The bottom line
Globally, the prevalence of coronary heart disease and heart failure is increasing,
and there is some evidence of the health benefits of cardiac rehabilitation
Effective implementation of cardiac rehabilitation after acute coronary syndrome,
coronary revascularisation, and heart failure has remained suboptimal, with overall
participation rates <50% over recent decades despite international recommendations
International guidelines now recommend that cardiac rehabilitation programmes include
health education and psychological counselling
Patients should be offered a choice of community based and home based cardiac rehabilitation
programmes to fit their needs and preferences
Clinicians should endorse cardiac rehabilitation for patients with a recent diagnosis
of coronary heart disease or heart failure
Cardiac rehabilitation is a complex intervention offered to patients diagnosed with
heart disease, which includes components of health education, advice on cardiovascular
risk reduction, physical activity and stress management. Evidence that cardiac rehabilitation
reduces mortality, morbidity, unplanned hospital admissions in addition to improvements
in exercise capacity, quality of life and psychological well-being is increasing,
and it is now recommended in international guidelines.1
2
3
4
5
6 This review focuses on what cardiac rehabilitation is and the evidence of its benefit
and effects on cardiovascular mortality, morbidity and quality of life.
Sources and selection criteria
RST is a member of the Cochrane Heart Group and has led and conducted several systematic
reviews of cardiac rehabilitation. We searched the Cochrane database (www.cochrane.org)
for cardiac rehabilitation and equivalent terms. We identified current national and
international clinical guidelines based on systematic reviews and meta-analyses. We
referred to the National Audit of Cardiac Rehabilitation annual report, which was
led by PD, and the British Heart Foundation’s website for statistics on coronary heart
disease in the UK. We also consulted recent review articles from the UK, US, Canada,
and Australia. We have included topics that would be of interest to hospital doctors
and general practitioners based on a previous review coauthored by HMD and also the
level 1 evidence provided by the Cochrane reviews. We also used our personal reference
collections.
Why is cardiac rehabilitation important?
Although mortality from coronary heart disease has fallen over recent decades, annually
it still claims an estimated 1.8 million lives in Europe,7 and 785 000 new and 470 000
recurrent myocardial infarctions occur in the US.8 In the UK, around 110 000 men and
65 000 women have an acute myocardial infarction every year, equivalent to one every
three minutes.9 With improved survival and an aging population, the number of people
living with coronary heart disease in the UK has increased to an estimated 2.3 million.9
What is cardiac rehabilitation and who should get it?
Various organisations and national bodies have defined cardiac rehabilitation, which
is encompassed by: “Cardiac rehabilitation (and secondary prevention) services are
comprehensive, long term programmes involving medical evaluation, prescribed exercise,
cardiac risk factor modification, education, and counselling. These programmes are
designed to limit the physiological and psychological effects of cardiac illness,
reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilise
or reverse the atherosclerotic process, and enhance the psychosocial and vocational
status of selected patients.” Although exercise training is a core component, current
practice guidelines consistently recommend “comprehensive rehabilitation” programmes
that should include other components to optimise cardiovascular risk reduction, foster
healthy behaviours and compliance to these behaviours, reduce disability, and promote
an active lifestyle.5
The National Institute for Health and Care Excellence (NICE), Department of Health,
British Association for Cardiovascular Prevention and Rehabilitation (BACPR), and
wider European guidelines agree that the patient groups listed in box 1 will benefit
from cardiac rehabilitation.1
2
4
10
11
12 and the core components of cardiac rehabilitation are illustrated in figure 2.1
Box 1: Patient groups who benefit from cardiac rehabilitation*
Patients with acute coronary syndrome—including ST elevation myocardial infarction,
non-ST elevation myocardial infarction, and unstable angina—and all patients undergoing
reperfusion (such as coronary artery bypass surgery, primary percutaneous coronary
intervention, and percutaneous coronary intervention)
Patients with newly diagnosed chronic heart failure and chronic heart failure with
a step change in clinical presentation
Patients with heart transplant and ventricular assist device
Patients who have undergone surgery for implantation of intra-cardiac defibrillator
or cardiac resynchronisation therapy for reasons other than acute coronary syndrome
and heart failure
Patients with heart valve replacements for reasons other than acute coronary syndrome
and heart failure
Patients with a confirmed diagnosis of exertional angina
*According to NICE, Department of Health, BACPR, and European guidelines1
2
4
10
11
12
Historically, cardiac rehabilitation in the UK, US, and most European countries has
been delivered to groups of patients in healthcare or community centres.13
14 Recent guidance from the UK Department of Health12 refers to a seven stage pathway
of care that begins with diagnosis of a cardiac event and is followed by assessment
of eligibility, referral, clinical assessment, and core delivery of cardiac rehabilitation
before progressing to long term management (fig 1).
