Heart 1996;75:89-93

GUIDELINES

Cardiac rehabilitation in the United Kingdom:guidelines and audit standards

David R Thompson, Gerald S Bowman, Alison L Kitson, David P de Bono,Anthony Hopkins

SummaryThis paper summarises a multidiscipli-nary workshop convened to prepare clini-cal guidelines and audit standards incardiac rehabilitation in the UnitedKingdom. The workshop developed athree element model of the rehabilitationprocess and identified needs relating tomedical and psychosocial care and thepotential contributions of exercise, edu-cation, secondary prevention, and voca-tional advice. Draft clinical standards areproposed as a basis for locally developedguidelines and firther research.

(Heart 1996;75:89-93)

Keywords: rehabilitation; medical and psychosocialcare; audit; guidelines

Institute ofNursingStudies, University ofHull, HullD R ThompsonG S BowmanNational Institute forNursing, RadcliffeInfirmary, OxfordA L KitsonDivision of Cardiology,University ofLeicester, LeicesterD P de BonoResearch Unit, RoyalCollege ofPhysiciansofLondonA HopkinsCorrespondence to:Professor D R Thompson,Institute of Nursing Studies,University of Hull, HullHU6 7RX.Accepted for publication19 September 1995

Cardiac rehabilitation has been defined by theWorld Health Organisation as "the sum ofactivities required to influence favourably theunderlying cause of the disease, as well as toensure the patients the best possible physical,mental and social conditions so that they may,by their own efforts, preserve or resume whenlost, as normal a place as possible in the life ofthe community".' An older but essentiallysimilar definition is "a process by which apatient is returned realistically to his greatestphysical, mental, social, vocational and eco-nomic usefulness, and if employable, toemployment in a competitive industrialworld".2 The necessity for rehabilitation asso defined is unarguable; the process bywhich rehabilitation is achieved has been thesubject of much argument and controversy,particularly with regard to the benefit or other-wise of specific rehabilitation programmes.Many of the crucial issues in cardiac rehabili-tation have previously been identified in thereport of a British Cardiac Society workingparty.

This paper summarises a multidisciplinaryworkshop on clinical guidelines and auditstandards in cardiac rehabilitation held underthe joint auspices of the National Institute forNursing and the Joint Medical Practice andAudit Committee of the British CardiacSociety and the Royal College of Physicians ofLondon. The workshop developed a three

element model of the rehabilitation process,and identified needs relating to medical andpsychosocial care and the potential contribu-tions of education, exercise, secondaryprevention, and vocational advice. Draftaudit standards are proposed as a basis forlocally developed guidelines and furtherresearch. In accordance with a conventionestablished in previous workshops, issues thatare potential audit points are identified by (A),consensus agreement points by (C), andpotential topics for future research by (R).Where there is clear evidence of effectiveness astatement is followed by a conventional refer-ence.

The rehabilitation processThe timecourse of cardiac rehabilitation canbe divided into four phases: in-hospital, earlypost discharge, later post discharge, and longterm follow up. Spanning these phases arethree essential elements, which are interlinkedand may be overlapping.

Element 1 is the process of explanation andunderstanding. It should start simultaneouslywith the process of medical diagnosis andmanagement, and its aim is to ensure thatpatients at all times have an accurate and up-to-date understanding of what has happenedto them and its implications, conveyed sympa-thetically and positively in terms they canreadily understand. This has traditionally beenregarded as an integral part of good medicaland nursing practice, but nevertheless fallswithin the definition of rehabilitation, and is ofsuch importance that it needs to be audited(A).

Element 2 includes specific rehabilitationinterventions-including where appropriatesecondary prevention, exercise training, andpsychological support-tailored to the needsof the individual patient and the setting of thespecific medical diagnosis. Usually these inter-ventions are applied for a defined period, cor-responding to the immediate and later phasesof post-hospital rehabilitation, and the desiredoutcomes are capable of being specified andmeasured.

Element 3 encompasses the long-termprocess of re-adaptation and re-education, andmaps to the long-term or open ended finalperiod of rehabilitation.

