pryor DB et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA 1992; 267(4): 520–524.

(30) Dracup K. Cardiac rehabilitation: the role of social support in recovery and compliance. In: Shumaker SA, Czajkowski SM, ed. Social support and cardiovascular disease. New York, Plenum Press, 1994; 333–353.

(31) Hill DR, Kelleher K, Shumaker SA. Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review. Gen Hosp Psychiatry 1992; 14(6 Suppl): 28S–42S.

(32) Ott CR, Sivarajan ES, Newton KM, Almes MJ, Bruce RA, Bergner M et al. A controlled randomized study of early cardiac rehabilitation: the Sickness Impact Profile as an assessment tool. Heart Lung 1983; 12(2): 162–170.

(33) Pitula RC, Burg M, Froelicher ES. Psychosocial risk factors: assessment and intervention for social isolation. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999: 279–285.

(34) Nielsen FE. Ervervsprognosen efter akut myokardieinfarkt [Occupational prognosis after acute myocardial infarction]. Copenhagen, Eget forlag, 2001.

(35) Pravikoff DS. Return to work: factors and issues of vocational counseling. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999: 295–302.

(36) Söderman E, Lisspers J, Sundin Ö. Depression as a predictor of return to work in patients with coronary artery disease. Soc Sci Med 2003; 56: 193–202.

(37) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(38) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(39) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(40) Cullberg J. Krise og udvikling [Crisis and development]. Copenhagen, Hans Reitzels Forlag, 1981.

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(42) Cullberg J. Dynamisk psykiatri [Dynamic psychiatry]. Copenhagen, Hans Reitzels Forlag, 1989.

(43) Bendix T. Din nervøse patient [Your nervous patient]. 3rd edn. Copenhagen, Lægeforeningens forlag, 1991.

(44) Kamper-Jørgensen L, Gry Poulsen J. Forebyggelse gennem gruppeaktiviteter [Preventing disease through group activities]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 312–321.

(45) Yonkers KA, Samson J. Mood disorder measures. Handbook of psychiatric measures.Washington, DC, American Psychiatric Association, 2000.

(46) Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67(6): 361–370.

(47) Levinson JL, Dwight M. Cardiology. Psychiatric care of the medical patient. Oxford: Oxford University Press, 2000.

(48) Glassman AH, Roose SP, Bigger JT Jr. The safety of tricyclic antidepressants in cardiac patients. Risk-benefit reconsidered. JAMA 1993; 269(20): 2673–2675.


2. METHODS

Chapter 10

Systematic Risk Factor Management And Clinical Assessment

Anne Merete Boas Soja & Marianne Frederiksen

[see illustration]

10.1 Introduction

Systematic risk factor management and clinical assessment is one of the seven components of cardiac rehabilitation at Bispebjerg Hospital. This chapter describes the purpose of the planned follow-up consultations and how they are carried out.

Illustration of Systematic risk factor management and clinical assessment

1 week after referral
Individually tailored programme:
Consultations with a physician
Consultations with a physical therapist
Consultations with a dietitian
Consultations with a nurse
Intensive cardiac rehabilitation

6-week programme
Intensive cardiac rehabilitation:
Follow-up with a nurse
Interprofessional conference
Consultations with a physician as needed

3, 6 and 12 months
Management and clinical assessment:
Consultations with a physician
Consultations with a nurse as needed


10.2 Evidence On The Effects Of Systematic Risk Factor Management And Clinical Assessment

There is solid evidence that treating modifiable risk factors among people with heart disease and people at high risk of cardiovascular disease can reduce the risk of cardiovascular disease. Denmark’s guidelines on pharmaceutical and nonpharmaceutical prophylactic treatment of patients with ischaemic heart disease, type 2 diabetes and patients at high risk of ischaemic heart disease (1–6) systematically review this evidence.


10.3 Purpose

The purpose of systematic risk factor management and clinical assessment is to ensure that the treatment goals set are achieved with the aim of improving patients’ quality of life and reducing their total morbidity and mortality in the long term.


10.4 Methods

The comprehensive cardiac rehabilitation programme considers reducing the risk factors for heart disease and clinical assessment as a task requiring interprofessional coordination. Clinical assessment in the programme is organized as consultations with a physician, since the physician has a key role as the professional responsible for pharmaceutical treatment. The consultations are conducted based on the same principles as the initial consultations, including preparation, patient-centred communication, continuity, documentation and quality assurance (Chapter 4).


10.4.1 Follow-up consultation with the physician

All patients are scheduled for a 30-minute follow-up consultation 3 months and 6 months after the 6-week intensive cardiac rehabilitation programme started. The patients have routine blood tests before each consultation (described in Danish at www.CardiacRehabilitation.dk). The physician knows each patient from the initial consultation and from the informal meetings in the programme and learns of progress in rehabilitation by reviewing the patient records and blood test results before the consultation. The consultation is conducted based on an interview guide for follow-up consultations (available in Danish at www.CardiacRehabilitation.dk).

Patients who have undergone percutaneous coronary intervention, patients who have undergone coronary artery bypass grafting and patients with an implantable cardioverter defibrillator are treated specially regarding patient information, physical activity, mental factors, rules concerning driving licences and pharmaceutical treatment. The Cardiac Rehabilitation Unit has prepared specific action plans to manage these groups of patients (available in Danish at www.CardiacRehabilitation.dk).

Cardiovascular symptoms
The physician asks the patient about trends since the last consultation. They discuss any new symptoms or recurrence of previous cardiovascular symptoms. The physician decides whether the symptomatic treatment is optimal and whether detailed assessment or referral to invasive investigations and treatment is needed in accordance with current guidelines (available in Danish at www.CardiacRehabilitation.dk).

Psychosocial well-being
At these follow-up consultations, patients have acquired some distance from the acute illness and have started a new life.The physician asks patients about their social life, sex life, relationship with spouse or cohabitant, children, friends and employment. The physician assesses whether patients who were in crisis have worked through the phases of the crisis or whether they may have developed depressive features. If depression is present or suspected, the physician refers patients to detailed assessment by a psychiatrist.

Alcohol
Many patients with alcohol problems comply less well with both behavioural and pharmaceutical recommendations. Suspected alcohol problems are discussed with patients, who are informed of the option for referral to treatment for alcohol dependence.

Pharmaceutical assessment
Each physician consultation systematically reviews pharmaceutical treatment. The physician assesses whether patients take the medicine as directed and whether there are any side-effects. Any uncertainty among patients on pharmaceutical treatment is discussed, and the physician updates the medicine forms and the medicine registration in the patient records. If the physician decides that the patient’s pharmaceutical treatment needs to be reviewed in detail, an appointment is made with the nurse.

Symptomatic pharmaceutical treatment: The physician ensures that patients’ symptoms are optimally treated and that patients are phased out on medicine that is no longer needed, such as diuretics. Denmark’s current guidelines for symptomatic pharmaceutical treatment and gradually increasing the dose (1–3;7) are followed.

Prophylactic pharmaceutical treatment: At every consultation, the physician ensures that patients are receiving and continue to take prophylactic pharmaceuticals. If there are side-effects, the physician decides whether to interrupt treatment and whether and when it will be resumed or whether another product should be chosen.The products in the following table are reviewed and prescribed depending on the diagnosis and comorbidity. Medicine is prescribed and dosed according to Denmark’s current guidelines on secondary prophylactic treatment (1–3;5–7), which are implemented in the local instructions of the Department of Cardiology (available in Danish at www.CardiacRehabilitation.dk).

Ideal goals for secondary prophylactic pharmaceutical treatment in the comprehensive cardiac rehabilitation programme
  Congestive heart failure
(7;8)
Ischaemic
heart disease

(1;2;5;9)
Type 2
diabetes

(3;10-12)
High risk
(5;6)
Thrombotic inhibition (13)
Acetylsalicylic acid 75 mg.
Clopidogrel bisulfate 75 mg

+
Optional b,c

+
Optional b,c

+

+
Optional c
Beta-blockers + + + Optional
Calcium antagonist
Optional when
beta-blockers
are not tolerated


ACE inhibitors + Optional + Optional
Angiotensin-II Optional Optional + Optional
Spironolactone +


Statins (5;14) + + + Optional
Antiplatelet treatment for atrial fibrillation or heart valve surgery (13)
Optional

Optional

Optional

Optional
a 150 mg of acetylsalicylic acid for previous stroke.
b 12-month supplement to acetylsalicylic acid following.
c When allergic to or intolerant of acetylsalicylic acid.


Systematic risk factor management
Systematic risk factor management means eliminating and managing as many risk factors for heart disease as possible simultaneously or consecutively depending on the motivation and resources of each patient. The physician achieves an overview of each patient’s risk factors at the initial consultation (Chapter 4). The physician also assesses the need for further assessment and follow-up and for prescribing tests and investigations. All risk factors are recorded in the joint patient records and in patients’ action plans. The treatment goals are also recorded so that both the physician and patient can determine the effect of rehabilitation activities. The treatment goals are based on Denmark’s current guidelines and are set in accordance with patients’ motivation, resources, diagnoses and overall risk (Chapter 4).

Blood pressure: At the initial consultation with the physician, all patients have their blood pressure measured in both upper arms while sitting and after resting in a calm environment for at least 10 minutes (6). The nurse ensures that the cuff is the correct size. The future measurements are performed on the arm that had the highest blood pressure. If arterial hypertension or white-coat hypertension is suspected or if the history indicates suspected dysregulation, blood pressure is measured for 24 hours. If the dose of antihypertensive drugs is being increased or new ones are being added, blood pressure checks are agreed after at least 14 days depending on whether the patient has other concurrent diseases.

The nurse increases the patient’s dose based on a detailed treatment plan formulated by the physician and also checks blood pressure. If the patient has mild hypertension and the physician does not believe that restricting salt intake, losing weight and exercise will lower blood pressure sufficiently, pharmaceutical treatment is started in accordance with Denmark’s current guidelines (6). Patients are treated with a maximum dose of one product if this is tolerated well before any new ones are added, to increase compliance.

Serum cholesterol: All patients with ischaemic heart disease and demonstrated arteriosclerosis are treated with statins regardless of their serum cholesterol concentration (5). Among patients with a high risk of heart disease, the physician assesses whether patients fulfil the criteria for starting stain treatment regardless of the serum cholesterol concentration (14).

To determine whether the treatment goals have been achieved, the serum cholesterol concentrations are determined at the follow-up consultations with the physician at 3 and 6 months. The results are compared with the initial values and the treatment goals. If the treatment goals have not been met, the physician ensures that the patients receiving pharmaceutical treatment take the medicine and the dose of statins is increased or supplemented by fibrate or nicotinic acid depending on the degree and type of hypercholesterolaemia and hypertriglyceridaemia. Patients who have not yet received statins are started on these.

Hyperglycaemia: Strictly controlling blood sugar levels has been shown to influence the rate of complications and survival among patients with both heart disease and type 2 diabetes (3). Chapter 11 describes how the comprehensive cardiac rehabilitation programme manages blood sugar levels.

Microalbuminuria: The presence of microalbuminuria is a sign that diabetes is starting to affect the kidneys. About 20–30% of all patients with type 2 diabetes and 10–15% of all elderly people without recognized type 2 diabetes have microalbuminuria (15). Microalbuminuria is associated with a two- to four-fold increased risk of cardiovascular disease, regardless of whether people have type 2 diabetes. For patients with type 2 diabetes, intensifying antihypertensive treatment and starting treatment to protect the kidneys are crucial, since 5–10% of patients progress to nephropathy each year. The comprehensive cardiac rehabilitation programme uses morning spot urine as a screening method. If two of three consecutive samples taken over several months show a ratio of albumin to creatinine exceeding 2.5 mg/mmol, the patient is defined as having microalbuminuria. Urine is collected for 24 hours to quantify any albuminuria.

Smoking: The physician informs patients that smoking over many years greatly influences the development of cardiovascular disease.The physician encourages ex-smokers to avoid starting again and explains to smokers that it never is too late to quit even though they have achieved some distance from the acute phase of heart disease. It is important to explain to smokers that most people who quit gain some weight but that this can be limited or avoided through physical activity. Some patients begin to smoke again at the follow-up consultations after 3 and 6 months, and the physician tries to motivate them to quit again and refers them to counselling with the nurse or another smoking cessation counsellor.

Physical activity: The physician informs patients about the significance of the relationship between physical activity and developing cardiovascular disease. The physician emphasizes that physical activity is as important a part of treatment as pharmaceutical treatment. At the follow-up assessment, the physician asks patients about their current level of functioning and assesses whether patients have regained their previous level of functioning and can manage as they did previously. The physician also assesses whether patients are physically active at least 30 minutes per day.

Weight: The physician explains that obesity is a risk factor for cardiovascular disease and emphasizes that losing weight is important to improve survival and the quality of life. The physician weighs patients at the follow-up consultations. This has turned out to have great psychological importance for patients in a weight-loss programme. Patients who achieve weight loss are praised. Patients who do not lose weight are offered more counselling from the dietitian.

Need for further assessment or follow-up
The current status and plan for the future are noted in the joint patient records and in the patient’s treatment plan. The patient is referred for relevant tests or examinations when detailed investigation or assessment is needed. In cooperation with the patient, the physician assesses whether consultations with other professionals in the Cardiac Rehabilitation Unit are necessary.


10.4.2 Concluding consultation

The concluding consultation with the physician uses 60 minutes to review the patient’s progress in the rehabilitation programme. The consultation is carried out based on an interview guide (available in Danish at www.CardiacRehabilitation.dk) so that the consultation includes all aspects of the programme.