Fig 1 BACPR standards pathway, showing a patient’s journey through cardiac rehabilitation
(reproduced with permission from BACPR1). *CR=cardiac rehabilitation
Formal rehabilitation programmes vary in intensity and duration. The European guide
for patients with established cardiac disease provides a full review of the impact
of the mode and dose of exercise based cardiac rehabilitation.15 In the UK, formal
rehabilitation is predominantly provided to supervised groups in outpatient hospital
clinics or community centres, starting 2–4 weeks after percutaneous coronary intervention
or myocardial infarction and usually 4–6 weeks after cardiac surgery.14 The BACPR
standard recommends delivery of the seven core components of cardiac rehabilitation
after clinical assessment (fig 2).1 Programmes are typically delivered by specialist
nurses or physiotherapists supported by exercise therapists, although ideally an integrated
multidisciplinary team led by an experienced clinician with a special interest in
cardiac rehabilitation should deliver the programme (BACPR standard 2, box 2).1 Most
programmes involve weekly attendance at group sessions for an average of 56 (SD 3.6)
days or approximately 8 weeks.16 Centre based sessions involve graduated exercise
training, education (covering coronary risk factors and diet), common cardiac misconceptions,
preventative medication, and stress management.14 Ideally, patients should be given
information about the cardiac event and lifestyle advice, including the importance
of smoking cessation (if appropriate), healthy diet, and physical activity to encourage
progressive mobilisation. Prior to discharge, clinicians should ensure that patients
are prescribed drugs for secondary prevention and drugs that are beneficial for those
with systolic heart failure such as angiotensin-converting enzyme (ACE) inhibitors
and beta-blockers.1 Good communication between secondary and primary care after discharge
can improve uptake of cardiac rehabilitation and optimise secondary prevention.17
Cardiac rehabilitation programmes in the US and Europe tend to be more intensive than
those in the UK and are delivered from outpatient departments over 3–6 months. Some
European countries offer residential programmes lasting 3–4 weeks. The focus is mainly
on “monitored exercise and aggressive risk factor reduction” in medically supervised
sessions.13
18
Fig 2 Core components of cardiac rehabilitation. Reproduced with permission from BACPR1
Box 2: Core components of cardiac rehabilitation. Adapted from BACPR Standard 21
1. Health behaviour change and education
2. Lifestyle risk factor management
- Physical activity and exercise
- Diet
- Smoking cessation
3. Psychosocial health
4. Medical risk factor management
5. Cardioprotective therapies
6. Long term management
7. Audit and evaluation
Delivery of the core components requires expertise from a range of different professionals.
The team may include:
Cardiologist, community cardiologist, physician, or general practitioner with a special
interest
Nurse specialist
Physiotherapist
Dietitian
Psychologist
Exercise specialist
Occupational therapist
Clerical administrator
What are the benefits of cardiac rehabilitation?