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Workshop participantsHJN Bethell (generalpractitioner, HealthCentre, Alton), tDP deBono (professor ofcardiology, University ofLeicester), G S Bowman(research fellow, NationalInstitute for Nursing,Radcliffe Infirmary,Oxford), *EL Cay(consultant inrehabilitation medicine,Astley Ainslie Hospital,Edinburgh), P Doyle(senior medical officer,Department of Health,Health Care (MedicalDivision), London), *MEdwards (chairman ofthe support group,Central MiddlesexHospital, London), *AGray (health economist,Wolfson College,Oxford), *A E Hardman(senior lecturer inphysical education andsports sciences,LoughboroughUniversity ofTechnology), tAHopkins (director of theresearch unit, RoyalCollege of Physicians,London), J H Horgan(consultant cardiologist,Beaumont Hospital,Dublin), *M Joy(consultant cardiologist,St Peter's Hospital,Chertsey, Surrey), A LKitson (director of theNational Institute forNursing, RadcliffeInfirmary, Oxford), *RLewin (director of theBHF RehabilitationResearch Unit, AstleyAinslie Hospital,Edinburgh), *A McLeod(consultant cardiologist,Poole Hospital NHSTrust), P Milston (seniorlecturer in occupationaltherapy, St Martin'sCollege, Lancaster), *ARadley (senior lecturer insocial psychology,LoughboroughUniversity ofTechnology), H Stokes(research anddevelopment fellow,National Institute forNursing, RadcliffeInfirmary, Oxford), DRThompson (reader,National Institute forNursing, RadcliffeInfirmary, Oxford), MThorogood (seniorlecturer in healthpromotion sciences,London School ofHygiene and TropicalMedicine), I Todd(senior registrar inrehabilitation medicine,Astley Ainslie Hospital,Edinburgh), S Tumer(cardiac rehabilitation co-ordinator, Health Centre,Alton).*Individuals whoprepared backgroundpapers.tChairmen.

The scope of cardiac rehabilitationRehabilitation is an intrinsic part of the man-agement of all cardiac disease. Most formalrehabilitation programmes have concentratedon patients recovering from myocardial infarc-tion, or who have had open heart surgery. Thisconcentration is based on the perception thatthese are groups with the maximum potentialfor health gain. In some programmes for thistype of patient selection criteria have in factselected patients for rehabilitation who arealready in an excellent prognostic category,and the "added value" in these patients will besmall. Conversely, patients with heart failure,valvular heart disease, angina, and hyperten-sion may also have a large potential for healthgain and they could be helped by targetedrehabilitation programmes (R). Such pro-grammes may need to take account of the spe-cial needs of the elderly, of different ethnicgroups, and of both sexes (R). All too often,the uptake of rehabilitation is lowest amongthose who could benefit most.

The components of cardiac rehabilitationMedical diagnosis and intervention-Risk strati-fication is important both to define high risksubgroups and as a basis for more intensivediagnostic efforts. High risk subgroups mayrequire specific resources and precautions, butsometimes offer an opportunity for high"health gain". The role of exercise testing,radionuclide studies, and other investigationsin risk stratification of patients with angina orfollowing infarction has been discussed indetail elsewhere.5 Exercise testing aftermyocardial infarction has a high predictiveaccuracy67 (that is, patients with a negativeexercise test at a good work load have anexcellent prognosis) and this information canbe of great psychological benefit (C). The spe-cific role of exercise testing as a guide to exer-cise in rehabilitation will be discussed below.

Detailed discussion of surgical (valvereplacement, coronary bypass grafting, angio-plasty) or pharmacological (aspirin, (B adreno-ceptor antagonists, angiotensin convertingenzyme inhibitors, cholesterol loweringagents) interventions is outside the scope ofthis paper. Despite good evidence of the effec-tiveness"'O of secondary prevention measuresin high risk cases, actual implementation ofpharmacological secondary prevention is stillvery weak (R, A). Possible reasons and solu-tions are discussed below.

Psychosocial care-Psychological conse-quences may stem from an attempt to adapt tochanges brought about by cardiac disease, andare not necessarily related to infarct size, or anyother measurable cardiac status.'1 12 The mainpsychological goals are to improve quality oflife and to aid secondary prevention. This canbe achieved through the identification andtreatment of psychological distress and psychi-atric illness, by restoring confidence, and byhelping patients to initiate and maintainlifestyle changes. In most patients, psychologicalreactions are transient. Persistent depressionand anxiety occur in about one in four patients

and partners: these symptoms are easily mea-sured and usually respond well to simple coun-selling aimed at addressing patients' andpartners' main concerns and correcting mis-conceptions.'3 14 Conversely, early careful andconsistent explanation can reduce these compli-cations. The main purpose of counsellingshould be to encourage behavioural changerather than simply to provide emotional sup-port.