Various factors may prevent some treatment goals from being fulfilled at the concluding consultation; a plan for future rehabilitation is made with the patient. Depending on the severity of the disease, how complicated the illness is and risk factor management, the physician determines where the patient will be followed up.

Most patients are referred to their general practitioner, who is sent an analysis of the patient’s entire rehabilitation programme, blood test results and recommendations on further treatment initiatives and need for consultation by the general practitioner.


References

(1) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(2) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(4) Forebyggelse af iskæmisk hjertekarsygdom i almen praksis [Prevention of ischaemic heart disease in general practice]. 2nd edn. Copenhagen, Danish College of General Practitioners, 2002.

(5) Færgeman O, Christensen B, Steen Hansen H, Jensen GH, Melchior TM, Nordestgaard BG et al. Sekundær og primær forebyggelse af koronar hjertesygdom med særligt henblik på dyslipidæmi [Secondary and primary prevention of coronary heart disease with a special focus on dyslipidaemia]. Copenhagen, Danish Society of Cardiology, 2000 (www.dadlnet.dk/klaringsrapporter/ 2000-07/2000-07_0.htm, accessed 22 March 2004).

(6) Abildgaard Jacobsen I, Bang LE, Borrild NJ, Feldt-Rasmussen BF, Steen Hansen H, Ibsen H et al. Hypertensio arterialis [Arterial hypertension]. Copenhagen, Danish Hypertension Society, 1999 (www.dadlnet.dk/klaringsrapporter/1999-09/1999-09-0.htm, accessed 22 March 2004).

(7) Kühn Madsen B, Johannessen A, Thomassen A, Egeblad H, Mortensen SA. Diagnostik og behandling af hjerteinsufficiens. Oversigt og vejledende retningslinjer [Diagnosis and treatment of congestive heart failure. Overview and guidelines]. Copenhagen, Danish Society of Cardiology and Danish Society of Internal Medicine, 1997 (www.dadlnet.dk/klaringsrapporter/1997-09/1997-09- 0.htm, accessed 22 March 2004).

(8) Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22(17): 1527–1560.

(9) Bertrand ME, Simoons ML, Fox KA,Wallentin LC, Hamm CW, McFadden E et al. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2002; 23(23): 1809–1840.

(10) Grundy SM, Howard B, Smith S Jr, Eckel R, Redberg R, Bonow RO. Prevention Conference VI: Diabetes and Cardiovascular Disease: executive summary: conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation 2002; 105(18): 2231–2239.

(11) European Diabetes Policy Group. A desktop guide to type 2 diabetes mellitus. Diabet Med 1999; 16: 716–730.

(12) American Diabetes Association. Clinical practice recommendations 2001. Diabetes Care 2001; 24(suppl 1): S33–S63.

(13) Godtfredsen J, Sandbjerg Hansen M, Elkjær Husted S, Pilegaard HK, Jespersen J. Antitrombotisk behandling ved kardiovaskulære sygdomme. “Trombokardiologi” [Antithrombotic treatment in cardiovascular diseases. “Thrombocardiology”]. Copenhagen, Danish Society of Cardiology and Danish Society of Clinical Biochemistry, 2002 (www.dadlnet.dk/klaringsrapporter/2002-05/2002- 05.HTM, accessed 22 March 2004).

(14) MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360(9326): 7–22.

(15) Donnelly R, Yeung JM, Manning G. Microalbuminuria: a common, independent cardiovascular risk factor, especially but not exclusively in type 2 diabetes. J Hypertens Suppl 2003; 21 Suppl 1: S7–12.


2. METHODS

Chapter 11

Type 2 Diabetes Mellitus

Anne Merete Boas Soja & Malene Ejlertsen

[see illustration]

11.1 Introduction

In the first part of the project period, we found that patients with type 2 diabetes mellitus were being inadequately treated in relation to the existing recommendations (1–4). In addition, we suspected that several of the patients had type 2 diabetes without having been diagnosed. To improve the diagnosis of type 2 diabetes and to improve the results of the treatment of patients with heart disease and diabetes,we developed a special diabetes module to supplement the comprehensive cardiac rehabilitation.

Illustration of Type 2 diabetes mellitus – supplementary module

1 week after referral
Individually tailored programme:
Counselling with a physician about type 2 diabetes
Counselling with a nurse about type 2 diabetes

6-week programme
Intensive cardiac rehabilitation:
Education on type 2 diabetes
Individual follow-up as needed

3, 6 and 12 months
Management and clinical assessment:
Individual counselling with a physician


This chapter describes the diabetes module, which includes screening for type 2 diabetes, individual counselling on diabetes, group education, individual education and a meeting on impaired glucose tolerance (pre-diabetes). Chapter 7 describes the individual counselling with a dietitian on diet and type 2 diabetes.


10.2 Evidence On Type 2 Diabetes And Ischaemic Heart Disease

The prevalence of type 2 diabetes in Denmark has increased sharply in recent years. An estimated 200,000 people in Denmark have type 2 diabetes (2;5). The prevalence of cardiovascular disease is 2–6 times as high among people with type 2 diabetes as among people without type 2 diabetes; cardiovascular disease accounts for 70–80% of the total mortality of people with type 2 diabetes (5). Systematic management of risk factors can prevent the development of late microvascular complications, such as retinopathy and nephropathy, and macrovascular diseases, such as stroke and cardiovascular diseases (6–15).

Type 2 diabetes seems to develop as a continuous process of disturbed glucose metabolism over many years, shifting from impaired glucose tolerance to manifest type 2 diabetes. The risk of cardiovascular disease among people with impaired glucose tolerance is 1.5–2 times higher than among people with normal glucose tolerance; strong evidence shows that intensive lifestyle intervention can prevent type 2 diabetes, and apparently with more success than with pharmaceutical treatment alone (16–18).

Type 2 diabetes is a hidden disease among the general population and among patients with heart disease (2;19;20). Type 2 diabetes has been carefully investigated among patients with ischaemic heart disease. Studies (19;20) indicate that 20% have previously diagnosed type 2 diabetes and 16–25% newly diagnosed type 2 diabetes. Cardiologists have tended to accept relatively high blood glucose concentrations in the acute phase among patients with heart disease as a natural response to a severe disease. Neither acute nor outpatient cardiology has traditionally managed the clinical assessment of type 2 diabetes status,much less delegated this task to general practitioners or type 2 diabetes clinics. The importance of diagnosing type 2 diabetes among patients with heart disease is emphasized by the fact that, among patients with heart disease, intensively rehabilitating those with type 2 diabetes provides greater absolute benefits than rehabilitating those without type 2 diabetes. Mortality after myocardial infarction is twice as high among people with type 2 diabetes as among those without type 2 diabetes (21;22). Strictly controlling blood glucose has been shown to influence the rates of complications and survival (23). Few studies have focused on the effects of intensive rehabilitation of patients with heart disease and type 2 diabetes, but the standardized cardiac rehabilitation programmes do not seem to be adequate (24).

According to recommendations in Denmark (2) and elsewhere (1;25), systematic management of risk factors through lifestyle intervention and pharmaceutical treatment including strict control of blood glucose are important aspects of treating patients with type 2 diabetes. The recommendations on cardiac rehabilitation (25–27) similarly emphasize the importance of systematically managing risk factors among patients with heart disease and type 2 diabetes.


11.3 Purpose

The purposes of the supplementary type 2 diabetes module of the comprehensive cardiac rehabilitation programme are 1) to screen patients for unrecognized type 2 diabetes and pre-diabetes and 2) to integrate systematic risk factor management of late macrovascular and microvascular complications in the overall rehabilitation of patients with both heart disease and type 2 diabetes through lifestyle intervention and pharmaceutical treatment with the aim of early detection of any vascular damage. Another purpose has been to integrate the rehabilitation of type 2 diabetes and heart disease physically and draw on the expertise of a core team in cardiac care and diabetes care.


11.4 Methods

11.4.1 Screening for type 2 diabetes and pre-diabetes

Patients without known type 2 diabetes are screened for diabetes with an oral glucose tolerance test (the procedure is available in Danish at www.CardiacRehabilitation.dk) about 3 months after the comprehensive cardiac rehabilitation programme starts and immediately before the 3-month consultation with the physician, regardless of the previous concentration of glycosylated haemoglobin A (Hb A1c).This test can determine whether the patient has undiagnosed type 2 diabetes, impaired glucose tolerance or impaired fasting glycaemia or none of these.

All patients without previously diagnosed type 2 diabetes are screened using the oral glucose tolerance test as part of a scientific project. This is an extended indication for performing an oral glucose tolerance test (1;5).


11.4.2 Initial type 2 diabetes consultation

The same physician and nurse manage the supplementary type 2 diabetes module to ensure continuity in treatment.

Initial type 2 diabetes consultation with a physician
The consultation with a physician for patients with both heart disease and type 2 diabetes is conducted based on the principles for the initial consultation in the comprehensive cardiac rehabilitation programme (Chapter 4). The physician attempts to get a through overview of the overall course of illness for both type 2 diabetes and cardiovascular disease.The physician gathers substantial supplementary information on type 2 diabetes that is systematically registered in the joint patient records (the type 2 diabetes interview guide is available in Danish at www.CardiacRehabilitation.dk).

History: The physician asks patients about familial disposition for type 2 diabetes, any previous type 2 diabetes during pregnancy, the duration of type 2 diabetes, previous dietary guidance, follow-up and treatment regimens and any participation in type 2 diabetes education. The physician assesses the degree to which patients understand the disease and exercise self-care, focusing on checking one’s own blood sugar and/or urine, symptoms of hyperglycaemia and hypoglycaemia and examining one’s feet. The physician asks the patient about symptoms of peripheral or autonomic neuropathy and arteriosclerotic manifestations from other vascular regions. The physician emphasizes detecting existing late diabetic complications such as retinopathy, nephropathy, neuropathy, previous foot ulcers and/or amputation. Records of followup within other specialties such as ophthalmology and orthopaedics are requested if needed.

Review of pharmaceutical treatment: The physician ensures that patients are receiving optimum prophylactic pharmaceutical treatment and that any plans for changing medicine or increasing the dosage of medicine are registered in the joint patient records. Based on the recently tested value of Hb A1c, the physician often assesses whether antidiabetic pharmaceutical treatment is necessary, but unless patients have very high values the physician usually waits to receive the 24-hour blood sugar profile.

Clinical examination: In addition to the objective cardiological examination, the physician always examines patients’ feet thoroughly: peripheral pulse, capillary response, examination for any gangrene or foot ulceration (arterial and neuropathic), and checks scars to see whether they are infected.

Paraclinical examination and tests: To supplement the objective cardiological examination, the physician often performs several simple tests to characterize the extent of arteriosclerosis and autonomic neuropathy (the paraclinical examination and tests are described in Danish at www.CardiacRehabilitation.dk). Blood pressure is measured for 24 hours if the physician suspects arterial hypertension. The physician uses several biochemical parameters to assess blood sugar control (fasting plasma glucose, blood sugar and Hb A1c) and to diagnose microalbuminuria (ratio of albumin to creatinine in morning spot urine). If microalbuminuria or macroalbuminuria is suspected, urine is always collected for 24 hours. Patients are referred to the Department of Nephrology for macroalbuminuria and elevated renal parameters: elevated serum creatinine and serum urea that cannot immediately be explained in other ways.

Treatment plan: The physician and the patient jointly determine realistic treatment goals that are recorded in the joint patient records and in the patient’s treatment plan. The treatment goals are set based on the standard goals of the comprehensive cardiac rehabilitation programme for patients with type 2 diabetes (Chapter 4). The physician assesses the need for further individual follow-up of type 2 diabetes with the physician and/or nurse. The physician emphasizes the importance of regular eye examinations and check-ups with a chiropodist/podiatrist.

Initial type 2 diabetes consultation with a nurse
The initial type 2 diabetes consultation with a nurse often takes place a few days before the initial type 2 diabetes consultation with a physician or the same day after the physician consultation.The nurse ensures that patients measure their blood sugar correctly and understand what to do about both hyperglycaemia and hypoglycaemia. The forms required to apply for public subsidies for expenses associated with type 2 diabetes are completed, and the nurse gives referral papers for the chiropodist and any written material on type 2 diabetes considered appropriate.

The nurse assesses the patient’s degree of self-care. This concept has especially been used in diabetes care and refers to several elements and methods that enable people with type 2 diabetes to master their illness. Diabetes care has many years of experience with self-care that can be transferred to and developed within cardiac care (28;29).The integrated cardiac and diabetes rehabilitation in the comprehensive cardiac rehabilitation programme attempts to expand and unify the self-care concept from each specialty.

The nurse is responsible for asking patients about symptoms of type 2 diabetes and late complications and informing patients about preventing foot ulceration and on social support schemes, the Danish Diabetes Association and local associations. The nurse also maintains contact with the home nurse and sometimes the general practitioner. In addition, the nurse is responsible for teaching patients how to correctly measure blood sugar; mastering angina pectoris by using a diary and nitroglycerin; tackling the initial signs of poor regulation, such as weight gain, through self-administered diuretics and nitroglycerin; and mastering crisis, anxiety and depression.

The physician largely focuses on managing risk factors and early treatment of late complications, whereas the nurse’s efforts in integrating cardiac and diabetes rehabilitation creates a good basis for patients to change lifestyle and to manage to master with greater flexibility the challenges that arise if more complications emerge.