The benefits of cardiac rehabilitation for individuals after myocardial infarction
and revascularisation and for those with heart failure have been reviewed comprehensively
in several meta-analyses, including six Cochrane reviews and a recent clinical review
from the US.18
19
20
21
22
23
24
Mortality
A 2011 Cochrane review and meta-analysis of 47 randomised controlled trials that included
10 794 patients showed that cardiac rehabilitation reduced overall mortality (relative
risk 0.87 (95% confidence interval 0.75 to 0.99), absolute risk reduction (ARR) 3.2%,
number needed to treat (NNT) 32) and cardiovascular mortality (relative risk 0.74
(0.63 to 0.87), ARR 1.6%, NNT 63), although this benefit was limited to studies with
a follow-up of greater than 12 months.25 With the exception of one large, UK based
trial that showed little effect of cardiac rehabilitation on mortality at two years
(relative risk 0.98 (0.74 to 1.30)),26 findings from meta-analyses and observational
studies support a mortality benefit.27 Another systematic review and meta-analysis
of 34 randomised controlled trials including 6111 patients after myocardial infarction
showed that those who attended cardiac rehabilitation had a lower risk of all-cause
mortality than non-attendees (odds ratio 0.74 (0.58 to 0.95)).28
The latest updated Cochrane review of exercise based cardiac rehabilitation for coronary
heart disease reports an absolute risk reduction in cardiovascular mortality from
10.4% to 7.6% (NNT 37) for patients after myocardial infarction and revascularisation
who received cardiac rehabilitation compared with those who did not.19 No significant
reduction occurred in overall mortality,19 which contrasts with results in previous
meta-analyses.25
29 The inclusion of patients from the UK based randomised controlled trial26 is cited
as one reason for this lack of reduction in mortality.19 The negative findings of
this trial have also led to scepticism about the content and delivery of UK based
cardiac rehabilitation programmes in the late 1990s,30
31 and this controversial trial has been the subject of much debate.27
30
31
32
Reduced hospital admissions
Although the 2015 Cochrane review in coronary heart disease reported no reduction
in the risks of fatal or non-fatal myocardial infarction or coronary revascularisation
(coronary artery bypass graft or percutaneous coronary intervention), there was a
reduced risk of hospital admission (from 30.7% to 26.1%, NNT 22).19 In another Cochrane
review of 33 randomised controlled trials and 4740 patients with heart failure, exercise
based cardiac rehabilitation reduced the risk of overall hospitalisation (relative
risk 0.75 (0.62 to 0.92), ARR 7.1%, NNT 15) and hospitalisation for heart failure
(relative risk 0.61 (0.46 to 0.80), ARR 5.8%, NNT 18).33
Improvement in psychological wellbeing and quality of life
A US observational study of 635 patients with coronary heart disease reported improvements
in depression, anxiety, and hostility scores after cardiac rehabilitation.34 Early
cardiac rehabilitation programmes only offered interventions that focused predominantly
on exercise, but significant (P<0.01) improvements in anxiety and depression scores
were reported in one randomised controlled trial of 210 men admitted with myocardial
infarction undergoing gym based exercise training.35 Furthermore, a meta-analysis
of 23 randomised controlled trials (3180 patients with coronary heart disease) that
evaluated the impact of adding psychosocial interventions to standard exercise based
cardiac rehabilitation reported a greater reduction in psychological distress (effect
size 0.34) and improvements in systolic blood pressure and serum cholesterol (effect
sizes −0.24 and −1.54 respectively).36
Several studies have reported improvement in psychological stress in patients with
coronary heart disease who have attended cardiac rehabilitation: one recent US observational
study of 189 patients with heart failure (left ventricular ejection fraction <45%)
reported a decrease in symptoms of depression by 40% after exercise training cardiac
rehabilitation (from 22% to 13%, P<0.0001).37 Also depressed patients who completed
their cardiac rehabilitation had a 59% lower mortality (44% v 18%, P<0.05) compared
with depressed dropout patients who did not undergo cardiac rehabilitation.37
A Cochrane review of exercise based rehabilitation for coronary heart disease showed
that seven out of 10 randomised controlled trials that reported quality of life using
validated outcome measures found “significant improvement,” but the authors were not
able to pool the data to quantify the effect because of the heterogeneity of the outcome
