Essay: Effective rehabilitation plan for NSTEMI patient

Mrs B, a 76 year-old woman with a history of smoking, OA and a BMI of 30 was admitted to hospital 4 days ago after sustaining an NSTEMI. An NSTEMI (or non-ST segment elevation myocardial infarction) is a less-serious form of heart attack, arising from thrombus formation on an atheromatous plaque. The term \’acute coronary syndromes\’ encompasses NSTEMIs, as well as unstable angina. (\”Unstable Angina And NSTEMI: Early Management | NICE”) Throughout this essay, I will be devising an effective rehabilitation plan for Mrs B.
Traditionally, cardiac rehabilitation has been offered to patients post-MI, angioplasty or surgical intervention. There is now increasing interest in the benefits for patients with angina, CHF and following heart transplant. (Jones and Moffatt, 2002) Several investigations have shown comprehensive cardiac rehabilitation to improve cardiac risk factors (e.g. high cholesterol, obesity, low exercise tolerance) in addition to significantly lowering long-term hospitalization and cardiac morbidity. (Jones and Moffatt, 2002) It is important to acknowledge that the outcome of reduced mortality is not attributable to the exercise alone, but to the multifactorial nature of cardiac rehabilitation programs. (Jobst, 2013)
Cardiac Rehabilitation commences as soon as it is medically practical, while the patient is awaiting discharge as an inpatient (termed ‘Phase 1’). The primary emphasis of Phase 1 is early mobilization, progressing to performance of low-level activities as the patient tolerates. (Jobst, 2013) Phase 1 also encapsulates education on prescribed medicine (benefits and potential side effects), initial advice on lifestyle (e.g. smoking cessation, physical activity, alcohol consumption and diet), involvement of family or relevant informal carers, provision of locally-written information packs or leaflets on cardiac rehabilitation, discharge planning. (Porter and Tidy, 2013) Reassurance and correction of common misconceptions is also vital at this stage. (Cardiac Rehabilitation: SIGN Guideline 57)
As early mobilization is a key focus of Phase 1 Cardiac rehab, a physiotherapist should conduct an activity and/or endurance assessment to evaluate the patient’s physiological responses to “progressively increasing submaximal intensities of activity or aerobic exercise”. This would typically involve an assessment of lie-sit-stand while monitoring Mrs B’s HR, ECG, BP oxygen saturations and relevant signs and symptoms e.g. breathlessness. If she responds well to the changes in position and is deemed safe to continue, Mrs B would be asked to undertake activities of daily living (ADLs) and simple active exercises by the physiotherapist. (Jobst, 2013) If, again, the results of this activity evaluation are deemed as safe and stable, the physiotherapist would perform an endurance evaluation in the form of a timed walk test, such as the six-minute walk test (6MWT). Mrs B would be asked to walk at a pace which would allow her to comfortably cover as much distance as possible for the course of 6 minutes. The therapist could then compare published norms with Mrs B’s final distance; the 6MWT is the most thoroughly researched walk test and its results correlate strongly with maximum O2 consumption. (Jobst, 2013) For the majority of patients, clinical risk stratification of the aforementioned – combined with an evaluation of medical history and diagnostic tests – is sufficient. (Cardiac Rehabilitation: SIGN Guideline 57) Additional consideration should be taken as Mrs B herself is on prescribed Beta-blocker medication. As these are known to slow pulse, promote hypotension and dizziness it is important all clinical staff in contact with Mrs B throughout her Cardiac Rehabilitation process are aware of these side effects. Their relevance to prescribed exercises in Phases 2 and 3 is such that she may have a suppressed heart rate response, thus RPE feedback may prove a more reliable outcome measure. Furthermore Beta-blockers increase the risk of postal hypotension, so floor-based exercises should be avoided in the case of Mrs B. (Pryor and Ammani Prasad, 2002)
Following on from this, Phase 2 of Cardiac Rehabilitation commences, whereby the patient has been immediately discharged home. It is vital patients are provided with a carry-over of rehabilitation before their main exercise provision begins in Phase 3, so as not to undo the progress they have made thus far as an inpatient. (Cardiac Rehabilitation: SIGN Guideline 57) Mrs B would be discharged with a 4 week plan issued by a physiotherapist, which may look like this:
