Cardiac Rehabilitation Explained: An in-Depth Guide to Understanding and Navigating Life after Heart Attack, Stenting, or Surgery

By Warrick Bishop and Alistair Begg

Cardiac Rehabilitation Explained is a must-read for anyone who has recently experienced a cardiac event, such as a heart attack, stenting, or cardiac surgery. This comprehensive guide not only explains the importance of cardiac rehabilitation, but also provides a thorough understanding of the causes of cardiac events, treatments available, and the steps individuals can take to recover or improve their cardiovascular health, thus also making Cardiac Rehabilitation Explained a powerful preventative tool for those who wish, at any age, to be proactive about their health.

• Language: English
• Publisher: Warrick Bishop
• Release date: Mar 6, 2023
• ISBN: 9780645268171

Warrick Bishop

Dr Warrick Bishop MBBS, FRACP, CardiologistDr Warrick Bishop graduated from the University of Tasmania, School of Medicine in 1988. He worked in the Northern Territory and subsequently commenced his specialist training in Adelaide, South Australia. He completed his advanced training in cardiology in Hobart, Tasmania, becoming a fellow of the Royal Australian College of Physicians in 1997.He has worked predominately in private practise combined with public sessions. In 2009 Warrick undertook training in CT Cardiac Coronary Angiography, being the first cardiologist in Tasmania with this specialist recognition. This area of imaging fits well with Warrick’s interest in preventative cardiology.Warrick has developed a particular interest in diabetic related risk of coronary artery disease, specifically related to eating guidelines and lipid profiles. He is a recognised examiner for the Royal Australian College of Physicians and is regularly involved with teaching of medical students and junior doctors.Warrick is a member of the Clinical Issues Committee of the Australian Heart Foundation which provides input into issues of significance for the management of heart patients, a member of the Australian Atherosclerosis Society, and a participant on the panel of “interested parties” to develop a model of care and national registry for Familial Hypercholesterolaemia.

Book preview

CARDIAC

REHABILITATION

Explained

an in-depth guide to understanding and navigating life after heart attack, stenting, or surgery

This book is for you, if you

have suffered a heart attack or other heart event, lived to tell the tale, and want to live as full and healthy a life as possible – or know a family member or a close friend who is in this situation

want to know more about cardiac rehabilitation and its long-term, life-enhancing benefits

need encouragement to start or continue a cardiac rehabilitation program

suffer from any form of cardiovascular disease, and want to live as full and healthy a life as possible – or know a family member or a close friend who is in this situation

need to know that you are not alone – as a sufferer or a carer or a support person

want to know what’s going on with your heart

are a doctor, nurse or student looking for a straight-forward refresher or instructive text

want a book that you can recommend to your patients, family or friends

enjoy an informative read.

This book is for you if you have a heart.

PUBLISHER’S NOTE

The authors and editors of this publication have made every effort to provide information that is accurate and complete as of the date of publication. Readers are advised not to rely on the information provided without consulting their own medical advisers. It is the responsibility of the reader’s treating physician or specialist, who relies on experience and knowledge about the patient, to determine the condition of, and the best treatment for, the reader. The information contained in this publication is provided without warranty of any kind. The authors and editors disclaim responsibility for any errors, mis-statements, typographical errors or omissions in this publication.

© 2023 Warrick Bishop MBBS FRACP

This publication is copyright. Other than for the purposes of and subject to the conditions prescribed under the Copyright Act, no part of it may in any form or by any means (electronic, mechanical, micro-copying, photocopying, recording or otherwise) be reproduced, stored in a retrieval system or transmitted without prior written permission.

Any information reproduced herein which has been obtained from any other copyright owner has been reproduced with that copyright owner’s permission but does not purport to be an accurate reproduction. Inquiries should be addressed to the publisher.

National Library of Australia Cataloguing-in-Publication entry

For book bonuses visit h​ttps:​//drw​arric​kbish​op.co​m/pag​e/car​diac-​rehab​-book​bonus​es

dedicated to

those committed to cardiac rehabilitation

who give so generously

so that our patients may recover

as fully as possible

to live as well as possible

for as long as possible

CONTENTS

foreword

references

introduction

patient’s perspective: Ron, a journey for which I was not prepared

chapter 1 a survival guide

Judy’s experience

interview: cardiothoracic surgeon Dr Ashutosh Hardiker

GETTING BACK TO BASICS: UNDERSTANDING THE HEART

chapter 2 a finely tuned pump

a closer look – flow of blood through the heart and the lungs

chapter 3 an electrical masterpiece

chapter 4 the ‘heart’ of the matter

answering your questions – what is plaque?