measures.25 Similarly, another Cochrane review of exercise based cardiac rehabilitation
for heart failure reported a clinically important improvement in the Minnesota Living
with Heart Failure questionnaire (mean difference 5.8 points (95% confidence interval
2.4 to 9.2), P=0.0007) in the 13 randomised controlled trials that used this validated
quality of life measure.33
Cardiovascular risk profile
Before the use of statins for the secondary prevention of coronary heart disease,
two observational studies demonstrated the beneficial effects of diet and exercise
in improving lipid profiles.38
39 The findings of a small case series of 18 patients prescribed a low cholesterol
diet and daily exercise for 30 minutes on a bicycle ergometer resulted in regression
of coronary artery atheroma on angiography in seven of the 18 patients, compared with
only one of 18 in the usual care group.39 Significant reductions in total serum cholesterol
concentration (−2%, P=0.05) and low density lipoprotein:high density lipoprotein cholesterol
ratios (−9%, P≤0.0001) were reported after 36 sessions of cardiac rehabilitation in
another US observational study from the 1990s involving 313 cardiac patients.38
The prevalence of obesity in those attending cardiac rehabilitation in the US has
increased in the past two decades, with >40% having a body mass index >30 and 80%
with a body mass index >25.40 Ades et al conducted a randomised controlled trial of
74 overweight patients with coronary heart disease and showed that a “walk often and
walk far” (“high calorie, high expenditure”) exercise protocol of 45-60 minutes per
session of lower intensity exercise (70% peak oxygen uptake) resulted in twice the
weight loss (8.2 kg v 3.7 kg, P<0.001) compared with the standard cardiac rehabilitation
exercise session of 25-40 minutes. This study also reported significant improvements
(P<0.05) in systolic blood pressure, body mass index, serum triglycerides, HDL cholesterol,
total cholesterol, blood glucose, and peak oxygen uptake in the high calorie, high
expenditure exercise group.
What are the risks of cardiac rehabilitation?
A French observational study of more than 25 000 patients undergoing cardiac rehabilitation
reported one cardiac event for 50 000 hours of exercise training, equivalent to 1.3
cardiac arrests per million patient-hours.41 An earlier US study reported one case
of ventricular fibrillation per 111 996 patient-hours of exercise and one myocardial
infarction per 294 118 patient-hours.42
Patients with unstable angina, uncontrolled ventricular arrhythmia, and severe heart
failure (New York Heart Association (NYHA) level 3 or 4, ejection fraction <35%) have
been considered at high risk, with formal risk stratification (to include factors
such as a history of arrhythmias and functional capacity) conducted by an experienced
clinician before they engage in the exercise component of cardiac rehabilitation.1
However, the most recent Cochrane review found “no evidence to suggest that exercise
training programmes cause harm in terms of an increase in the risk of all cause death
in either the short or longer term” in patients with stable chronic heart failure
(NYHA level 1–3).22
Access to cardiac rehabilitation
For those who have difficulty accessing centre based cardiac rehabilitation, or those
who dislike groups, home based cardiac rehabilitation programmes are sometimes available.17
43 The most widely used programme in the UK is the Heart Manual
44—a six week intervention that uses written material and a relaxation CD and is delivered
by a trained healthcare facilitator who makes home visits and provides telephone support—which
has been shown to be just as effective as centre based programmes.45
46
Overcoming barriers to cardiac rehabilitation
Despite robust evidence of clinical and cost effectiveness, uptake of cardiac rehabilitation
varies worldwide and by patient group, with participation rates ranging from 20% to
50%.1
18
47
48 Poor uptake has been attributed to several factors, including physicians’ reluctance
to refer some patients, particularly women and those from ethnic minorities or lower
socioeconomic classes, and lack of resources, capacity, and funding.6
18
49
50
51
52 Adherence to cardiac rehabilitation programmes is affected by factors such as psychological
wellbeing, geographical location, access to transport, and a dislike of group based
rehabilitation sessions (box 3).13
18
43 The most effective way to increase uptake and optimise adherence and secondary
prevention is for clinicians to endorse cardiac rehabilitation by inviting patients
still in hospital after a recent diagnosis of coronary heart disease or heart failure