11.4.3 Follow-up type 2 diabetes consultations

The individual clinical assessment and follow-up of type 2 diabetes among patients with heart disease depend on the degree of dysregulation, but the staff attempt to perform as much of this as possible during the planned follow-up consultations when rehabilitation starts and at the follow-up consultations after 3, 6 and 12 months. Among patients with heart disease, those with type 2 diabetes often have more severe heart disease and more difficult-to-treat risk factors than those without type 2 diabetes. This therefore requires more individual follow-up consultations with both the physician and the nurse, and starting insulin treatment always requires intensive follow-up and assessment by the physician and nurse and often renewed dietary guidance to avoid weight gain.

Physician
At the follow-up consultation, the physician determines whether patients have achieved the treatment goals set, and if these have not been achieved, revises the previous treatment plan for the rest of the rehabilitation programme in cooperation with patients. The physician determines individually how often patients have to monitor blood sugar for 24 hours at a time. When patients are increasing the dose of antidiabetic agents, more follow-up and 24-hour profiles by the physician may be necessary. The physician discusses the examination results from various specialist health professionals (ophthalmologists, chiropodists, orthopaedic surgeons and dermatologists) with patients.Any patients who have not achieved the treatment goals at the 3-month follow-up consultation (Hb A1c < 6.5%, fasting blood sugar <6.0 mmol/l and blood sugar after eating a meal <8.0 mmol/l) despite optimum change in lifestyle and maximum antidiabetic pharmaceutical treatment are prepared for starting insulin treatment. The physician follows Denmark’s current guidelines for dosage at the start and enters the plan for increasing dosage in the patient records. The physician from the Cardiac Rehabilitation Unit is present for the first few times when insulin treatment is started, and the nurse follows up thereafter (the instructions for starting insulin treatment are available in Danish at www.CardiacRehabilitation.dk).

Nurse
At follow-up consultations, the nurse ensures that patients optimally master self-care for both type 2 diabetes and cardiovascular disease. The nurse and patient discuss the patient’s outstanding questions about measuring blood sugar and the concentrations obtained as well as sex and marital relations. The nurse assesses whether patients need to update their knowledge or action related to changing lifestyle. The nurse asks the patient about any variation in blood sugar, focusing on hypoglycaemia with or without manifest symptoms.The nurse examines the patient’s feet for new ulceration and examines the needle marks of patients receiving insulin. The nurse measures the patient’s blood pressure if necessary and follows up on any plans to increase the dose of medicine.


11.4.4 Group type 2 diabetes education

The type 2 diabetes education in the comprehensive cardiac rehabilitation programme is mainly group education.The groups comprise patients who have had type 2 diabetes for many years and ones who have been diagnosed recently, and the education is adapted to this.The ideal interval between each meeting is 14 days, and they are planned for the same time and day of the week. The meetings are conducted in connection with the heart-health meetings in the intensive part of the comprehensive cardiac rehabilitation programme, and 6–8 patients with type 2 diabetes are recruited from two or more of the ongoing heart-health groups. The physician and nurse conduct three type 2 diabetes meetings of 2.5 hours each. They introduce each meeting by briefly describing the purpose and duration.A special educational programme has been developed for each meeting (available in Danish at www.CardiacRehabilitation.dk), and patients get copies of the educational material to place in their heart-health orientation binder.

All three meetings focus on giving patients insight into the necessity of intensive multifactorial rehabilitation with changing lifestyle as a key component to prevent late complications and reduce their progression. The patients are encouraged to take responsibility for ensuring that this process succeeds. The meetings are structured around the following themes and slides for each that are viewed at each meeting:

Type 2 diabetes meetings
Meeting Topic
1 Type 2 diabetes – a cardiovascular disease
2 The significance of lifestyle – risk factors and late complications
3 Living and coping with type 2 diabetes as a patient with cardiovascular disease


Type 2 diabetes meeting 1
Type 2 diabetes – a cardiovascular disease

Purpose
The purposes of the meeting are to educate patients and family members on the causes and symptoms of type 2 diabetes and late arteriosclerotic complications and to teach patients how to measure their blood sugar concentration.

The meeting
The nurse and physician inform patients about the causes of type 2 diabetes and the close relationship between type 2 diabetes and subsequent arteriosclerosis diseases, especially cardiovascular diseases. They explain the significance of genetics, gender, tobacco use, overweight and physical inactivity and the importance of multifactorial intervention. The nurse manages the practical exercises in measuring blood sugar. The patients measure their blood sugar at least twice under supervision and discuss the values obtained. All patients borrow a measuring device until they achieve the desired level of skill and have obtained their own machine. The patients receive a preprinted form with precise instructions for the desired times for measuring blood sugar and are encouraged to complete this for the second meeting.


Type 2 diabetes meeting 2
The significance of lifestyle – risk factors and late complications

Purpose
One purpose is to get patients to understand the relationship between the accumulation of risk factors and the development of type 2 diabetes and that type 2 diabetes can contribute to late complications if it is not well regulated. Another purpose is for patients to learn and act upon variation in blood sugar concentration. The message communicated is that the progression of type 2 diabetes can optimally be prevented by changing lifestyle and by strictly controlling blood sugar, blood pressure, serum cholesterol and other parameters.

The meeting
The nurse explains how to measure blood sugar and describes the symptoms and treatment of hyperglycaemia and hypoglycaemia. The physician informs patients about action to reduce risk factors and type 2 diabetes, focusing on the significance of various risk factors for type 2 diabetes and preventing or promoting late macrovascular and microvascular complications. Pharmaceutical treatment is reviewed, often referring to the products used by the attending patients. This includes information on antidiabetic agents (including insulin) and medicine for treating cardiovascular disease. The goal is that patients understand that treatment with several types of medicine is necessary to prevent or reduce late complications. The patients have the opportunity to reflect about the often drastic changes in lifestyle they are implementing, and each patient has an opportunity to evaluate his or her own course of illness, both type 2 diabetes and cardiovascular disease. The relationships between these two types of disease are explained, and patients can ask questions about symptoms and other illness-related events. The nurse ensures that patients have learned to measure their blood sugar correctly. The group discusses any problems in measuring blood sugar at home, and patients who need help in measuring blood sugar are supervised.


Type 2 diabetes meeting 3
Living and coping with type 2 diabetes as a patient with cardiovascular disease

Purpose
The purposes are to communicate the necessity of a high level of self-care for both type 2 diabetes and heart disease and to inform patients about the need for close clinical assessment and follow-up by general practitioners, ophthalmologists and chiropodists. Patients should learn about social support schemes and local activities related to type 2 diabetes.

The meeting
The nurse and the patients discuss the measured blood sugar concentrations. The physician reviews the late complications of type 2 diabetes and explains the background for establishing treatment goals, future blood tests and follow-up by ophthalmologists and chiropodists, including social support schemes. The group discusses sex and marital relations.The nurse informs about future control, including which tests are performed, how and how often, buying home medical supplies and buying ideal shoes. The nurse informs about the Danish Diabetes Association and the activities of local associations and how they can support individuals in the future. Finally, all patients get individual appointments with the nurse and physician for clinical assessment and follow-up consultations.

Individual type 2 diabetes education
A few severely dysregulated patients or patients with special needs may require individual follow-up between group type 2 diabetes meetings. The comprehensive cardiac rehabilitation programme offers individual type 2 diabetes education for patients in crisis, patients with an especially complicated course of illness and patients who want an individual programme. This education is organized to review as many of the topics from the group education as possible.


11.4.5 Meeting on impaired glucose tolerance

All patients in the comprehensive cardiac rehabilitation programme who are determined to have impaired glucose tolerance are invited to a 2.5-hour meeting. The physician and nurse conduct the meeting jointly. They inform patients that impaired glucose tolerance is not a disease but a condition that can be normalized or develop into type 2 diabetes and that 3–5% of the people with impaired glucose tolerance develop type 2 diabetes each year.

Many patients will experience this meeting as a summation of the knowledge they have received on changing lifestyle from the heart-health meetings.The main message communicated by the meeting is that the optimum treatment of impaired glucose tolerance is losing weight and keeping it off, exercising at least 30 minutes daily and quitting smoking.


References

(1) Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. 1. Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998; 15(7): 539–553.

(2) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(3) Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ 1998; 316(7134): 823–828.

(4) Pedersen OB, Gaede PH. [Intensive treatment of type 2 diabetes mellitus. Is polypharmacy necessary and justified?] Ugeskr Laeger 2000; 162(25): 3582–3591.

(5) Borch-Johnsen K, Beck-Nielsen H, Christiansen JS, Heickendorff L, Brandslund I, Faber JO et al. [Guidelines on diagnosis of type 2 diabetes. Investigation, diagnosis and glucose measurement.] Ugeskr Laeger 2003; 165(15): 1558–1561.

(6) Videbaek J, Madsen M. Hjertestatistik 2000–2001 [Statistics on heart disease in Denmark, 2000–2001]. Copenhagen, Danish Heart Foundation and National Institute of Public Health, 2002.

(7) Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351(9118): 1755–1762.

(8) Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996; 335(14): 1001–1009.

(9) Aronson D, Rayfield EJ, Chesebro JH. Mechanisms determining course and outcome of diabetic patients who have had acute myocardial infarction. Ann Intern Med 1997; 126(4): 296–306.

(10) Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000; 355(9200): 253–259.

(11) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352(9131): 837–853.

(12) Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317(7160): 703–713.

(13) Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 1999; 353(9153): 617–622.

(14) Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383–393.

(15) Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345(12): 861–869.

(16) Pan XR, Li GW, Hu YH,Wang JX, Yang WY, An ZX et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance.The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20(4): 537–544.

(17) Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM,Walker EA et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346(6): 393–403.

(18) Tuomilehto J, Lindstrom J, Eriksson JG,Valle TT, Hamalainen H, Ilanne-Parikka P et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344(18): 1343–1350.

(19) Tenerz A, Lonnberg I, Berne C, Nilsson G, Leppert J.Myocardial infarction and prevalence of diabetes mellitus. Is increased casual blood glucose at admission a reliable criterion for the diagnosis of diabetes? Eur Heart J 2001; 22(13): 1102–1110.

(20) Norhammar A, Tenerz A, Nilsson G, Hamsten A, Efendic S, Ryden L et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002; 359(9324): 2140–2144.

(21) Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339(4): 229–234.

(22) Gustafsson I, Hildebrandt P, Seibaek M, Melchior T, Torp-Pedersen C, Kober L et al. Long-term prognosis of diabetic patients with myocardial infarction: relation to antidiabetic treatment regimen. The TRACE Study Group. Eur Heart J 2000; 21(23): 1937–1943.

(23) Malmberg K, Ryden L, Efendic S, Herlitz J, Nicol P, Waldenstrom A et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol 1995; 26(1): 57–65.

(24) Suresh V, Harrison RA, Houghton P, Naqvi N. Standard cardiac rehabilitation is less effective for diabetics. Int J Clin Pract 2001; 55(7): 445–448.

(25) American Diabetes Association. Clinical practice recommendations 2001. Diabetes Care 2001; 24(suppl 1): S33–S63.

(26) Grundy SM, Howard B, Smith S Jr, Eckel R, Redberg R, Bonow RO. Prevention Conference VI: Diabetes and Cardiovascular Disease: executive summary: conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation 2002; 105(18): 2231–2239.

(27) Bonow RO, Mitch WE, Nesto RW, O’Gara PT, Becker RC, Clark LT et al. Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group V: management of cardiovascular-renal complications. Circulation 2002; 105(18): e159–e164.

(28) van Dam HA, van der HF, van den BB, Ryckman R, Crebolder H. Provider–patient interaction in diabetes care: effects on patient self-care and outcomes.A systematic review. Patient Educ Couns 2003; 51(1): 17–28.

(29) Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ 2003; 29(3): 488–501.


2. METHODS

Chapter 12

Organizing Interprofessional Clinical Practice

Lone Schou & Ann-Dorthe Olsen Zwisler

[se illustration]

12.1 Introduction

AThe clinical practice in the Cardiac Rehabilitation Unit is organized based on the fundamental principles of an interprofessional approach and a comprehensive treatment ideology in accordance with existing guidelines (1–4).This chapter describes the structural and organizational conditions in the Cardiac Rehabilitation Unit.


12.2 Purpose

The purpose of an interprofessional form of organization is to ensure that the activities within the seven components of treatment are coordinated with the aims of ensuring an optimal rehabilitation programme for each patient and of achieving the treatment goals.


12.3 Staff

12.3.1 Organization

The Cardiac Rehabilitation Unit is organizationally under the Department of Cardiology, Centre for Internal Medicine. A physician under the head of the Department of Cardiology heads the Unit and is responsible for daily operations. The Unit is organized with a flat management structure based on the principles of an organization carrying out this type of project.

The Unit head has numerous administrative and clinical tasks. The Unit head takes responsibility for ensuring that patients are treated in accordance with the established goals and that the comprehensive rehabilitation programme is coordinated satisfactorily. The Unit head ensures daily operations in cooperation with the interprofessional staff and takes responsibility for ensuring an environment in which interprofessional cooperation functions optimally both internally and externally. The Unit head is also responsible for ensuring that all staff are trained and for team-building, such that all staff are working towards the same goals. The Unit head participates in the conference of physicians in the Department of Cardiology each morning and in meetings of department heads.


12.3.2 Staff composition and qualifications

The core team in the Cardiac Rehabilitation Unit comprises the following positions (numbers relative to full time): 0.8 physicians, 1.0 nurse, 1.0 physical therapist, 0.5 clinical dietitians, 1.0 secretary and 1.0 receptionist.