Appendix 1
(ACSM 2010)
Mrs B would additionally be encouraged to proceed with the resumption of light household tasks and ADLs as the main means of gradually increasing functional capacity. Risk factor modification goals are a common feature of discharge plans, often with long-term time scales. (Pryor and Ammani Prasad, 2002) As Mrs B quit smoking eleven years ago, cessation of this habit does not apply to her, however often does to individuals whom have recently suffered a cardiac event. Mrs B does, on the contrary, have a BMI of 31, which would classify her as obese. As obesity is strongly linked to CVD as well as respiratory conditions, diabetes and some cancers (Stockley, 1996) a weight-loss goal should be implemented to her discharge plan with the guidance of a Dietician. This goal may be especially important to Mrs B given she already wants to lose weight ahead of a potential knee replacement operation. A dietician may also advise on reducing alcohol consumption in order to lower CVD risk factors further. (Stockley, 1996) Taking into consideration her osteoarthritic knee pain, physiotherapeutic education should be distributed to Mrs B as she embarks on her home exercise programme. It is known her knee pain worsens with walking long distances, so conveying to our patient that the walking exercise she has been prescribed is ‘little and often’ and ‘gradually progresses’ is advised. It should also be explained to Mrs B that light weight-bearing exercise such as walking is proven to improve bone density and strength, reiterating the benefits of this HEP to her health. (ACSM 2010) Mrs B should also be advised to take all medication as prescribed upon discharge, with education on the importance of her GTN in Angina management, Simvastatin in lowering her blood cholesterol etc all explained thoroughly by a Pharmacist. (Pryor and Ammani Prasad, 2002)
During Phase 2, it is common for patients to feel vulnerable and isolated. (Cardiac Rehabilitation: SIGN Guideline 57) To combat patient’s fears and misconceptions, support is often provided via home visits, telephone calls and the provision of guideline information leaflets. These manuals take a self-help approach and have been shown to reduce anxiety, depression and hospital readmission rates in individuals recovering from MIs. (Cardiac Rehabilitation: SIGN Guideline 57) Contact from rehabilitation staff during Phase 2 also provides an opportunity to reinforce daily walking and home exercises as appropriate, review risk factor modification goals, activity and symptom diaries and generally prepare for the transition to Phase 3. (Pryor and Ammani Prasad, 2002)
Next, Mrs B would progress to Phase 3 Cardiac Rehabilitation; this has traditionally taken the form of a disciplined exercise programme in an outpatient setting, offering psychosocial support, education on smoking cessation, weight management etc and advice on risk factors.
Mrs B should attend these exercise classes twice weekly for eight weeks or longer, depending on how quickly she progresses. (Cardiac Rehabilitation: SIGN Guideline 57)
Correct warm-up and preparation for activity in the cardiac population of older adults must be gradual – 15 minutes dedicated to the warm-up component is recommended. (Pryor and Ammani Prasad, 2002) Low impact, dynamic movements which use the main muscle groups and take all major joint complexes through their normal AROM should be included. A slow build-up in the range/size of movements undertaken will “delay the onset of ischaemia by allowing adequate time for cornonary blood flow to increase in response to the greater myocardial demand.” (Pryor and Ammani Prasad, 2002) A steady incline in cardiac workload will also lessen the risk of arrhythmias.
As Mrs B suffers painful OA in her knees, possibly worsened due to her high BMI (31), it is important we consider this factor in her exercise programme, while ensuring her lower body is still sufficiently trained. To account for this, high-impact exercises on joints should be avoided. (Porter and Tidy, 2013) Loosening joints and muscles though a specially tailored warm-up should ensure she feels minimal pain throughout the class. (Caldow 2-8)
Individualising an exercise programme should follow FITT principles; frequency, intensity, time (duration) and type of exercise. (Porter and Tidy, 2013) Current recommendations suggest Phase 3 rehabilitation classes run 2-3 times weekly, with the main exercise component (excluding warm-up and cool-down) lasting 20-30 minutes, with the type of exercise delivered being mainly aerobic with some resistance exercises included.