to participate and for nurse led prevention clinics to be linked with primary care
and cardiac rehabilitation services.2
53
54
55
56
Novel ways of providing cardiac rehabilitation are emerging using the internet and
mobile phones.57
58 A recent systematic review has evaluated alternative models of delivery59 that
can be provided via secondary prevention clinics.60 Offering patients a choice of
centre based, home, or online programmes on an equitable basis is likely to improve
uptake across all groups of cardiac patients. Self management and collaboration with
care givers can also improve uptake and outcomes.61
62
63
Box 3: Barriers to cardiac rehabilitation participation. Adapted from Menezes et al18
Poor referral rates, especially for certain groups:
- Women
- People from ethnic minority groups
- Elderly people
- People living in rural settings
- People in low socioeconomic classes
Poor patient adherence, leading to low enrolment and high dropout rates
Lack of endorsement by a doctor
Obesity (high body mass index)
Multiple morbidities, leading to poor functional capacity
Poor exercise habits
Cigarette smoking
Depression
Problems with transport
Poor social support
Lack of leave from work to attend centre-based sessions
Ongoing research and unanswered questions
Ongoing research
The NIHR has sponsored two UK based studies:
- REACH-HF aims to develop a new self help manual for people with heart failure and
their caregivers, which may help them to manage the condition using the principles
of cardiac rehabilitation. The team will then evaluate the clinical effectiveness,
cost effectiveness, and acceptability of the manual for people with heart failure
and their caregivers. www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/WorkingWithUs/TeachingAndResearh/ReachHF/Homepage.aspx.
(A protocol paper on REACH-HF has been submitted to BMJ Open.)
- CADENCE is a feasibility study and pilot randomised controlled trial to establish
methods to assess the acceptability and the clinical and cost effectiveness of enhanced
psychological care in cardiac rehabilitation services for patients with new onset
depression. http://medicine.exeter.ac.uk/esmi/workstreams/cochranecardiacrehabilitationreviews/
WREN pilot study of web based cardiac rehabilitation for those declining or dropping
out of conventional rehabilitation. http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=19260
Telerehab III, a multicentre randomised controlled trial of 140 patients with coronary
heart disease in Belgium, is evaluating the effectiveness of tele-rehabilitation,
which has been proposed as an adjunct or alternative to standard, centre based cardiac
rehabilitation. The study aims to investigate the long term effectiveness of adding
to standard cardiac rehabilitation a patient tailored, internet based, rehabilitation
programme that implements multiple core components of cardiac rehabilitation and uses
telemonitoring and telecoaching strategies. www.biomedcentral.com/content/pdf/s12872-015-0021-5.pdf
Unanswered questions
What characteristics are associated with uptake and adherence to cardiac rehabilitation
after an acute myocardial infarction when rehabilitation is started early?
How can referral and participation rates for eligible patients be increased?
Should referral be the responsibility of the physician or the healthcare team?
How will working and non-working patients afford to pay for these services?
Can advances in information and communication technologies be used to develop novel
ways of delivering cardiac rehabilitation to improve uptake and adherence?
How can we improve uptake in hard to reach groups, such as patients living in rural
communities, patients from ethnic minority groups, and those from low socioeconomic
classes?
Is cardiac rehabilitation, as delivered in routine clinical practice, still effective?
Additional educational resources
Resources for healthcare professionals
Anderson L, Taylor RS. Cardiac rehabilitation for people with heart disease: an overview
of Cochrane systematic reviews. Cochrane Database Syst Rev 2014;(2): CD011273. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011273.pub2/abstract
This overview describes six Cochrane systematic reviews in cardiac rehabilitation,
which included 148 randomised controlled trials in 98 093 participants.
British Heart Foundation. The National Audit of Cardiac Rehabilitation: annual statistical
report 2014. British Heart Foundation, 2014. www.bhf.org.uk/~/media/files/publications/research/nacr_2014.pdf.
Provides information to commissioners and clinicians on the inequalities and insufficiencies
in delivery against key service indicators for over 320 cardiac rehabilitation programmes
in the UK.