case study: Penny, prevention is better than cure

answering your questions – what is a coronary calcium score?

interview: patient, Brian

chapter 5 the clock is ticking

answering your questions – what is a stent?

a closer look – trials support the use of stents

answering your questions – what is a coronary artery bypass graft?

chapter 6 risk factors

THE CARDIAC REHABILITATION JOURNEY: YOUR WORLD HAS CHANGED

chapter 7 pathway of care

interview: heart attack survivor Darren Lehmann

chapter 8 are you prepared to change?

interview: CR nursing unit manager Robert Zecchin

chapter 9 an arsenal of highly effective drugs

a closer look – aspirin

answering your questions – what is the best treatment for cholesterol?

a closer look – the kidneys

chapter 10  taking medications

chapter 11  what about supplements?

chapter 12  nutrition for life

chapter 13  exercise

interview: CR nurse and service provider Angela Hartley

chapter 14  when the heart gets heavy

interview: psychiatrist Ralf Ilchef

from the Darren Lehmann interview

chapter 15  when can I ...?

chapter 16  life after a cardiac event

interview: cardiac arrest survivor Greg Page

answering your questions – what is a heart attack? what is cardiac arrest? how are they different?

media release – world first registry to tackle sudden cardiac death in Australia

chapter 17  maintenance and prevention

patient’s perspective: an unwelcome interruption disrupts and ordered life

chapter 18  rehab for life

your DIY rehab program – for life

your rehab journey – the 3 Es

epilogue

APPENDICES

appendix 1  will you recognise a heart attack

appendix 2  more about valves

media release – Australian cardiology first gives Nadeane new lease on life

appendix 3  more about atrial fibrillation

a closer look – keeping score

appendix 4  recipes

list of illustrations, photographs, tables

access to interviews and further information

glossary

index

acknowledgements and thanks

behind the scenes

FOREWORD

The concept of ‘holding someone’s heart in your hands’ has enthralled many surgeons and physicians for decades, if not centuries.

Restoring blood flow and creating new pathways for blood to travel are amazing medical advances and often profoundly life-altering for patients. These advanced techniques of revascularisation and treatment, however, are merely the first step in a patient’s journey back to health and a desirable quality of life. Without a pathway to recover, heal and rebuild, the benefits of surgery and stenting are harder to achieve, difficult to realise and maybe even beyond reach.

Cardiac Rehabilitation Explained is a guide for those patients who entrust us with their lives and, of course, their hearts. When my patients nervously sign the form to consent for major surgery, they want to not only know that the plumbing will be good but also that there is a path back to life, exercise, work, and their families.

Cardiac Rehabilitation Explained is there for these patients.

Many questions are asked prior to the operation, but even more come afterwards as the nerves settle and the ‘light switches on at the end of the recovery tunnel’. This book is an excellent reference point for cardiac patients, answering all those questions that are remembered in the middle of the night whilst machines go ‘beep’ and blood pressure cuffs inflate.

Most of my patients remark, But doctor, I was perfectly healthy a week ago, and now I have to have my chest cut open for three bypass grafts! More than half a million Australians have ischaemic heart disease, but the diagnosis is still surprising for some. For these patients, the focus is very much on the upcoming surgery or stenting procedure. Their life is placed on hold to enable them to get through a lifesaving operation. After the initial thrill of I have survived!, there is a letdown when they suddenly realise the effort then required to heal and recover. Almost 50 per cent do not return to their normal work capacity after a heart attack, and nearly 25 per cent do not return to work at all. Cardiac rehabilitation looks to support patients back to a healthy lifestyle and the work capacity they desire.

Even in the complex area of cardiac transplantation, cardiac rehabilitation is recognised as critical to patient outcome and quality of life. As the wounds gradually heal, patients realise they have swapped a Morris Minor for a Ferrari. Spurred on by the excitement of a new heart (and high-dose corticosteroids!), the post-operative cardiac transplant patient will benefit from this book, too. For it not only is it about educating the patient on the new medications and a healthy lifestyle, but also the graduated return to exercise, physical activity, and mental preparation for the challenges ahead.

The book takes us on a journey and utilises a wide spectrum of interviews with patients, medical professionals and specialists in rehabilitation sciences. The language is engaging and easy to read, and information is well referenced.