Intensity is measured by either RPE or training heart rate (should be 60-75% of predicted maximum heart rate). Maximum heart rate can be calculated using the age-adjusted predicted maximum heart rate formula, or, more, accurately, the Karvonen formula (heart rate reserve). Guidelines suggest participants should be within 20 bpm of their predicted training heart rate during a warm up. (Pryor and Ammani Prasad, 2002)
An alternative outcome measure to monitor cardiac output during rehabilitation is the Borg Scale – measuring Rate of Perceived Exertion (RPE). A rating of around 12-13 equates to 60% of maximum heart rate reserve on the 15-point Borg Scale, while a rating of 15 equates to 75%. This outcome measure would be fully explained to the participant, and during a warm-up Mrs B would be expected to work at an RPE of 9 – ‘Very light’. (Caldow 2-8)
Appendix 2
This warm-up would be undertaken until 15 minutes had passed, with guidelines suggesting participants should be within 20 bpm of their predicted training heart rate. Training heart rate should be 60-75% of predicted maximum heart rate. Maximum heart rate can be calculated using the age-adjusted predicted maximum heart rate formula, or, more, accurately, the Karvonen formula (heart rate reserve). (Pryor and Ammani Prasad, 2002)
An alternative outcome measure to monitor cardiac output during rehabilitation is the Borg Scale – measuring Rate of Perceived Exertion (RPE). A rating of around 12-13 equates to 60% of maximum heart rate reserve on the 15-point Borg Scale, while a rating of 15 equates to 75%. This outcome measure would be fully explained to the participant, and during a warm-up Mrs B would be expected to work at an RPE of 9 – ‘Very light’. (Caldow 2-8)
In clinically supervised rehabilitation programmes, interval-style circuit training seems to be the favourable format. Class participants spend a fixed time (from 30 seconds – 2 minutes) at cardiovascular stations, and partake in an ‘active recovery’ (lower intensity) station before proceeding to the next CV station. Active recovery stations typically aim to improve the endurance of muscles frequently used in ADLs, such triceps, pectorals and trapezius. (Pryor and Ammani Prasad, 2002)
Appendix 3
(Physiotherapy for Respiratory & Cardiac Problems)
When completed twice, this station provides 24 minutes of appropriate exercise for Mrs B. She should aim to work between 11-14 RPE at CV stations and around 9-10 during Active Recovery exercises.(Caldow 2-8) Progressions to this programme should be tailored to Mrs B as her exercise tolerance increases, her RPE drops and as she progresses through the weeks of this Phase 3 rehabilitation class. Potential progressions include increasing the gradient/speed of the treadmill, adding light weights/hold times to MSE stations, increasing resistance of the exercise bike etc. (Pryor and Ammani Prasad, 2002)
A 10 minute cool-down period is suggested following the main exercise component. (Cardiac Rehabilitation: SIGN Guideline 57) This is due to increased risk of hypotension, arrhythmias and venous pooling following vigorous exercise in cardiac groups. (Pryor and Ammani Prasad, 2002) The cool-down may include passive stretching of major muscle groups to gradually relax the participant and allow their heart rate to return to pre-exercise rates. At least 5-10 minutes of patient relaxation/observation is recommended by SIGN cardiac guidelines. (Cardiac Rehabilitation: SIGN Guideline 57)
Following Mrs B’s completion of Phase 3, she would progress to Phase 4 Cardiac Rehabilitation – outpatient maintenance. This begins when the patient is able to maintain outcomes attained in Phases 2 and 3 for themselves. These could include survival, achieving desired functional capacity, smoking cessation, attaining positive psychosocial goals, and/or particularly in the case of Mrs B – weight loss. We are aware this is an especially important aim for her, as it will better prepare her for eventual right knee replacement. This phase of rehabilitation continues indefinitely, with the desired result being prolonged patient exercise adherence, improved self-management knowledge and a reduction of risk factors. It would be recommended Mrs B attend follow-up checks with her GP or Cardiac nurse to note functional capacity progress and general health. (Brannon, 1998)
Multi-disciplinary team input (MDT) is an essential to provide an ‘expertise and skills package’ to the Cardiac Rehabilitation patient. Mrs B would encounter a number of individuals – from the inpatient stage of her rehab, all the way through to outpatient maintenance. These MDT members include consultant cardiologists, nurses, physiotherapists, dieticians, pharmacists, exercise physiologists, occupational therapists and even psychologists. (Porter and Tidy, 2013)
Respectively, each MDT member contributes their own role in caring for the patient, while liaising with fellow team members in the process. Following an initial admission to hospital, Mrs B will have encountered a consultant cardiologist/physician which performed her PCI with a stent. (Pai and Philippides, 2015) This procedure would be closely followed by the administration of postoperative medications to decrease the workload of the heart. These could include statins (lowering cholesterol), Beta-blockers (decreasing HR and BP), ACE inhibitors (reducing hypertension) or even anti-arrhythmics on a short term basis. As Mrs B is already on a number of the aforementioned drugs, a Pharmacist would review her current prescriptions and potentially look to increase these dosages, while a nurse would administer them to our patient. (Jobst, 2013) In the case of Mrs B, MDT communication between the consultant cardiologist, nursing staff and physiotherapists would have been key, as day 1 post-op Cardiac Rehabilitation (Phase 1) can only commence when the patient is deemed ‘medically stable’ – this decision must be made by a physician. (Jobst, 2013) Pharmacists and nurses in conjunction also offer smoking cessation advice.