The peripheral team includes a social worker, who participates in all interprofessional conferences. This team also includes a liaison psychiatrist who does not participate in interprofessional conferences, and the Unit cooperates closely with the Department of Psychiatry in the form of regular education and supervision.

The Unit staff require great professional and personal independence, since each profession is responsible for its own field. The functions of all positions in the Unit have been detailed in writing (available in Danish at www.CardiacRehabilitation.dk), including the qualifications required, job functions and areas of responsibility.

All staff are required to have specialized education within their profession. The staff are required to have specialized knowledge within cardiology and experience in treating patients with heart disease since the patients in rehabilitation have complicated cases of heart disease.

Educating patients and their families is a component of rehabilitation, and the ability of each practitioner to communicate knowledge on heart disease, influence attitudes and promote changes in lifestyle is decisive for the success of each patient’s rehabilitation programme. The staff must therefore have experience in adult education and motivational counselling techniques and be motivated to take further education or training on the theoretical aspects of adult education and behavioural change, communication and lifestyle intervention. Since the Unit is also engaged in scientific research, all professions must also be given the opportunity for further education and continual updating within science.

The staff preferably have experience with interprofessional cooperation and problemsolving. The approach with an interprofessional organization places great demands on the staff to be oriented towards and committed to development and change. Finally, the staff should fundamentally respect the work of all professions.


12.4 Interprofessional Cooperation

The interprofessional approach of the Cardiac Rehabilitation Unit is based on the premise that decisions on the goals of treatment should be influenced by the insight of several professions and a common framework. This form of organization requires that practitioners both excel in their own profession and be skilled in an interprofessional approach. Practitioners should begin with and appreciate their own professional interpretation of each situation but also enter into dialogue and be critical of their own professional views (5).

The staff attended team-building and training courses taught by organizational psychologists to ensure a good foundation for an interprofessional approach. The staff have focused on developing communication skills, profession-based and interprofessional supervision, developing a common culture and giving priority to professional and social interaction.

The staff have participated in the patient services offered by other professions to obtain insight into an interprofessional approach and have regularly been updated within the individual components of rehabilitation through extended staff meetings and interprofessional conferences.


12.5 Organizing Clinical Practice

The Cardiac Rehabilitation Unit strongly emphasizes that staff resources should be used optimally and that the Unit should be a flexible workplace that can meet the needs of each individual staff member.

Clinical practice is organized with the opportunity for flextime at the beginning and the end of the working day. Patient consultation is scheduled between 0830 and 1530. Time before and after this is used for administrative tasks. An interprofessional conference is scheduled weekly and a staff meeting every two weeks. The work schedule accounts for the availability of staff and offices and the complex integration of individual schedules and several parallel group sessions for six weeks (see www.CardiacRehabilitation.dk for the work schedule (in Danish) and a description of the schedule).

The weekly interprofessional conference discusses the tasks of the coming week, appointments and planned absence with the aim of carrying out tasks optimally. In addition, the conference carries out long-term planning and adaptation.


12.6 Physical Setting

All treatment components are located in the Cardiac Rehabilitation Unit, which is separate from the Department of Cardiology. The fact that the Unit is in one location is decisive for treatment and gives patients the sense that the individual components are coordinated. Similarly, the daily formal and informal contact between the various professions is very important for interprofessional cooperation.

The physical separation from the acute inpatient ward of the Department of Cardiology is in accordance with the natural progression of patients from the inpatient ward during the acute phase to an outpatient role in early rehabilitation but physically separated from the acute inpatient ward. This de-emphasizes the person’s role as a patient, and the patients takes joint responsibility for treatment.

Reception area: The reception area is the command centre of the Cardiac Rehabilitation Unit. Its most important function is receiving patients and coordinating each patient’s programme. The reception area includes a counter; workplaces with computers, telephones and telefax; and archives.

Waiting room: The waiting room is located in the centre of the Unit and has chairs for patients and family members. This room has relevant magazines and information material, hot and cold sugar-free drinks and fruit.

Toilet and bathroom: The toilet and showering facilities are located near the waiting room, with facilities for both men and women. Nevertheless, few patients use these facilities.

Consultation rooms: The Unit has three consultation rooms; each has a computer, telephone, examination table and sphygmomanometer.

Weighing: Patients are weighed in a small, independent room that has a scale everyone uses to avoid differences because scales need to be calibrated. The scale is electronic and is calibrated regularly. It can weigh patients up to 200 kg, and the display is at chest height so that very obese patients can visually follow their progression in weight, including any loss.

Testing room: A consultation room has a testing cycle and examination table to test aerobic functioning.

Exercise facilities: The aerobics room is 40 m2 and has space for about eight people, a music system, parallel bars, wall bars, mats, balls and other equipment. Next to the aerobics room is an exercise room with cycles, a computer station and a blackboard for educational purposes. The main stairway in the Unit to the fourth floor is part of the exercise facilities. The aerobics and exercise rooms have telephones in case patients become acutely ill in connection with exercise and testing.

Kitchen: The Unit has a kitchen in which the dietitian and the patients and their families cook. The kitchen is furnished in accordance with the hygienic principles of Bispebjerg Hospital and is ergonomically designed. The kitchen has two cooking islands; each has a sink, oven and cooking equipment. There is a refrigerator–freezer, a dishwasher and a blackboard.

Dining and consultation room: The dietitian’s consultation room has a table used for meetings and for eating the meals prepared in the cooking classes. This room has instructional equipment and a workplace with a computer and telephone.

Group room: Patients receive group education in a room designed for 12 people with plenty of space, a bright atmosphere and a window. This room has a table, chairs, computer with a projector, whiteboard, screen, overhead projector and television with videocassette player.

Workplaces: The workplaces in the Unit can accommodate any staff member; each has a computer with access to the Internet, an intranet and the nationwide hospital information system (Green System) in all rooms. Each staff member has a mobile chest of drawers.

Storage depot: The Unit has a storage depot with storage space, a printer, a photocopier, a locked medicine cabinet and other equipment.


12.7 Safety

Physical activity can trigger adverse cardiac events. Nevertheless, the risk is low in supervised activities (6).There is little experience with exercise training among patients with congestive heart failure, who have increased risk for life-threatening arrhythmia, but if the principles related to exercise intensity are followed, the risk of exercise training among this group of patients is considered minimal (7). Denmark has no safety recommendations for physical activity among patients with heart disease, and both departments of cardiology and countries vary widely in their safety routines (8).

Despite the assessed low risk of exercise, the Cardiac Rehabilitation Unit gives high priority to patient safety. The Unit always requires two staff members to be present whenever patients are in the exercise rooms. All staff have been trained in basic cardiac resuscitation and the physicians and nurses in advanced cardiac resuscitation. An instructor in cardiac resuscitation trains staff every six months. The Unit has equipment for and instructions for cardiac resuscitation (available in Danish at www.CardiacRehabilitation.dk).

Cardiac resuscitation cart: A cart including a defibrillator and other cardiac resuscitation equipment is located in the waiting room. Pharmaceuticals for cardiac resuscitation are in the medicine cabinet for safety reasons (the medicine present is available in Danish at www.CardiacRehabilitation.dk). A nurse checks the defibrillator weekly. The defibrillator can be used anywhere in the Unit with or without an electrical outlet.

Pharmaceuticals: In accordance with the guidelines of the Copenhagen Hospital Corporation, pharmaceuticals are kept in a locked medicine cabinet.The range of drugs available meets the needs of the Unit.There is medicine to treat all types of acute illness, such as cardiac arrest, heart and lung disease and acute diabetic conditions. There are various analgesics and a broad selection of cardiac pharmaceuticals for testing and starting treatment. Since smoking cessation is part of treatment in the Unit, there are many nicotine replacement products. A nurse checks all pharmaceuticals regularly for date of expiry and adjusts them in accordance with current guidelines.

Acute illness: The Unit has the following procedure for congestive heart failure, tachycardia, syncope, chest pain and other acute illness. 1) The physician and the care staff in the Unit are summoned and any necessary treatment is initiated. 2) The physician assesses whether the patient needs to be transferred to intensive care or the acute inpatient ward. 3) The physician accompanies the patient in the transfer.

Cardiac arrest: The Unit has the following procedure for cardiac arrest. 1) The alarm is sounded. 2) Resuscitation and treatment are initiated. 3) The patient is transferred to intensive care. 4) The physician accompanies the patient in the transfer.

Fire: All staff are trained in extinguishing fires, and the Unit has fire blankets, powder extinguishers and water extinguishers. The Unit has the following procedure for fire. 1) The alarm is sounded. 2) People who are immediately threatened are evacuated. 3) All doors and windows are closed. 4) The fire is extinguished if possible. 5) Firefighters are informed on arrival of the location and extent of the fire.

Safety procedures and the physical setting comply with the Working Environment Act (9) and the standards of the Copenhagen Hospital Corporation, which are based on international standards (10).


Referencesr

(1) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(2) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(3) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(4) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(5) Seemann J. Distriktspsykiatrien i et organisatorisk spændingsfelt [District psychiatry in an organizational field of tension]. In: Blinkenberg S, Vendsborg PB, Lindhardt A, Reisby N, ed. Distriktspsykiatri. En lærebog [District psychiatry. A textbook]. Copenhagen, Hans Reitzels Forlag, 2002.

(6) Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA 1986; 256(9): 1160–1163.

(7) Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22(2): 125–135.

(8) Vanhees L, McGee HM, Dugmore LD, Schepers D, van Daele P. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey. J Cardiopulm Rehabil 2002; 22(4): 264–272.

(9) The Working Environment Act. Act No. 784 of 11 October 1999. Copenhagen: Danish Working Environment Authority, 1999 (www.at.dk/sw8800.asp, accessed 22 March 2004).

10) Joint Commission International standards for hospitals. 2nd edn. Oakbrook Terrace, IL: Joint Commission International, 2003.


3. EXPERIENCE


Chapter 13

Project Development And Patient Material

Ann-Dorthe Olsen Zwisler


13.1 Introduction

The comprehensive cardiac rehabilitation programme and the Cardiac Rehabilitation Unit at Bispebjerg Hospital were founded as a project in late 1999 in accordance with the recommendations of a local working group on reorganizing cardiac rehabilitation 1). The cardiac rehabilitation project has undergone a process of development, and the staff have gathered considerable experience in clinical practice. This chapter describes the main aspects of the development process and the patient material. The development of the project is described in detail elsewhere (2).


13.2 Project Development

The comprehensive cardiac rehabilitation project has gone through several development phases in its three years that are typical of reorganization (3;4). The figure on page 158 outlines the individual phases and traces them chronologically.


13.2.1 Project phases

Founding
The staff, who were recruited through internal selection (Chapter 12 describes the joint training programme), broadly supported the founding of the comprehensive cardiac rehabilitation programme. All staff helped to furnish the offices (more details available in Danish at www.CardiacRehabilitation.dk) and to establish practical procedures corresponding to the overall guidelines (1;5). The methods and procedures were tested on three pilot groups and adjusted based on patients’ evaluation.

Illustration of Project phases in the comprehensive cardiac rehabilitation programme

Gathering experience
The project began in March 2000. Considerable organizational and practical experience was obtained in comprehensive cardiac rehabilitation in the first year based on patient material equivalent to full operation. The need to adjust the project in relation to full operation was identified, and the project was adjusted in several ways.

Adjustment
The programme was carefully adjusted in relation to the scientific protocol (available in Danish at www.CardiacRehabilitation.dk), since the programme has been subject to the premises of a scientific study throughout the project period.

The most extensive adjustments were associated with the individual tailoring of patient programmes, which solely included a consultation with a physician at the start of the project. The consultation with a physician did not provide the staff with adequate knowledge of the patients’ motivation, resources and barriers, and the treatment goals were not clear to the interprofessional team of practitioners. Based on the interprofessional discussions, the rehabilitation programme was extended to include individual counselling with a physical therapist, clinical dietitian and nurse. The standardized interview guides (available in Danish at www.CardiacRehabilitation.dk) were prepared to ensure uniform information content for the individual counselling, and the focus for the interprofessional conference was changed to emphasize the individually tailored rehabilitation programmes and establishing goals and planning clinical assessment. This adjustment allowed the team of practitioners to get to know the patients better, and the patient programmes could thereby be targeted and tailored better.

During the adjustment period, the Unit decided that all patients would take an introductory test of aerobic functioning to individually tailor the exercise training and a follow-up aerobic test and counselling with a physical therapist at 3 and 12 months. The adjustment improved the focus on individual exercise, following up the effects of exercise, biofeedback and adjustment.

Experience from the first year showed that the treatment of patients with type 2 diabetes did not comply with the current guidelines (6), and the team of practitioners suspected that type 2 diabetes was being underdiagnosed among patients in the programme. The rehabilitation programme was adjusted by focusing on type 2 diabetes, and cardiac rehabilitation was extended to a special diabetes module (Chapter 11).

Experience with organization in the first year showed that the daily management of the interprofessional team needed to be strengthened. The purpose of this change was to ensure closer follow-up of the comprehensive performing of tasks, which had not yet become firmly established, and to meet the staff demand for clearer guidelines for internal and external cooperation. As several professions are involved in treating patients, the tasks and division of labour needed to be defined clearly in relation to treating patients and in relation to administrative and technical tasks. The cardiac rehabilitation team found that each profession tends to focus on its profession instead of focusing on the interaction with other professions and how this can contribute to the comprehensive efforts. The significance of an integrated approach therefore needed to be discussed regularly in relation to the profession-specific activities.