One of my patients once remarked how he read the same newspaper for the first three days after surgery, and each time it was like reading it anew. But as he recovered, his voracious appetite for reading left no book unturned. Combined with the discovery of a fitness tracker, he hasn’t looked back unless it is to take a selfie with the other ‘mamils’ (middle-aged men in lycra) on their Saturday morning bike ride. Now I have the perfect book for him!

EMILY GRANGER MBBS (Hons) FRACS

cardiothoracic and heart and lung transplant surgeon,

St Vincent’s Hospital, Sydney, New South Wales

lecturer

Clinical Medical School at St Vincent’s Hospital,

the University of Notre Dame

member

Royal Australasian College of Surgeons

Dr Emily Granger has performed more than 3000 general cardiothoracic operations and more than 300 heart and lung transplants.

Emily completed her medical degree at the University of Queensland and her surgical fellowship with the Royal Australasian College of Surgeons (RACS) in 2006. She is involved with the NSW Organ Tissue Donation Service and Deceased Donor Organ Procurement and, in 2014, was involved in the world’s first successful ‘donation after circulatory death’ heart transplant. Since then, the Transplant Unit at St Vincent’s Hospital has performed 80 procedures of this type.

Dr Granger lectures at the Clinical Medical School at St Vincent’s Hospital and the University of Notre Dame, and is active in teaching medical students, junior doctors, and trainee surgeons. She is an instructor with the RACS and involved with the RACS NSW State Regional Committee. In 2017, she was appointed to the Board of Cardiothoracic Surgical Examiners. She is president of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS).

REFERENCES

Cardiac Rehabilitation Explained has been informed by

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

NHFA CSANZ Heart Failure Guidelines Working Group John J. Atherton, Andrew Sindone, Carmine G. De Pasquale, Andrea Driscoll, Peter S. MacDonald, Ingrid Hopper, Peter M. Kistler, and others.

Heart, Lung and Circulation, Vol. 27, Issue 10, p1123–1208

Published in issue: October 2018

© 2018 National Heart Foundation of Australia. Published by Elsevier B.V. on behalf of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).

A Pathway to Cardiac Recovery

Standardised program content for Phase II Cardiac Rehabilitation

Working group: Institute for Physical Activity, Deakin University, Dr Susie Cartledge, Dr Emma Thomas, Professor Ralph Maddison; Heart Foundation and Nutrition, Deakin University, Kerry Hollier, Roni Beauchamp, Dr Sue Forrest, Eugene Lugg, Expert Advisory Group (EAG), Professor Robyn Gallagher, Dr Adrienne O’Neil, Cate Ferry, Professor Nicholas Cox, Professor Lis Neubeck, Professor Robyn Clark, Stephen Woodruffe, Emma Boston, Kim Gray, A/Professor Julie Redfern, Beth Meertens, Dr Bridget Abell, Dr Carolyn Astley, Maria Sheehan, A/Professor Rosemary Higgins, Content experts (outside of EAG), Cia Connell (Heart Foundation), Sian Armstrong (Heart Foundation), Sarah White (QUIT Victoria).

© 2019 National Heart Foundation of Australia

h​ttps:​//www​.hear​tfoun​datio​n.org​.au/g​etmed​ia/00​6fd24​7-616​3-4d0​4-9b8​59e90​a5adb​ea0/A​_Path​way_t​o_Pha​se_II​_Card​iac_R​ecove​ry_(F​ull_R​esour​ce)-(​3).​pdf

and the paper about how the resource was written:

Development of standardised programme content for phase II cardiac rehabilitation programmes in Australia using a modified Delphi process

Susie Cartledge, Emma Thomas, Kerry Hollier, R Maddison

BMJ Journals (Open) volume 9, issue 12 h​ttps:​//bmj​open.​bmj.c​om/co​ntent​/9/12​/e032​279

Improving the Monitoring of Cardiac Rehabilitation Delivery and Quality: A Call to Action for Australia

Emma Thomas, MPH, Carolyn Astley, PhD, Robyn Gallagher, PhD, Rachelle Foreman, MPhil, Julie Anne Mitchell, MPH, Sherry L. Grace, PhD, Dominique A. Cadilhac, PhD, Stephen Bunker, PhD, Alexander Clark, MPH, Adrienne O’Neil, PhD.