Specific steps to improve psychological carein the context of hospital inpatients include:* Psychological assessment within three daysof admission using a simple nurse-adminis-tered assessment tool"(A)* A clear written statement of health-improvement goals at the time of hospital dis-charge (A)

Cardiac disease disrupts families and partic-ularly affects partners and carers. Social fac-tors can impinge on recovery: for examplepatients' and partners' beliefs about the causa-tion of an illness will determine their emo-tional and practical response.'5

Patients should be encouraged to remainindependent, and should have a say in whatthey are willing to do (autonomy). Relation-ships in the home, finances, and changes inwork and social activity may create problemswhich are difficult to resolve. Strong partnersupport is possibly the single most importantfactor in buffering these effects.'6 Once apatient is discharged from hospital, less gen-eral information about disease and more spe-cific advice about activity is appropriate.'7 Thefamily should be offered participation in allaspects of rehabilitation. Group discussionswith patients and partners offer opportunitiesfor comparisons and shared experience, andmay be more cost effective.

Exercise-Supervised physical exercise hastraditionally been a central component of car-diac rehabilitation, for several reasons. First, itis believed that supervised exercise will helprestore the patient's confidence, feeling ofwell-being, and actual level of physical activitymore rapidly. Second, it is hoped thatincreased physical activity will help reverseadverse risk factors and contribute to sec-ondary prevention. Third, exercise may act as acore activity which provides a vehicle for psy-chological and social support and for othersecondary prevention activities.Most patients experience a spontaneous

improvement in functional capacity over thefirst few months after myocardial infarctionthat does not seem related to previous activitylevels.'8 19 Patients who do exercise achievetheir optimum functional state more rapidlythan patients who do not,20 21 have fewer visitsto their doctors and hospitals,22 and are morelikely to return to work.2' Patients with anginacan benefit from exercise training by experi-encing fewer symptoms and increased exercisecapacity,2425 and patients with impaired leftventricular function have reported sympto-matic improvement after exercise training.26Some patients with congestive heart failuremay show improved functional capacity afterexercise training, but results are unpredictable

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in individual patients.2728 The main con-traindications to exercise are susceptibility toexercise induced arrhythmias and unstableangina.

There is extensive epidemiological evidencethat increased physical exercise is associatedwith a lower risk of atherosclerotic heart dis-ease29 30 but individual intervention studieshave either lacked power to demonstrate a"hard end point" benefit or have been con-founded by other interventions besides exer-cise. A meta-analysis of trials suggests apotential overall mortality reduction of about20%." The potential interaction betweenexercise and other secondary prevention mea-sures, including better control of diabetes andthe correction of adverse lipid and prothrom-botic profiles needs further research (R).

Types of exercise that improve cardiovascu-lar fimess are now well characterised: moder-ate rather than high intensity exercise (forexample, brisk walking) sustained for periodsof about 20 minutes and repeated regularly(C).32 High intensity exercise may have a rolein some patients (for example, those returningto strenuous jobs) but requires careful supervi-sion. If increased exercise levels are to carryover from specific rehabilitation programmesinto longer term unsupervised daily living,then the resource implications of activities thatare heavily facility dependent or require muchtravelling or special clothing need to be con-sidered. Low risk patients may move rapidly tounsupervised exercise with regular (for exam-ple, telephone) support, and education abouta healthy exercise pattern.

Pre-exercise assessment is important bothin devising appropriate exercise programmesand for detecting potential risks. Formal tread-mill exercise testing is useful both for pre-exer-cise assessment and to monitor progress.Elderly patients or those with arthritis, heartfailure, or respiratory disease may find tread-mill testing difficult, and bicycle ergometrymay be useful. Other possible simple alterna-tives include timed corridor or shuttle walktests. Hospital patients can be taught simpleways of self-assessing the level of physicalactivity achieved, such as pulse rate measure-ment and the Borg perceived exertion scalebefore discharge." Exercise prescription needsto be individualised to take into account boththe underlying disease and the patient's ownrequirements and targets. Inability to keep upwith an exercise programme may indicate aneed for medical reassessment.

Education-In-hospital education pro-grammes for patients and partners improveknowledge,3435 reduce anxiety and depression,and decrease disability.'6 With increased trendstowards outpatient management and early dis-charge, similar outpatient facilities are needed(R). Staff should have clear, specific items fordiscussion, covering the diagnosis and its impli-cations, medication and its effects, and avail-able support when needed (A). Co-ordinationis required to avoid conflicting advice. Writtenand taped information should back-up verbalcommunication'7 and should be available ifrequired in appropriate languages and braille.

Educational impact can be increased by using avariety of formats and media.