Consultants from Bispebjerg Hospital’s Department of Development, Education and Training have monitored and supervised the Unit head and staff during the process of development. Two seminars were held during the project period: one in connection with the founding of the comprehensive cardiac rehabilitation programme and one in connection with the adjustment of the rehabilitation programme.


13.2.2 Patient material

During the three-year project period, 389 patients received comprehensive cardiac rehabilitation within the Unit; 86% of these carried out the intensive programme. The mean age was 63.4 years, and 37% were women. Twelve percent had congestive heart failure, 58% had ischaemic heart disease and 30% had a high risk of ischaemic heart disease. Twenty percent had known type 2 diabetes. Forty-seven per cent of the patients in the comprehensive cardiac rehabilitation programme lived alone at the start of the rehabilitation programme, and 20% were on the labour market.

Scientific articles will present information on patient attendance, patient evaluation of the cardiac rehabilitation services, the resources used and cost calculations and will calculate the effects and analyse the health economics of the programme in accordance with the evaluation model for the project (available in Danish at www.CardiacRehabilitation.dk).


References

(1) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(2) Zwisler ADO. DANREHAB-studiet. Efterbehandlingstilbud til patienter udskrevet fra en hjerteafdeling. Status [The DANREHAB study. Rehabilitation services for patients discharged from a department of cardiology]. Copenhagen, Bispebjerg Hospital and National Institute of Public Health, 2002.

(3) Enderud H. Beslutninger i organisationer [Decisions in organizations]. 7th edn. Copenhagen, Fremad, 1986.

(4) Rasmussen NK, Poulsen J. Evaluering af forebyggende sundhedsarbejde [Evaluation of diseasepreventive health activities]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 246–251.

(5) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(6) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.


3. EXPERIENCE

Chapter 14

Experience With The Comprehensive Programme

Cardiac rehabilitation team, Cardiac Rehabilitation Unit


14.1 Introduction

This chapter presents the experience of the cardiac rehabilitation team and the reflections on comprehensive cardiac rehabilitation in its present form. The reflections are based on the interprofessional discussions during the last year of the project. The project has not systematically evaluated the process by interviewing the cardiac rehabilitation team. The patients, in contrast, have been involved in evaluating the rehabilitation programme during the entire project period and have regularly evaluated the cardiac rehabilitation services in connection with the gathering of experience and adjustment (the form used to evaluate the programme is available in Danish at www.CardiacRehabilitation.dk).

The comprehensive rehabilitation services offered by the Unit include several core components in accordance with the national guidelines (1–3). This chapter describes the clinical experience of the cardiac rehabilitation team with the content of treatment and the organization of clinical practice in the Unit.


14.2 Content Of Treatment

14.2.1 Systematic clinical assessment and referral

Well-functioning cardiac rehabilitation services require that all patients be assessed systematically for referral. In the comprehensive cardiac rehabilitation programme, a nurse independent of the discharge process systematically assesses all patients for the need for cardiac rehabilitation (Chapter 2). In an operational situation, the patients’ suitability for cardiac rehabilitation would most appropriately be assessed as part of the discharge process. An assessment form (a form that can be used at discharge or for outpatient assessment is available in Danish at www.CardiacRehabilitation.dk) can be used to ensure that all aspects of a patient’s condition are assessed systematically.

We find that patients are more motivated to participate in comprehensive cardiac rehabilitation if they are asked to attend an outpatient assessment interview than if they are asked to participate while inpatients. Patients are more clarified about their illness and have determined their need for support after the acute illness period when they attend an outpatient interview. We therefore recommend that patients in the future be referred to outpatient discharge counselling in the Unit when their acute situation has been fully assessed.

The patients we receive at the Unit have been referred one week after discharge, which is equivalent to the referral interval for cardiac rehabilitation for a typical patient after acute myocardial infarction. We have found that referral back to the Unit of patients who have received acute and subacute invasive treatment at other hospitals is not systematic. This referral requires that health personnel have adequate insight into the effects and extent of cardiac rehabilitation services at the local hospital. In the future, effective routines should be implemented that ensure that all patients undergo uniform systematic assessment and referral.

Based on our experience in the Unit,we find a general need for clear referral procedures that indicate the optimum time for referral to cardiac rehabilitation of the broad and heterogeneous group of patients targeted by cardiac rehabilitation services: patients who have had coronary artery bypass grafting or percutaneous coronary intervention, patients with stable ischaemic heart disease or congestive heart failure and patients at high risk for developing ischaemic heart disease.


14.2.2 Individual tailoring of patient programmes, risk factor management and clinical assessment

Patient programmes are individually tailored through individual consultation and subsequent coordination at the interprofessional conference (Chapter 4). This model, in which all professions counsel the patients, strengthens both the individual professions and the interprofessional approach and thereby improves the overall patient programmes.

A nurse coordinated patient programmes in the last part of the project.We believe that rehabilitation could be improved if a nurse consulted the patients at a follow-up discussion during or after the six-week intensive programme as a supplement or alternative to the follow-up clinical assessment with a physician. The nurse can have difficulty in following up on planned initiatives or problems if a follow-up consultation is not scheduled, and patients seldom ask for such a consultation with a nurse.

Striving to achieve pharmaceutical compliance in the comprehensive cardiac rehabilitation has been a great challenge, since many patients are scheduled to take substantial medicine at various times of the day. We used a form for patients’ medicine (see www.CardiacRehabilitation.dk for this form and instructions in Danish), systematically assessed the pharmaceuticals used and updated the records at each follow-up consultation with a physician. Ensuring good pharmaceutical compliance is difficult in the long term.This should be in special focus in the future, since optimum pharmaceutical treatment and good compliance are very important for the overall effect of cardiac rehabilitation.

Coordinating the multifactorial intervention has been very challenging. Various software (PRECARD and HjerteRask) has been used to carry out the complex tasks, but this software was not developed for a cardiac rehabilitation programme. The software has therefore inadequately fulfilled the overall needs of the Cardiac Rehabilitation Unit.The needs during the project period were met using patients’ treatment plans, with manual entry of additional information1 combined with a standard interview guide for the counselling. In the future, cardiac rehabilitation software is needed that can be used as part of individual tailoring and the risk factor management and clinical assessment. Systematic and clear assessment of the cardiac rehabilitation activities for each patient would provide valuable information for evaluation and for continuing development. This registration could also form the basis for a future national clinical database on cardiac rehabilitation. This database could be linked to the Danish Heart Disease Registry (4) and the Danish Clinical Database on Invasive Cardiac Procedures and thereby provide valuable knowledge on cardiac rehabilitation activities at the individual level.2


14.2.3 Patient education

The comprehensive cardiac rehabilitation programme has mainly organized patient education as group programmes (Chapter 5). To ensure uniform communication of information, the education is organized based on a standard educational programme and standard materials. Nevertheless, the educator has the autonomy to modify the educational material and to structure the educational sessions based on patients’ desires and needs.

In contrast to our expectations, substantial differences in age may create good dynamics in a group if everyone is allowed to participate.

If several patients in a group have been recommended to lose weight or stop smoking, we find that patients enter into mutual agreements, which promotes motivation. The patients quickly organize themselves and learn how to benefit from one another, which creates a positive group effect. Nevertheless, a negative group effect may arise if one or more patients express opposition to changing lifestyle. These patients may ultimately demotivate a group, and the educator must assess whether such a patient should be transferred to an individual educational programme.

The size of the group strongly influences patient education. The smaller the group, the fewer patients can exchange experience, and a group may rapidly seem very small if a few members do not attend. In contrast, very large groups can create difficulty in taking individual consideration, and less active patients can easily be ignored or have difficulty in participating.

The demand for courses in cardiac resuscitation has been unexpectedly large, and waiting lists have therefore been created. Patients and their family members are very committed in participating in the course, and the family members say that this course has given them confidence that they could act appropriately if they suddenly witness a cardiac arrest. Several patients have further stated that seeing their family members participate actively in the course has made them feel more secure in daily life.

The groups formed in comprehensive cardiac rehabilitation have had various diagnoses because of the broad target group. This heterogeneous composition has mostly created problems in educational programmes. A high-risk patient, for example,may have difficulty in identifying with the problems of a patient with congestive heart failure. This can be solved by offering additional education to patients with special diagnoses: ischaemic heart disease, congestive heart failure and type 2 diabetes or special problems, such as patients with an implantable cardioverter defibrillator or pacemaker and patients with auricular fibrillation. This has not been possible in the comprehensive cardiac rehabilitation programme, however, because the patient flow was relatively low during the project period. A larger patient flow in an operational situation would allow more homogeneous groups to be created.


14.2.4 Exercise training

The Cardiac Rehabilitation Unit asks all patients to participate in an intensive supervised exercise training programme over six weeks (Chapter 6).

We were surprised at how rapidly patients take responsibility for exercise training, assisted by heart rate monitoring.We find that the heart rate monitoring and individual evaluation encourages the patients to exercise. Nevertheless, the patients have expressed the desire for more comprehensive exercise training than that offered in the Unit, which is based on activities that can easily be transferred to daily life. We have therefore bought balls for balance and equilibrium exercises and walking sticks and aerobics elastics to train the muscles of the upper body extremities.

Patients with congestive heart failure and with ischaemic heart disease can easily exercise together and carry out everyday activities such as cycling,walking and climbing stairs if the exercise training is monitored individually and the necessary precautions are taken (Chapter 6).

The physical therapist has registered symptoms, injuries and accidents in the supervised exercise training. The 389 patients exercised for about 6000 hours during the project period without any form of adverse cardiac event.

By closely cooperating with the physical therapist, the rest of the cardiac rehabilitation team has gained insight into the methods of the physical therapist and the opportunities to improve patients’ level of physical functioning with relatively little effort. The clinical team observes how pleased patients are to be getting physical exercise and obtains insight into how much patients can manage in daily life.


14.2.5 Support for changing diet

The Unit has organized support for changing diet as individual counselling with the dietitian and group cooking classes (Chapter 7). The patients seldom fail to attend dietary counselling in comprehensive cardiac rehabilitation, in contrast to a traditional dietary consultation at a hospital. The probable reason is that the patients feel that dietary intervention is a key component of the overall treatment.

Many patients are sceptical when they attend the cooking classes. Several are selfconscious about being educated on how to cook; others are sceptical about whether healthy food really tastes good. This especially arises when the group is eating for the first time, as many patients say they are surprised by how good the food tastes. Several patients then subsequently report that they use the heart-healthy recipes for both daily meals and when entertaining guests. The patients call the dietitian long after leaving the cardiac rehabilitation programme to get inspiration for new recipes. The cardiac rehabilitation team is thus convinced that cooking classes give many patients the courage to prepare different types of meals than those they usually prepare; experience shows that this is a difficult process.

The close cooperation with the dietitian gives the rest of the cardiac rehabilitation team insight into the significance of diet and the opportunities to motivate patients to change their diet; especially physicians have traditionally not been aware of this. The cardiac rehabilitation team also obtains insight into the professional fields and methods of the dietitian.


14.2.6 Support for smoking cessation

Support for smoking cessation in the comprehensive cardiac rehabilitation programme includes individual counselling with a nurse, smoking cessation counselling in groups and individual smoking cessation programmes (Chapter 8).

It is decisive that the patients receive uniform information on the important of smoking and quitting as part of preventing disease and treating heart disease. Patients who are told that they are healthy in connection with invasive treatment are less motivated to stop smoking. Health personnel should strive in the future to make uniform all information as well as attitudes towards the importance of quitting for preventing and treating heart disease.

Getting patients to quit smoking is very difficult. When patients start to smoke again, practitioners tend to lose faith in the utility of intervention. Nevertheless, practitioners must maintain that quitting smoking, like all other changes in lifestyle, is a process, and many attempts may be required to change lifestyle in the long term.

Group education in which patients are at very different phases in the cycle of motivation may be difficult. Many of the smoking cessation programmes in the comprehensive cardiac rehabilitation programme have therefore been carried out individually.

Smoking cessation counselling in groups requires clear agreements with the patients at the first meeting stipulating that they must explicitly indicate whether they are ready to stop smoking. This avoids the ambivalence of individual patients from adversely affecting the rest of the group. Many patients who thought they were motivated to stop smoking lose courage at the start of the group counselling. These patients should instead be offered individual health counselling.

Patients tend to leave the group counselling if they have started smoking again. This can be avoided if the smoking cessation counsellor emphasizes at the first meeting that most smoking cessation programmes include relapse.


14.2.7 Psychosocial support

The structured psychosocial intervention of the comprehensive cardiac rehabilitation programme includes individual therapeutic counselling, group intervention, treatment of anxiety and depression, a 24-hour helpline and social support (Chapter 9).

Patients’ crisis period can be reduced considerably if they have the opportunity to talk to a professional about their situation early in this period. This requires the interprofessional clinical team to have through knowledge of crisis situations and crisis management.

Some patients treated in comprehensive cardiac rehabilitation are referred to detailed assessment by a liaison psychiatrist. Telling patients that they require psychiatric assessment may be difficult. Such patients often get concerned and defend themselves by saying that their situation is not that serious and that they do not consider themselves as mentally unstable. The patient should therefore be told that many people get anxiety and depression in connection with acute illness and that this can and should be treated just like the other sequelae of heart disease.

Informal discussions between the patient and professionals and among the patients play an important role in psychosocial support. The meal that is part of the cooking classes has an important social aspect, and during the exercise training the patients bond to the extent that several of the groups have continued group exercise training voluntarily after the comprehensive cardiac rehabilitation programme ended. In the future, the Cardiac Rehabilitation Unit should support the continuation of these spontaneously arising groups with the aim of continuing psychosocial support and maintaining exercise training in phase III of the programme.