Received 25 May 2019; online published-ahead-of-print 16 August 2019

(editorial) Heart, Lung and Circulation (2020) 29, 1–4

h​ttps:​//doi​.org/​10.10​16/j.​hlc.2​019.0​7.013

© 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

The BACPR (British Association for Cardiovascular Prevention and Rehabilitation) Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2017

h​ttps:​//www​.bacp​r.com​/reso​urces​/BACP​R_Sta​ndard​s_and​_Core​_Comp​onent​s_201​7.​pdf

Cochrane Library

Cochrane Reviews – cardiac rehabilitation

h​ttps:​//www​.coch​ranel​ibrar​y.​com

Australian Cardiovascular Health and Rehabilitation Association (ACRA) Core Components of Cardiovascular Disease Secondary Prevention and Cardiac Rehabilitation 2014

Stephen Woodruffe, Lis Neubeck, PhD, Robyn A. Clark, PhD, Kim Gray, Cate Ferry, Jenny Finan, MN, Sue Sanderson, Tom G. Briffa, PhD.

Online published-ahead-of-print 12 January 2015

(review) Heart, Lung and Circulation (2015) 24, 430–441 1443-9506/04/

h​ttp:/​/dx.d​oi.or​g/10.​1016/​j.hlc​.2014​.12.​008

© 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC)

Antonio Pelliccia, Erik Ekker Solberg, Michael Papadakis, Paolo Emilio Adami, Alessandro Biffi, Stefano Caselli, Andrè La Gerche, Josef Niebauer, Axel Pressler, Christian M. Schmied10, Luis Serratosa, Martin Halle, Frank Van Buuren, Mats Borjesson, Francois Carrè, Nicole M. Panhuyzen-Goedkoop, Hein Heidbuchel, Iacopo Olivotto, Domenico Corrado, Gianfranco Sinagra, and Sanjay Sharma.

Received 5 August 2017; revised 8 March 2018; editorial decision 19 October 2018; accepted 20 October 2018; online publish-ahead-of-print 14 December 2018

European Society of Cardiology, European Heart Journal (2019) 40, 19-23. (doi:10.1093/eurheartj/ehy730) Special article, Sports cardiology

Cardiac rehabilitation: a comprehensive review

Scott A Lear and Andrew Ignaszewski

Published online: 10 September 2001. Curr Control Trials Cardiovasc Med 2001, 2:221-232 © 2001 BioMed Central Ltd (Print ISSN 1468-6708; Online 1468-6694)

Austroads and the National Transport Commission, Assessing Fitness to Drive

h​ttps:​//aus​troad​s.com​.au/

Qantas Group Medical Travel Clearance Guidelines

h​ttps:​//www​.qant​as.co​m.au/​infod​etail​/flyi​ng/be​foreY​ouTra​vel/m​edifo​rm.​pdf

other websites:

books, text:

Begg, Alistair; What’s Wrong With My Heart? (unpublished text)

Bishop, Warrick; Have You Planned Your Heart Attack? (2016)

Bishop, Warrick; Atrial Fibrillation Explained (2019)

Bishop, Warrick; Cardiac Failure Explained (2020)

It does not matter how slowly you go

as long as you do not stop.

Confucius

introduction

In 2018, Ron, aged 66, was living what seemed a healthy enough life. At 180 cm tall, he weighed around 78 kg. He didn’t smoke, wasn’t diabetic, ate mostly vegetarian, drank a bottle of wine over two days on the weekend and consumed no alcohol on the remaining five days. He rarely ate junk food and consistently observed the 5/2 fast diet, having done so for three years. At least three days a week, he walked for an hour or more.

On a Monday morning in August 2018, he had a heart attack.

PATIENT’S PERSPECTIVE

a journey for which I was not prepared

Rehabilitation after heart surgery was not a journey for which I was prepared. My surgery was necessitated by an unforeseen heart attack, and it was only then that I discovered I had serious heart disease. There was little time to learn what the surgery would involve (four coronary artery bypass grafts). There was no time to ask about or consider what it would be like post-surgery.

When I woke from surgery and discovered the state my body was in, I really confronted what lay ahead and retrospectively learned what had led to this. For a person who regularly walked an hour a day, ate a well-balanced diet and considered himself fit and healthy, I was reduced to an exhausted shell of my former self.

In the immediate aftermath of surgery, my rehabilitation was a medical one and began in intensive care. When I regained consciousness, a breathing tube was removed from my throat and replaced with prongs fixed in my nose to support my oxygen intake. A tube remained inserted into a vein in my neck and a catheter to drain my bladder was connected. There was a tube inserted in my wrist, two drains inserted through my lower chest wall to drain excess fluid and a canula fixed in my arm on the inside of my elbow. I was attached to a drip supported on a wheeled metal frame beside my bed. For a number of days this drip and metal frame were my annoying companions whenever I ventured from my bed. Electrical nodes were plastered all over my chest, attached by wires to a portable monitoring device that also went with me whenever I left my bed. This device was particularly difficult to keep dry when, after a couple of days of recovery, and to my great relief, I was allowed to shower. Frequently, I was fitted with a face mask nebuliser to help improve the condition of my lungs and my breathing. I didn’t understand at first why my lungs were an issue until I was told that during surgery my heart and lungs were effectively shut down and I was maintained on a heart lung device.