Vocational assessment-Return to work isconsidered a major end point in cardiac reha-bilitation. Between 62% and 92% of patientswho were working before myocardial infarc-tion will return to work,'8 but a high propor-tion leave work again or change jobs in theyear after the first return to work. Thepatient's attitude towards return to work in theacute phase of the illness is a powerful predictorof subsequent return to work. Except in thecase of patients with persisting angina or heartfailure, failure to return to work is more oftendue to psychological or financial considera-tions than to statutory or physical constraints.Even in the case of occupations where healthstandards are prescribed by statute, there is anincreasing move towards an individual assess-ment of risk and capacity and away from arbi-trary standards.'940 There needs to becollaboration between cardiac rehabilitationand occupational health medicine to ensureoptimum and effective return to work.

The cost effectiveness of cardiacrehabilitationWe know of no cost effectiveness studies of thecomprehensive cardiac rehabilitation processas defined above (R). Several studies, princi-pally from the United States, have looked atspecific outpatient exercise based pro-grammes, but the designs of most are suspectand the results ambiguous. In general thesestudies have shown that medical costs weremarginally lower and patient income greater inpatients who participated in rehabilitation pro-grammes4'-43 and that quality of life was alsoimproved.4' In a recent review Chua andLipkin concluded that "cardiac rehabilitationprogrammes are cost effective and should bemade available to all who would benefit".44Several "secondary prevention" interventionsare regarded as cost effective, but are notapplied to the whole of the population thatmight benefit. Proper cost effectiveness assess-ments of integrated rehabilitation programmesare urgently needed.

The setting of cardiac rehabilitationCardiac rehabilitation is a multidisciplinaryprocess that crosses traditional boundariesbetween hospital and general practice, andbetween hospital specialties. Provision for car-diac rehabilitation under the National HealthService in the United Kingdom is very vari-able, and there is little consistency about fund-ing, scope of rehabilitation programmes, oraudit.' A perception that "cardiac rehabilita-tion is not effective" is often advanced as a rea-son for lack of investment.The workshop agreed that responsibility for

"phase I" rehabilitation rested with everyonewho dealt with or treated cardiac patients,whether in a hospital or a primary care setting.There was scope for coordination of approachand for clinical audit at practice, unit, or dis-trict level.

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Phase II and III rehabilitation requires facil-ities that are best provided and coordinated atsecondary care level. Every hospital that treatscardiac patients should have a policy for car-diac rehabilitation, and an organisation toimplement it. Both the policy and the organi-sation should be open to audit. The rehabilita-tion team should include a designatedclinician, both to provide medical input and toliaise with clinical colleagues. Funding forrehabilitation should be explicitly agreed withpurchasers and linked to agreed performanceindicators.

Phase IV rehabilitation falls largely withinthe primary care setting, but there should becontinuing support and feedback from sec-

ondary care, and ideally standards and auditpoints should be agreed on a district-widebasis.

Clinical standardsEssential points relating to clinical standardsare listed below. Audit proformas are availablefrom the Research Unit of the Royal Collegeof Physicians.

MEDICAL CARE* Patients, and where appropriate partners

and carers, should receive accurate and under-standable information about medical findingsand proposed management

* Patients should routinely be assessed forrisk factors as part of inpatient or outpatientmanagement, and clear advice given on risk-factor correction.* Evidence-based secondary prevention mea-

sures should be instituted and recorded

PSYCHOSOCIAL CARE

Patients admitted to hospital with acute car-

diac events should have a simple formalassessment for depression/anxiety before dis-charge.Where this indicates a potential problem,

patients should have access to appropriatetreatment/counselling, and to follow-upassessment. Partners should be invited to

counselling sessions.Patients should have access to expertise as

needed-for example, psychiatrist/clinical psy-

chologist, vocational counsellor, smokingcounsellor.

EDUCATIONPatients should have access to information rel-evant to their medical condition and healthstatus. Information may be provided orally, byprinted material, education classes, or group

discussions. Differing patient requirementsshould be catered for.

EXERCISEPatients with diagnoses of myocardial infarc-tion, unstable angina, or heart failure shouldhave a recorded assessment of exercise capacitybefore hospital discharge. Where appropriatethis could be based on clinical assessment or a

simple walking assessment rather than a for-mal treadmill test.

Patients should have access to a personalexercise plan that can be monitored either in agroup setting or at home.

Patients should be medically assessedbefore embarking on exercise-based rehabilita-tion programmes.

Contracting for cardiac rehabilitationPurchaser/provider contracts for cardiac reha-bilitation need to specify the scope of the con-tract (all cardiac diagnoses or selecteddiagnoses, whether access will be open or lim-ited to hospital referrals); the selection criteria(if any) to be used and who will apply them;the type of services to be offered (ideally, acomprehensive service); and whether the com-mitment to individual patients is to be fixed-term or open ended. The level of clinicalinvolvement needs to be specified.Contractors will need to be satisfied aboutarrangements for a seamless transitionbetween hospital and community.

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