Family members (especially spouses) can demonstrate the same reaction as the patient, and the patient and family members can influence one another negatively. Some family members react more strongly to the illness than the patient does. Many patients report that family members become afraid and insecure in connection with activities of daily living that the patients previously managed without problems. Including family members in education and individual counselling is important, perhaps after the patients have had an independent opportunity to begin to cope with their new role.

In evaluating treatment services, patients strongly emphasize the 24-hour telephone access to the Cardiac Rehabilitation Unit. The significance patients attribute to this function contrasts with the fact that the helpline is seldom used outside regular business hours. Implementing a 24-hour helpline requires very few additional resources compared with the security this creates for the patients.

The fact that a social worker has participated in the interprofessional conference and has assisted in advising on the opportunities for support from social services has been very important for the overall cardiac rehabilitation efforts. The clinical team considers that acquiring expertise in this field would be an impossible challenge for them, since legislation and practice change often.


14.2.8 Supplementary diabetes module

The diabetes module in the comprehensive cardiac rehabilitation programme includes screening for type 2 diabetes, individual diabetes counselling, group education and meetings on impaired glucose tolerance (pre-diabetes) (Chapter 11). Systematically screening for diabetes in the programme has revealed surprisingly many patients with newly discovered diabetes (5). Diabetes screening can be carried out without great difficulty in a cardiac rehabilitation programme. The Cardiac Rehabilitation Unit has tackled the logistical problems that are often mentioned as a barrier using computer software.

Patients with type 2 diabetes are known to be more severely ill than non-diabetics. Diabetic patients must therefore be monitored more closely and be treated more intensively to achieve the strict treatment goals in cardiac rehabilitation. This often results in increased use of multiple pharmaceuticals, which creates problems with compliance.

Intervention in the lifestyles of patients with diabetes is an even greater upheaval than for non-diabetics. For example, similar to other people, patients with type 2 diabetes should anticipate gaining weight when they stop smoking. Many patients who start taking or increase the dosage of certain anti-diabetes pharmaceuticals when they quit smoking gain even more weight, which makes quitting even more difficult over time. Patients with heart disease often follow the recommendation of reducing intake of fat and sweets and eating more fruit, but patients with diabetes also need to limit their fruit consumption.

Many patients with diabetes have sexual problems. Diabetic impotence can successfully be treated with pharmaceuticals. Practitioners should discuss sexual problems with both men and women.

The Cardiac Rehabilitation Unit has attempted to meet the established treatment goal for glycaemic control. Nevertheless, achieving the goal and maintaining the optimal level for 12 months has been difficult. Achieving and maintaining the treatment goal requires very close follow-up and continual further training of the clinical team.


14.2.9 Cooperation with primary health care

The comprehensive cardiac rehabilitation programme has not taken special initiatives to strengthen cooperation with primary health care other than routinely forwarding comments to the general practitioner after the programme ends at the 12-month physician consultation. In addition, during the long programme the general practitioner is informed of changes in pharmaceutical administration through the patient’s medicine form.

The transfer to primary health care poses a great risk of losing the treatment effects achieved. Similarly, the patients risk experiencing a lack of continuity in overall health care.

Cooperation with primary health care needs to be in focus in the future to ensure the patients a coherent treatment programme and to maintain the treatment effects achieved.


14.3 Organization

14.3.1 Interprofessional organization and performing of tasks

The clinical practice of the comprehensive cardiac rehabilitation programme is organized based on the principles of an interprofessional approach and comprehensive treatment ideology (Chapter 12).

The programme is optimized when the various professional approaches and competencies are used in a coherent programme in which the tasks performed are coordinated. Nevertheless, practising interprofessional cooperation can be extremely difficult. One prerequisite is common definitions within the interprofessional team.

The interprofessional rehabilitation programme places very high demands on profession- specific competence. If a high level of profession-specific competence is not ensured by hiring and training highly qualified staff, the interprofessional group risks acquiring an approach in which everyone is merely superficially familiar with the other professions and the advantages of a strong profession-specific approach thus disappear.This project has emphasized the importance of continual further education and training for each profession together with further education and special training within cardiac rehabilitation with the aim of ensuring professional excellence within all components of rehabilitation.

Complying with the dual demands of profession-specific excellence and an interprofessional approach can be difficult for practitioners. When professionals are discussing treatment strategy, the profession that historically has achieved the highest status, physicians, will often dominate, since the entire clinical team has been trained in a culture in which physicians decide treatment. The requirement for dialogue means that discussion on profession-specific excellence and an interprofessional approach has to be prominent, and the well-known loyalty to one’s own profession can be severely strained. Interprofessional cooperation is a process that requires continual follow-up and supervision, especially since the Cardiac Rehabilitation Unit regularly employs new personnel with new values.

An interprofessional approach poses great demands on the priorities and overview of management in ensuring coherent programmes for patients by involving and coordinating the various professional approaches while maintaining and developing profession- specific excellence.

Ensuring common attitudes towards participating in interprofessional cooperation, including both specific tasks and organizing and coordinating practice, is important in employing staff and in setting priorities in organizing clinical practice.

Challenges in cooperation can especially arise in the following situations: uncertainty about carrying out tasks, disagreement on the division of tasks and responsibility, disagreement on goals and assessment criteria, differences in how involved the staff are in the programme and differences in the forms of management and cooperation desired by staff. In the future organization of cardiac rehabilitation, the management should take positions on and involve staff actively in these challenges and establish a structure for these.


14.3.2 Joint electronic patient records

The clinical team has used a joint electronic patient record, a cornerstone of an interprofessional approach to performing tasks. Implementing an electronic patient record unexpectedly became a prominent subproject and required considerable staff resources. Similar to other settings (6), introducing electronic patient records has had several or-ganizational effects and sparked a need for redefining the roles and functions of each profession.We found that successfully implementing electronic patient records places greater demands on organizational culture than on the software used. The Cardiac Rehabilitation Unit implemented electronic patient records in connection with a comprehensive change in the organization of treatment. This turned out to be a good time for such a thorough change of established work routines since the clinical team was very open and willing to change.

A joint information base developed through common systematic information collection has turned out to be decisive for coordinating an interprofessional programme. Finally, the joint information base is an important prerequisite for assuring a high-quality coherent programme for each patient.

The patients are actively involved in using the Unit’s electronic patient records. The patients are initiated into viewing the electronic patient records from the initial consultation with a physician, at which they are informed that they may read and comment on the notations.We find that most patients feel secure about this and are quite attentive, similar to the experience from using electronic patient records in general practice. Nevertheless, a few mostly elderly patients have expressed uncertainly about rehabilitation activities because of the lack of a paper record.


14.3.3 Physical setting

All components of cardiac rehabilitation are located at the Cardiac Rehabilitation Unit. This physical unity plays a great role in interprofessional cooperation, since daily in-formal contact allows the professions to exchange experience. The daily contact also reduces the cultural barriers to cooperation.

When the Cardiac Rehabilitation Unit was founded, one emphasis was access to showering facilities, which cost considerable money to build. Nevertheless, few patients use these facilities.

It has been very important that the kitchen is designed so that it can be used for both theoretical and practical education. Older patients and patients with congestive heart failure may have difficulty standing up during an entire cooking session, and these patients benefit greatly from the ergonomically adjustable stools. A kitchen must be designed based on the fact that many patients in cardiac rehabilitation are overweight and therefore take up more space than people of normal weight.

The cardiac rehabilitation programme was installed in suitable offices, but the accessibility was poor. In acute situation, access conditions must comply with existing standards for access for disabled people for safety reasons and to accommodate the group of patients with severely reduced functioning.


References

(1) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(2) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(4) Videbaek J, Madsen M. Hjertestatistik 2000–2001 [Statistics on heart disease in Denmark, 2000–2001]. Copenhagen, Danish Heart Foundation and National Institute of Public Health, 2002.

(5) Soja AM, Zwisler ADO, Melchior T, Hommel E. Abnormal glucose metabolism among patients attending cardiac rehabilitation. The DANSUK study. Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation, Kansas City, Missouri, 13–16 October 2003.

(6) Svenningsen S. Electronic patient records and medical practice. Reorganization of roles, responsibilities, and risks. Dissertation. Copenhagen, Copenhagen Business School, 2003.


3. EXPERIENCE

Chapter 15

Future Challenges

Ann-Dorthe Olsen Zwisler


15.1 Introduction

Based on scientific studies and our experience, cardiac rehabilitation is a key part of the overall future efforts to treat and prevent heart disease. This project has been implemented as an initiative to strengthen and develop this field.We have made considerable progress, but this field needs to be developed further.

Implementing the project has stimulated consideration on more fundamental aspects of cardiac rehabilitation. This chapter describes the subjective considerations of the cardiac rehabilitation team on a coherent cardiac rehabilitation programme, intersectoral cooperation and educational requirements in the future.


15.2 Ensuring A Coherent Cardiac Rehabilitation Programme

The comprehensive cardiac rehabilitation programme comprises not only the efforts of the Cardiac Rehabilitation Unit but can be divided into three phases that succeed one another in a continuous, chronological programme. The purpose, content and actors of each phase have specific characteristics (1).

Phase I is the introductory phase in which disease and treatment needs arise, diagnosis is made, acute treatment is initiated, the prognosis is assessed and the cardiac rehabilitation programme is planned. Phase II is the early phase in which rehabilitation is initiated and followed up. Phase III is the late phase of rehabilitation in which the initiatives are maintained and remission is prevented.

Illustration of The comprehensive cardiac rehabilitation programme and action by various sectors

The programme is often based on activities by several actors in various sectors, and it is decisive that the patients consider the cardiac rehabilitation programme to be logical and coherent.


15.2.1 The cardiac rehabilitation programme

Phase I
Optimum cardiac rehabilitation in phase I and subsequent systematic clinical assessment and referral to phase II are prerequisites for a successful phase II hospital-based cardiac rehabilitation programme.

Experience from the cardiac rehabilitation programme at Bispebjerg Hospital shows that systematic assessment identifies many patients with heart disease or a high risk of heart disease who need systematic cardiac rehabilitation. Nevertheless, experience at Bispebjerg Hospital also shows that not all patients want or are well suited for a hospital-based outpatient cardiac rehabilitation programme. Elderly patients and patients with congestive heart failure especially have difficulty in taking a position on participating in a long programme with many visits to the hospital. Denmark offers very few alternatives to hospital-based outpatient treatment, such as home-based cardiac rehabilitation or, as in other countries, phase II inpatient cardiac rehabilitation.

Phase II
Repeated surveys of cardiac rehabilitation (3–7) have shown that the phase II outpatient cardiac rehabilitation programmes at Denmark’s hospitals needs to be expanded. The comprehensive cardiac rehabilitation project at Bispebjerg Hospital has shown that outpatient cardiac rehabilitation that complies with the existing guidelines for cardiac rehabilitation in Denmark (8–10) can be organized.

The cardiac rehabilitation team finds that an interprofessional approach requires a different organizational structure than the traditional hierarchical structure of hospitals and hospital departments, which tends to support the specialized profession-specific culture. One future challenge is therefore to develop an organizational design and a form of management for rehabilitation that better supports interprofessional methods of performing tasks and continuity in patient programmes across traditional professions and professional cultures while ensuring profession-specific excellence.

One alternative to hospital-based phase II cardiac rehabilitation is home-based cardiac rehabilitation, which may turn out to be just as effective as hospital-based programmes (11–15). Nevertheless, home-based cardiac rehabilitation requires well-functioning hospital-based programmes at which staff are based or from which staff can obtain experience and expertise. Experience with home-based cardiac rehabilitation in Denmark needs to be developed and assessed so that cardiac rehabilitation in the future can reach out to a broader target group than merely the relatively well-functioning patients who can manage to participate in the hospital-based programmes.

Phase III
At the end of phase II, it is very important that the patients can be referred to well-functioning phase III services with the aim of maintaining the effects achieved.

The practical experience in the Unit and a survey of cardiac rehabilitation (3) show that Denmark has very few phase III cardiac rehabilitation services. Similar to other countries, Denmark urgently needs to scale up phase III cardiac rehabilitation. Local health centres, which are currently being debated in Denmark, have been proposed as a vehicle for expanding phase III cardiac rehabilitation to local areas in other European countries (16).


15.2.2 Intersectoral cooperation

Attention has increased in recent years to the fact that patients are especially vulnerable during the transition between phases because coordination may be lacking between actors and activities (17). The problem is not solely that the intersectoral cooperation or lack thereof does not support the programme optimally. The most important prob- lem is that poorly functioning intersectoral cooperation adversely affects the otherwise positive activities within the individual phases and sectors.

Ensuring a coherent and optimum patient programme in the comprehensive cardiac rehabilitation programme has turned out to be difficult. This task becomes even more difficult when a coherent programme has to be coordinated across the various sectors. Clinical assessment and referral are an important aspect of ensuring intersectoral cooperation. Ensuring clear guidelines for assessment and referral procedures is key as well as establishing joint responsibility for implementing assessment and referral across sectors. The cardiac rehabilitation team believes that intersectoral cooperation will be able to be improved considerably in the future. Current models for strengthening cooperation include shared care (a model practised in the United Kingdom) and local health centres.


15.3 Educating And Training Staff

One of the most important lessons the cardiac rehabilitation team learned is that an interprofessional approach must be based on profession-specific excellence and on fundamental mutual respect among the professions involved.