Psychologists can provide support for stress management, counselling, vocational guidance. Another key role of the psychologist in Cardiac Rehabilitation is educating participants on the benefits of these programmes. Benefits include an improved sense of wellbeing and sleep patterns, raised self-confidence, reduced anxiety and depression and improved social communication. Psychologists must make any existing psychosocial issues in class participants known to members of the MDT, particularly physiotherapists and exercise physiologists, in case any relevant adjustments have to be made during exercise classes. (Porter and Tidy, 2013)
Exercise physiologists and fitness instructors themselves tend to supervise long-term exercise classes in the community during Phase 4. They must be qualified to S/NVQ Level 3 as an Instructor and hold a place on the Exercise and Fitness Register. (Cardiac Rehabilitation: SIGN Guideline 57) As it is their role to maintain participant’s exercise capacity indefinitely, they have a certain responsibility to encourage patient adherence to the programme, while also liaising with medical and physiotherapy staff in hospitals/GP clinics if participants report relevant cardiac signs/symptoms or musculoskeletal aches and pains during exercise. (Pryor and Ammani Prasad, 2002)
Dieticians inform patients of the health benefits accompanying dietary changes, such as encouraging fruit and vegetables, discouraging excessive trans-fat intake and suggesting simple changes to regular foods e.g. low fat spreads as opposed to rich butters. (Frame, 2003) Dietician education on the way improved diets can reduce overall body weight tends to compliment physiotherapy-led exercise programmes in Cardiac Rehabilitation well, as this further encourages participants like Mrs B to adhere to classes and goals e.g. reducing BMI. (Stockley, 1996)
Occupational therapists offer ADL assessments of cardiac patients during phase 1, such as washing, dressing and home setting assessments to gain a picture of an individual’s functional capacity. A key role of an OT throughout all phases of Cardiac Rehabilitation is advice on pacing, time management and highly personalised goal setting – this can be particularly beneficial and calming in patients suffering anxiety and stress following a cardiac event. (\”What Does An Occupational Therapist Do?”)
Physiotherapists possess ‘core skills’ in assessing, rehabilitating and managing complex patients, using a combined knowledge of exercise delivery and education. The provision of exercises, however, cannot be confined to this single profession, as often patient’s altering psychosocial status (fear, inappropriate activity goals, negative attitude to exercise) requires a ‘teamwork approach’ from other MDT members in order to continue with cardiac rehabilitation. (Pryor and Ammani Prasad, 2002)
A huge physical factor potentially affecting the way Mrs B engages with her Cardiac Rehabilitation exercises during each phase is the painful OA she suffers in both knees (R > L). Mrs B may, as a result, adopt an ‘avoidance’ habit – e.g. avoiding tasks she struggles with due to OA pain. These include getting out of bed, climbing up and down stairs, and getting in and out of her car. There is thought to be a strong link between physical muscle weakness and psychological distress, both of which are mediated by avoidance of activity. (Dekker, 2014) This avoidance habit leads to overall reduced functional capacity, hence it is important correct physiotherapeutic education is given to Mrs B regarding arthritic pain and management.
Psychosocial factors in Mrs B may be evident following her NSTEMI. It is highly common for individuals to feel anxious or depressed following a cardiac event, with up to 27% of patients reporting feeling depressed as an acute inpatient. (Alvarenga and Byrne, 2016) ‘Post-event anxiety and depression put cardiac patients at a distinct disadvantage in terms of engagement in activities that promote health and well-being’. These patients are known to be less adherent to recommended treatments – initially showing poor medication adherence (e.g. being more likely to forget to take medications and to skip doses) and secondly disinclining to attend Cardiac Rehabilitation programs/potentially discontinuing altogether. As it has been researched that medication adherence and Cardiac Rehabilitation attendance have been shown to impact positively on survival, it is important Mrs B is monitored carefully for signs of these common psychosocial factors. (Alvarenga and Byrne, 2016)
Socially, Mrs B may feel isolated upon being discharged from hospital, as activities she regularly took part in (day trips in the car, going out for meals, visiting family) prior to her NSTEMI are currently out of question – potentially due to the laborious nature of these activities and any potential anxiety she now possesses. Emery et al. 2004 states that good social surroundings were found to have a positive effect on multiple aspects of Quality of life (QoL) including self-confidence in cardiac patients, thus it should be encouraged that Mrs B engages with friends, family and neighbours as well as her husband where possible to ensure she feels well-supported socially. (Alvarenga and Byrne, 2016)
Mrs B may, understandably, feel intimidated by her own home environment following hospital discharge. It is known she previously struggled with climbing up and down stairs, and getting out of bed in the morning as this aggravated her knee pain, thus a recent NSTEMI only further complicates her functional capacity at home. Driving her car again may be an environmental barrier for Mrs B – previously this was her main mode of transport, however following an NSTEMI, considering her age and potential co-morbidities associated with ageing (slower reaction times, reduced visual field/spatial awareness), driving agencies may question her fitness to hold a licence, furthermore increasing potential feelings of social isolation. (McIntyre, AAA 2013) Restricted driving abilities, if even for a short number of weeks, will restrict Mrs B in partaking in occupations such as going out for meals and enjoying day trips in the car.