For the first day or so I had a self-operated handset to give myself controlled doses of pain relief. Other medications by both tablet and injection were delivered to me throughout the day and night and my blood pressure was taken every few hours. Though understandable for safety reasons, I became tired of confirming my name and date of birth at every nursing visit. Being unable to use my arms or upper body to roll over in bed contributed to my inability to get much sleep. I also discovered that frequent interruptions meant that sound sleep was not key to my hospital rehabilitation.

Within a few days, I was visited by a cardiac rehabilitation nurse and encouraged to get out of bed, spend time sitting in a chair, and as soon as possible begin walking around the ward. I was also shown a series of breathing exercises and told to repeat them a number of times each hour. This involved a series of deep breaths followed by a couple of ‘huffs’ to expel the air in my lungs through my open mouth. Then came the painful part which was to cough strongly from my lungs. Despite supporting my breastbone (sternum) by clutching a folded towel to my chest, this brought pain and an anticipatory fear of damaging my chest wound where the bone had not had time to heal.

Because of the amount of time spent in bed or sitting uncomfortably in the bedside chair and the consequent risk of deep vein thrombosis, I had to wear pressure socks for weeks after my surgery. These socks were almost impossible to put on and take off without assistance, given the constraints on using my upper body and arms because of my still-healing breastbone. There were also ankle rotations, knee lifting and buttock squeezing exercises to do (if I remembered to do them). I might even inadvertently have ended up strengthening my pelvic floor muscles, though constipation remained a problem!

Prior to discharge from hospital, my recovery status was assessed by a cardiac rehabilitation nurse. This involved an interview, the usual tests (such as blood pressure) and a walking assessment up and down a marked-out section of the ward corridor.

When I was discharged, I was meant to continue some of the hospital exercises at home, along with an additional program of exercises. I had never been one for exercise routines and I felt totally exhausted from the impacts of major surgery. It took considerable will power and my partner’s hectoring to comply to a reasonable level with the program.

Fortunately, frequent walking was highly recommended as the best initial rehabilitation exercise after heart surgery, and I had always been a walker. The advice was to keep to flat or gentle grade routes, and with my initially diminished lung function I found this necessary. Before my heart surgery, I had never experienced any diminishment of my lung function and could walk up quite steep hills without puffing. I became quite concerned and stressed at having to catch my breath with anything more than the gentlest of exercise and feared that this was to be my new normal. I gained an inkling of what it might be like to have emphysema. Fortunately, over a couple of months my lung function returned more or less to normal. My appetite, normally healthy, was diminished for a few weeks and I slept a lot.

The hospital provided me with a cardiac rehab booklet with guidelines on returning progressively to everyday activity, covering each week for the first 12 weeks after discharge. Some of the examples given were specific for certain occupations or recreational activities that a person might be returning to, for example farming, golfing, fishing, woodworking, as well as household tasks such as making the bed, ironing, and vacuuming. It was reassuring to be advised that by week four I could begin to practice my putting, develop photos, hang light washing on the line and resume gentle sexual activity with a familiar partner provided I did not assume the upper dominant position! Apparently, an unfamiliar partner might induce anxiety. By week eight I could be dancing rock and roll or square dancing. More usefully, and with the approval of my cardiovascular surgeon at my six-week post discharge clinic, I was given the all clear to drive and travel.

Three weeks after discharge from hospital, I commenced a six-week program of rehabilitation organised and run by cardiac rehabilitation nurses. The program was run at a facility on Hobart’s eastern shore set up for rehabilitation purposes. Each 2.5-hour session was divided into two parts. The session started with registration and an introduction and explanation of the circuit of exercises new participants would undertake.

Some participants were already part way through their six-week program. Observing their familiarity with the exercise circuit helped me catch on to what was expected. Participants were also in various states of health and physical capacity, so we each received personal attention on what level of exercise we should do and on how to pace ourselves safely as our physical recovery progressed.

Most exercises in the circuit were set for a one-minute duration before moving to the next exercise. Exercises included simple pacing up and down, stepping up and down on a set of steps, raising each knee in turn to waist