Creating a formal educational programme within cardiac rehabilitation is a decisive aspect of realizing these aims. Education of the future, including educational programmes for specialists in cardiology, should require knowledge of and ability to manage cardiac rehabilitation. Ensuring professional excellence requires that the basic education and further education support this through well-documented methods, types of activities, documentation and evaluation within each profession. Successfully implementing cardiac rehabilitation in the future requires that basic assumptions on coherent cardiac rehabilitation programmes and on the necessity of interprofessional cooperation within various types of activity areas be shaped and profiled in connection with both basic education and further education.


15.4 Conclusion

Solid documentation exists on the effects of comprehensive cardiac rehabilitation (18–23), and there is broad professional, political and administrative consensus in Denmark that these services are an integral part of treatment (8–10;23–28). Despite this consensus, Denmark still has none of the desired specific national, regional and local implementation plans for cardiac rehabilitation activities (29).

The comprehensive cardiac rehabilitation project at Bispebjerg Hospital has demonstrated that hospital-based outpatient cardiac rehabilitation in accordance with existing national guidelines (8–10) can be organized in Denmark. This book comprises a model for an implementation plan that we hope can benefit health personnel and health planners in the field of cardiac rehabilitation.We hope that these activities will benefit Denmark’s heart patients so that all patients in need will be offered cardiac rehabilitation in the future.


References

(1) Vanhees L, McGee HM, Dugmore LD, Schepers D, van Daele P. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey. J Cardiopulm Rehabil 2002; 22(4): 264–272.

(2) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and preventive of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(3) Zwisler ADO, Traeden UI, Videbaek J, Madsen M. Implementing cardiac rehabilitation services in Denmark – room for expansion. Presented at the 19th Nordic Congress of Cardiology, 4–6 June 2003, Odense, Denmark.

(4) Videbaek J, Madsen M. Hjertestatistik 2000–2001 [Statistics on heart disease in Denmark, 2000–2001]. Copenhagen, Danish Heart Foundation and National Institute of Public Health, 2002.

(5) Videbaek J, Madsen M. Hjertestatistik 1999 [Statistics on heart disease in Denmark, 1999]. Copenhagen, Danish Heart Foundation and National Institute of Public Health, 2002.

(6) Brinksby L. A questionnaire study on cardiac rehabilitation at Danish hospitals. IV Nordic Conference on Cardiac Rehabilitation, 14–16 August 1996, Copenhagen, Denmark.

(7) Danish Heart Foundation. Kardial rehabilitering i Danmark 1994 [Cardiac rehabilitation in Denmark, 1994]. Copenhagen, Danish Heart Foundation, 1994 (Hjertenyt 1994).

(8) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(9) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(10) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(11) Arthur HM, Smith KM, Kodis J, McKelvie R. A controlled trial of hospital versus home-based exercise in cardiac patients. Med Sci Sports Exerc 2002; 34(10): 1544–1550.

(12) Collins L, Scuffham P, Gargett S. Cost-analysis of gym-based versus home-based cardiac rehabilitation programs. Aust Health Rev 2001; 24(1): 51–61.

(13) Frasure-Smith N, Lesperance F, Prince RH, Verrier P, Garber RA, Juneau M et al. Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction. Lancet 1997; 350(9076): 473–479.

(14) Imich J. Home-based cardiac rehabilitation. Nurs Times 1997; 93(50): 48–49.

(15) Miller NH,Warren D, Myers D. Home-based cardiac rehabilitation and lifestyle modification: the MULTIFIT model. J Cardiovasc Nurs 1996; 11(1): 76–87.

(16) Marquez-Calderon S, Villegas Portero R, Briones Perez De La Blanca E, Sarmiento Gonzalez-Nieto V, Reina Sanchez M, Sainz Hidalgo I et al. [Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service.] Rev Esp Cardiol 2003; 56(8): 775–782.

(17) Comoss PM. The new infrastructure for cardiac rehabilitation practice. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999.

(18) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(19) Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease.N Engl J Med 2001; 345(12): 892–902.

(20) McAlister FA, Lawson FM,Teo KK,Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323: 957–962.

(21) Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316(7142): 1434–1437.

(22) Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003; 123(6): 2104–2111.

(23) Government of Denmark. Government Programme on Public Health and Health Promotion, 1999–2008. Copenhagen, Ministry of Health, 1999.

(24) Government of Denmark. Healthy throughout life – the targets and strategies for public health policy of the Government of Denmark, 2002–2010. Copenhagen, Ministry of the Interior and Health, 2002.

(25) National Association of Local Authorities in Denmark, Danish Regions and Ministry of Finance. Udfordringer og muligheder – den kommunale økonomi frem mod 2010 [Challenges and opportunities – local government finances towards 2010]. Copenhagen, Schultz Information, 2002.

(26) Klarlund Pedersen B, Saltin B. Fysisk aktivitet – håndbog om forebyggelse og behandling [Physical activity – manual on disease prevention and treatment]. Copenhagen, National Board of Health, Centre for Health Promotion and Disease Prevention, 2003.

(27) Cardiac Follow-up Group, National Board of Health. Det fremtidige behov for revaskulariserende behandling af iskæmisk hjertesygdom – herunder PCI-behandling [The future need for revascularization treatment of ischaemic heart disease – including percutaneous coronary intervention]. Copenhagen, National Board of Health, 2003.

(28) Larsen ML, Sjøl A, Videbæk J. Hjerterehabilitering på sygehuse [Hospital-based cardiac rehabilitation]. Copenhagen, National Network of Health Promoting Hospitals in Denmark and Danish Society of Cardiology, 2003.

(29) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.


Postscript

Cardiac rehabilitation is integrated into the treatment programme of the Department of Cardiology of Bispebjerg Hospital and starts at admission. Patients with angina pectoris, congestive heart failure or myocardial infarction and patients at high risk of developing ischaemic heart disease are immediately informed about the importance of smoking, diet, obesity, exercise, blood pressure and diabetes. In addition, patients’ mental reactions to acute illness are also managed during admission. Nevertheless, the admission period is so short today – often under 4–5 days – that we cannot inform about and initiate changes in lifestyle and obtain insight into the patients’ current physical, mental and social functioning. Many patients are so acutely ill that they cannot receive and understand the considerable information and activities.

Information about lifestyle factors is so important because changing lifestyle is the most important factor in avoiding relapse with exacerbation of illness, readmissions and new cases of myocardial infarction. Ensuring and optimizing patients’ physical, mental and social functioning are prerequisites for returning to a normal life after illness and thereby improving the quality of life.

The comprehensive cardiac rehabilitation programme at Bispebjerg Hospital, with physicians, nurses, secretaries, physical therapists and clinical dietitians and close contact with social workers and liaison psychiatrists, has resulted in the establishment of opportunities to influence the lifestyle factors and the level of functioning in the long term for patients admitted to the Department of Cardiology.The cardiac rehabilitation team has contributed to a comprehensive view of the patients and to creating a continuous patient programme for heart patients. This comprehensive view has influenced the overall attitudes in the Department.

International research has shown that influencing patients’ risk profile and level of functioning requires focused and integrated activities in which all aspects of rehabilitation are assessed simultaneously, in contrast to the previous practice of assessing each factor individually. A fruitful research environment has been created in the Cardiac Rehabilitation Unit, which will be a future basis for developing and adjusting the activities and services for patients.

Comprehensive cardiac rehabilitation is here to stay.

Jørgen Fischer Hansen
Head, Department of Cardiology

Karin Højgaard Jeppesen
Chief Nurse, Department of Cardiology

October 2003
Centre for Internal Medicine
Bispebjerg Hospital
Copenhagen Hospital Corporation
Copenhagen, Denmark


3. ANNEXES


Annex 1

Interprofessional Working Group, Scientific Board And Academic Supervisors

Interprofessional working group, 1997

Physicians
Bjarne Sigurd
Søren Højbjerg
Ann-Dorthe Olsen Zwisler
Nurses
Leif Degn
Agnete Lou
Kirsten Jeppe
Camilla Fabricius
Jeanette Larsen
Lone Schou
Physical therapists
Trine M. Carstensen
Claus Bull Andersen
Birgit Mathiasen
Other professions
Tine Bjerre Christensen, dietitian
Anne Ahlgreen, social worker
Kirsten Ravn, secretary
Karsten Kihl, clinical coordinator Lars Iversen, professor


Scientific board

Jørgen Fischer Hansen
Head, Department of Cardiology, H:S Bispebjerg Hospital
Bjarne Sigurd
Chief Physician, Department of Cardiology, H:S Bispebjerg Hospital
Mette Madsen
Deputy Director, National Institute of Public Health
Lars Iversen
Head, Division of Health Services, Quality Assurance and Health Development, Ribe County
Henrik Brønnum-Hansen
Statistician, National Institute of Public Health
Leif Degn
Chief Nurse, Department of Cardiology, H:S Bispebjerg Hospital
Lars Bo Andersen
Associate Professor, Institute of Exercise and Sport Sciences, University of Copenhagen
Peter Marckmann
Associate Professor, Research Institute for Human Nutrition, Royal Veterinary and Agricultural University, Denmark
Troels Thomsen
Research Centre for Prevention and Health, Copenhagen County Hospital in Glostrup
Pia Bruun Madsen
Consultant, Danish Centre for Evaluation and Health Technology Assessment
Hanne Tønnesen
Chief Physician, Clinical Unit of Preventive Medicine and Health Promotion, H:S Bispebjerg Hospital
Jacob Kjellberg Christensen
Economist, DSI Danish Institute for Health Services Research
Lis Wagner
Senior Researcher, University Hospitals’ Centre for Nursing and Care Research, Rigshospitalet (National Hospital)
Stefan Hochstrasser
Director of Finance, H:S Bispebjerg Hospital


Academic supervisors

Supervisors for the main study and the PhD study on cardiac rehabilitation by Ann-Dorthe Olsen Zwisler
Jørgen Fischer Hansen
Head, Department of Cardiology, H:S Bispebjerg Hospital
Bjarne Sigurd
Chief Physician, Department of Cardiology, H:S Bispebjerg Hospital
Lars Iversen
Head, Division of Health Services, Quality Assurance and Health Development, Ribe County
Mette Madsen
Deputy Director, National Institute of Public Health
Henrik Brønnum-Hansen
Statistician, National Institute of Public Health

Supervisors for the PhD study on type 2 diabetes mellitus by Anne Merete Boas Soja
Mette Madsen
Deputy Director, National Institute of Public Health
Eva Hommel
Chief Physician, Steno Diabetes Center, Gentofte
Thomas Melchior
Chief Physician, Department of Cardiology, Roskilde County Hospital


3. ANNEXES


Annex 2

Project Sponsors

External

Copenhagen Hospital Corporation Research Council
Danish Research Academy
Danish Heart Foundation
Apotekerfonden af 1991
Sabbath Programme for Chief Physicians in the Copenhagen Hospital Corporation
Villadsen Family Foundation
Ministry of the Interior and Health, Denmark
Development funds from the City of Copenhagen
Eva & Henry Frænkels Mindefond
Health technology assessment funds from the National Board of Health
Murermester LP Christensens Fond
Fund for Alternatives for Research Animals of the Danish Animal Protection Society
Bristol-Myers Squibb
Merck Sharp & Dohme Danmark
AstraZeneca A/S


Internal support from H:S Bispebjerg Hospital

Management
Department of Cardiology
Centre for Internal Medicine
Department of Rheumatology
Clinical Unit of Preventive Medicine and Health Promotion
Bispebjerg Hospital internal funds for health promotion and disease prevention


3. ANNEXES


Annex 3

Cardiac Rehabilitation Team At Bispebjerg Hospital

October 1999–March 2003

Physicians

Affiliations and qualifications

Period

Bjarne Sigurd

Chief physician with overall responsibility for the project

1999 - 2003

Ann-Dorthe Zwisler

Scientific project manager, physician,
PhD student and smoking cessation counsellor

1999 - 2003

Sadollah Abedini

Physician

2000 - 2001

Jon Appel

Physician and PhD student

2000 - 2001

Marianne Frederiksen

Project manager, physician
and master student

2001 - 2003

Hanne Rasmusen

Physician and PhD

2002 - 2003

Anne Merete Boas Soja

Physician and PhD student

2001 - 2003

Nurses

Lone Schou

Project manager, cardiological nurse,
smoking cessation counsellor
and master student

1999 - 2003

Jeanette Larsen

Cardiological nurse and smoking
cessation counsellor

1999 - 2002

Lene Thuesen

Cardiological nurse

1999 - 2003

Lone Brunse

Cardiological nurse,
smoking cessation counsellor,
cardiac resuscitation instructor
and master student

2000 - 2003

Gitte Harboe

Cardiological nurse

2001 - 2002

Malene Ejlertsen

Cardiological nurse
and smoking cessation counsellor

2003

Physical therapists

Thomas Hvass Villadsen

Physical therapist

1999 - 2003

John B. Kristensen

Physical therapist

2002 - 2003

Clinical dietitians

Tine Bjerre Christensen

Clinical dietitian

1999 - 2000

Inger Bols Jeppesen

Clinical dietitian

2000 - 2002

Mette Dupont

Clinical dietitian

2002 - 2003

Pernille Østergaard

Clinical dietitian

2003

Social workers

Else Krag

Social worker

1999 - 2002

Dorete Gad

Social worker

2003

Secretaries

Pernille Kriegsbaum

Medical secretary and advanced
information technology user

1999 - 2003

Marian Olsen

Receptionist, medical secretary
and nurse’s assistant

2002 - 2003

Other personnel

Simon Serbian

Intern and medical student

1999 - 2001

Peter Gørtz

Intern and medical student

2001 - 2003

Eva Margrethe Holst

Intern, medical student
and scholar student

2001 - 2003

Maria Drewes Nielsen

Intern and nursing student

2001 - 2002

Ann-Katrine Madsen

Intern and nursing student

2002 - 2003

Anja Nissen

Intern and nursing student

2002 - 2003

Lotte Vind Sørensen

Editor and master of arts

2003


3. ANNEXES


Annex 4

Authors

Morten Birket-Smith
Chief Physician, Liaison Psychiatry Unit, Department of Psychiatry, H:S Bispebjerg Hospital
E-mail: mbs01@bbh.hosp.dk

Lone Kjems Brunse
Cardiological Nurse, master student, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: lb07@bbh.hosp.dk

Malene Ejlertsen
Cardiological Nurse, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: me10@bbh.hosp.dk

Marianne Frederiksen
Specialist Physician in Internal Medicine, master student, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: egakiri@dadlnet.dk

Inger Bols Jeppesen
Clinical Dietitian, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital and private practice
E-mail: bachbols@tiscali.dk

Pernille Kriegsbaum
Medical Secretary, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: pk01@bbh.hosp.dk

John Kristensen
Physical Therapist, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: mrjohnk@sport.dk

Jeannette Larsen
Cardiological Nurse, Bristol-Myers Squibb, Denmark
E-mail: jeannette.larsen@bms.com

Lone Schou
Cardiological Nurse, master student, Clinical Unit of Preventive Medicine and Health Promotion, H:S Bispebjerg Hospital
E-mail: ls28@bbh.hosp.dk

Anne Merete Boas Soja
Physician and PhD student, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: ams02@bbh.hosp.dk

Lotte Vind Sørensen
Editor, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital and National Institute of Public Health
E-mail: lvs@niph.dk

Thomas Hvass Villadsen
Physical Therapist, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital
E-mail: thv01@bbh.hosp.dk

Ann-Dorthe Olsen Zwisler
Scientific project manager, physician, PhD student, Cardiac Rehabilitation Unit, Department of Cardiology, H:S Bispebjerg Hospital and National Institute of Public Health
E-mail: ado@niph.dk


3. ANNEXES


Annexes 5

Documents available in Danish at www.Cardiacrehabilitation.dk

The web site has links to relevant web sites on cardiac rehabilitation (In Danish).


METHODS

Tailoring of individual programmes
Welcoming letter
Brochures
Interview guide for the initial consultation with the physician
Interview guide for the initial consultation with the physical therapist
Interview guide for the initial consultation with the clinical dietitian
Interview guide for the initial consultation with the nurse
Patient overview – a working paper for nurses
Appointment care for the intensive 6-week programme
Film excerpts and photographs

Patient education
Educational programmes for each education session
Overview of the heart-health meetings

Exercise training
Internal procedures for aerobic functioning test and exercise cycle
Evaluation scales for individual evaluation
Interview guide for follow-up consultations with the physical therapist

Support for changing diet
Form for agreement on weight loss
Instruction for screeening patients at risk of undernutrition
Overview of medication known to influence diet and nutrition

Support for smoking cessation
Interview guide for smoking history
Fagerström Test for Nicotine Dependence
Form to assess the advantages and disadvantages of smoking
Smoking cessation form
Instructions for measuring carbon monoxide in expired air
Smoking cessation certificates

Psychosocial support
Registration form for acute consultation
Screening form for anxiety and depression
Excerpts from the activity folder
Rules for public subsidies for medicine

Systematic risk factor management and clinical assessment
Interview guide for follow-up consultation with the physician
Interview guide for 12-month concluding consultation with the physician
Overview of routine blood tests
Guidelines for referral for assessment for invasive treatment
Instructions of the Department of Cardiology on pharmaceutical treatment
Special considerations for patients who have undergone percutaneous coronary intervention
Special considerations for patients who have undergone coronary artery bypass grafting
Special considerations for patients who have an implantable cardioverter defibrillator
Special considerations for patients who have congestive heart failure

Type 2 diabetes mellitus
Interview guide for diabetes consultation with the physician
Interview guide for diabetes consultation with the nurse
Description of the procedure for the oral glucose tolerance test
Patient guide for the oral glucose tolerance test
Description of the paraclinical tests of patients with type 2 diabetes
Blood glucose measurement
Instructions for starting insulin treatment
Guide for patients starting insulin treatment
Educational programme for type 2 diabetes meetings

Organizing interprofessional clinical practice
Description of work functions
Work plan and description of work plan
Instructions for advanced cardiac resuscitation
List of pharmaceutical products used in the comprehensive cardiac rehabilitation programme
Electronic patient records and other computer-based support software




STUDY-RELATED MATERIAL
Broad evaluation model
Scientific board
Sponsors
Budget
Protocol for the DANREHAB Study
Inclusion and exclusion criteria
Reference database
Registration forms and questionnaires
Publications list
Oral dissemination (lectures and educational sessions)
Mass-media coverage
Visits to the Cardiac Rehabilitation Unit
Film excerpts and photographs



PUBLICATIONS
Reports and books (available in electronic form)

Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation, disease prevention and health promotion at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

Zwisler ADO. Cardiac rehabilitation – a survey on implementation in Denmark and presentation of a local model. PhD dissertation, University of Copenhagen. Copenhagen, H:S Bispebjerg Hospital and National Institute of Public Health, 2004.

Zwisler ADO. DANREHAB-studiet. Efterbehandlingstilbud til patienter udskrevet fra en hjerteafdeling. Status [The DANREHAB study. A cardiac rehabilitation programme for patients discharged from a department of cardiology. Status]. Copenhagen, H:S Bispebjerg Hospital and National Institute of Public Health, 2002.

Zwisler ADO, Schou L, Vind-Sørensen L, ed. Hjerterehablitering – rationale, arbejdsmetode og erfaringer fra Bispebjerg Hospital [Cardiac rehabilitation – rationale, methods and experience from Bispebjerg Hospital]. Copenhagen: H:S Bispebjerg Hospital and National Institute of Public Health, 2003.

Zwisler ADO, Schou L, Vind-Sørensen L, ed. Cardiac rehabilitation – rationale, working methods and clinical experiences from Bispebjerg Hospital. Copenhagen: Bispebjerg Hospital and National Institute of Public Health, 2003.


3. ANNEXES


Glossary

Aerobic exercise: Exercise requiring oxygen that especially strengthens the cardiovascular system;
contrasts with anaerobic exercise focusing on muscle strength
Acute myocardial infarction: A “heart attack”. Damages the tissue of the myocardium by interrupting blood flow to this area, usually caused by atherosclerosis of the coronary arteries
Angina pectoris: Sporadic pain in the chest often radiating to the arms, especially the left arm, sometimes accompanied by a feeling of suffocation and impending death; most often caused by ischaemia of the myocardium and precipitated by effort or excitement (stable) or while resting (unstable); often called angina
Antiplatelet drug: A substance that inhibits or destroys blood platelets, which have a role in blood clotting; administered for prophylaxis or treatment of thromboembolic disorders
Aortic stenosis: Narrowing of the orifice of the aortic valve or of the supravalvular or subvalvular regions
Apnoea: Cessation of breathing or asphyxia
Arrhythmia: Variation from the normal rhythm of the heartbeat
Arteriosclerosis: A group of diseases characterized by thickening and loss of elasticity of arterial walls
Atherosclerosis: A form of arteriosclerosis in which deposits of yellow plaques are deposited within arteries
Body mass index: (Weight in kg)/(height in cm)2; normal values are between 20 and 25, 25–30 is overweight and over 30 is obese
Carbon monoxide measurement: Measuring the concentration of carbon monoxide in expired air; used as feedback to show smokers attempting to quit the benefits of quitting.
Capillaries: Minute blood vessels
Capillary response: Rate at which capillaries fill with blood after induced pressure is released
Cardiovascular: Pertaining to the heart and blood vessels
Coronary artery: An artery that supplies the heart muscle
Congestive heart failure: A clinical syndrome due to heart disease, characterized by breathlessness and abnormal sodium and water retention, often resulting in oedema
Coronary artery bypass grafting: A section of vein or other conduit grafted between the aorta and a coronary artery distal to an obstructive lesion in the coronary artery
Coronary heart disease: See ischaemic heart disease
Diuretic: An agent that increases the excretion of urine
Dyspnoea: Difficulty in breathing
Ejection fraction: The percentage of blood driven out into the vascular system during systole (normal values 55–70%)
Endocarditis: Inflammatory alterations of the endothelial lining membrane of the cavities of the heart and the connective tissue bed on which it lies
Fibrillation, atrial: Arrhythmia characterized by minute areas of the atrial myocardium being in various uncoordinated stages of depolarization and repolarization due to multiple re-entry circuits within the atrial myocardium
Fibrillation, ventricular: Arrhythmia characterized by fibrillary contractions of the ventricular muscle due to rapid repetitive excitation of fibres of the myocardium without coordinated contraction of the ventricle
Hb A1c: Glycosylated haemoglobin A, a marker for poorly controlled diabetes
High-density lipoprotein: A class of lipoproteins that promotes transport of cholesterol from extrahepatic tissue to the liver for excretion in the bile
Hypercholesterolaemia: Abnormally increased concentration of serum cholesterol
Hyperglycaemia: Abnormally increased concentration of blood glucose
Hypertension, arterial: Elevated blood pressure, often defined as exceeding 140/90 mmHg
Hypertriglyceridaemia: Abnormally increased concentration of serum triglycerides
Hypoglycaemia: Abnormally diminished concentration of blood glucose, which may lead to tremulousness, cold sweat, hypothermia and other symptoms
Impaired fasting glycaemia: Fasting glucose concentration exceeding normal but below that of diabetes mellitus (6.1–7.0 mmol/l): risk factor or risk marker for type 2 diabetes
Impaired glucose tolerance: Elevated plasma glucose two hours after an oral glucose tolerance test; risk factor or risk marker for type 2 diabetes and may be more strongly associated with cardiovascular outcomes than impaired fasting glycaemia
Implantable cardioverter defibrillator: An implantable device that detects sustained ventricular tachycardia or fibrillation and terminates it by a shock or shocks delivered directly to the myocardium
Intermittent claudication: Pain in the legs on exertion caused by occlusive arterial diseases of the limbs.
Ischaemia: Deficiency of blood in a part, usually due to functional constriction or actual obstruction of a blood vessel
Ischaemic (coronary) heart disease: Insufficient supply of oxygenated blood to the heart, usually due to functional constriction or actual obstruction of a blood vessel such as that caused by atherosclerosis or by increased oxygen demand or diminished blood oxygen transport
Low-density lipoprotein: A class of lipoproteins responsible for transporting cholesterol to extrahepatic tissues
Macrovascular: Pertaining to large blood vessels
Microalbuminuria: Excretion of albumin in the urine of 30–300 mg per day, often seen with the elevation in the glomerular filtration rate of diabetes mellitus
Microvascular: Pertaining to small blood vessels, including capillaries
Myocarditis: Inflammation of the myocardium
Myocardium: The middle and thickest layer of the heart wall, composed of cardiac muscle
Nephropathy, diabetic: Disease of the kidneys that commonly accompanies later stages of diabetes mellitus
Neuropathy, autonomic: A functional disturbance or pathological change in the autonomic nervous system; here, it results from diabetes mellitus
Neuropathy, peripheral: A functional disturbance or pathological change in the peripheral nervous system; here, it results from diabetes mellitus
New York Heart Association classes I to IV: Classes of symptoms of congestive heart failure from I (no symptoms) to IV (symptoms at rest)
Nicotine replacement therapy: Supplying nicotine delivered through various means to smokers attempting to quit to reduce their abstinence symptoms
Nitroglycerin: Used in the prophylaxis and treatment of angina pectoris, administered sublingually
Oedema: The presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body
Oral glucose tolerance test: Administration of a standard amount of glucose to a fasting person to test glucose tolerance
Palpitation: A subjective sensation of an unduly rapid or irregular heartbeat
Paraclinical: Pertaining to abnormalities, such as biochemical ones or underlying clinical manifestations, such as chest pain or fever
Patient with a high risk of heart disease: In the comprehensive cardiac rehabilitation programme, a person with three or more of the classical risk factors for ischaemic heart disease.
Percutaneous coronary intervention: Minimally invasive mechanical expansion of a constricted heart vessel with a catheter that is introduced through a large blood vessel, usually the groin or underarm
Pericarditis: Inflammation of the fibroserous sac that surrounds the heart
Prophylaxis: Treatment to prevent disease
Retinopathy: Inflammation of the retina often seen in late diabetes mellitus
Risk factor: A factor that is known to be associated with an increased incidence or prevalence of a specific disease
Saturated fatty acids: Fatty acids without double bonds in their chains
Statin: A class of pharmaceuticals used to lower serum cholesterol
Symptom-limited: Limited by the patient’s symptoms: for example, an exercise test that is stopped if the patient develops symptoms
Syncope (cardiac): Sudden fainting due to obstructions in cardiac output or arrhythmia
Tachycardia: Excessive rapidity in the action of the heart
Thrombophlebitis: Inflammation of a vein associated with thrombus formation
Thrombus: An aggregation of blood factors frequently causing vascular obstruction at the point of its formation
Trans-fatty acids: Polyunsaturated fatty acids that have been hydrogenated (hardened); strongly linked to heart disease
Triglycerides: Fat synthesized from carbohydrate for storage in adipose cells
Vascular region: The part of the vascular system, including capillaries, supplying a tissue