Menezes AR, Lavie CJ, Milani RV, Forman DE, King M, Williams MA. Cardiac rehabilitation
in the United States. Prog Cardiovasc Dis 2014;56:522-9.
A clinical review that provides clinicians with information on the benefits of cardiac
rehabilitation, risk factors, and factors affecting participation from a US perspective.
National Institute for Health and Care Excellence. Secondary prevention in primary
and secondary care for patients following a myocardial infarction (clinical guidance
172). NICE, 2013. www.nice.org.uk/guidance/cg172.
Provides clinicians and commissioners with new and updated recommendations on cardiac
rehabilitation, drug therapy, and communication of diagnosis.
Piepoli M, Corrà U, Adamopoulos S, Benzer W, Bjarnason B, Cupples M, et al. Secondary
prevention in the clinical management of patients with cardiovascular diseases. Core
components, standards and outcome measures for referral and delivery. Eur J Prev Cardiol
2014;21:664-81.
A policy statement for clinicians and commissioners from the Cardiac Rehabilitation
Section of the European Association for Cardiovascular Prevention & Rehabilitation.
Sandesara PB, Lambert CT, Gordon NF, et al. Cardiac rehabilitation and risk reduction:
time to “rebrand and reinvigorate.” J Am Coll Cardiol 2015;65:389-95.
A clinical review article that argues that the current model of centre based cardiac
rehabilitation is unsustainable and requires a patient centred strategy.
Clark RA, Conway A, Poulsen V, Keech W, Tirimacco R, Tideman P. Alternative models
of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2015;22:35-74.
Provides evidence on alternatives to the traditional hospital based model of cardiac
rehabilitation.
Clark AM, Hartling L, Vandermeer B, McAlister FA. Secondary prevention program for
patients with coronary artery disease: a meta-analysis of randomized control trials.
Ann Intern Med 2005;143:659-72.
Evaluates clinical evidence to on the effectiveness of secondary cardiac prevention
programmes with and without exercise components.
Resources for patients and carers
American Heart Association: What is cardiac rehabilitation? www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp.
Provides answers to frequently asked questions about cardiac rehabilitation, including
who needs it and for how long.
Association of Chartered Physiotherapists in Cardiac Rehabilitation. Patient information.
http://acpicr.com/patient-information
Information on cardiac rehabilitation, its main components, and when to start it.
British Heart Foundation. www.bhf.org.uk/heart-health/living-with-a-heart-condition/cardiac-rehabilitation.
Information on cardiac rehabilitation programmes and how they can help prevent a heart
attack and cardiac surgical interventions. Also has a video clip.
Healthtalkonline. www.healthtalk.org/peoples-experiences/heart-disease/heart-attack/cardiac-rehabilitation-support,
www.healthtalk.org/peoples-experiences/heart-disease/heart-attack/topics#ixzz3lzyXycCp.
Text and personal stories on film from UK patients who have had a heart attack. Has
stories from 37 people (including four carers) in their own homes.
NHS Choices. CHD Dave’s story: high cholesterol. www.nhs.uk/video/Pages/chd-high-cholesterol.aspx?searchtype=Tag&searchterm=Heart_vascular.
A video in which Dave shares his battle with his cholesterol levels and talks about
how he got to where he is now, successfully managing his condition.
NHS Choices. Coronary heart disease-recovery. www.nhs.uk/Conditions/Coronary-heart-disease/Pages/Recovery.aspx.
Information on what to do after having heart surgery or problems such as a heart attack
and how it is possible to resume a normal life.
NHS Choices. Heart attack: real story. www.nhs.uk/video/Pages/heart-attack-mike.aspx?searchtype=Tag&searchterm=Heart_vascular.
An account of how a man who is nearly 60 has survived three heart attacks. He explains
how the attacks affected him and how his recovery was different for each of them.
NICE information for the public. www.nice.org.uk/guidance/cg172/ifp/chapter/Helping-you-recover-from-a-heart-attack#/your-cardiac-rehabilitation-programme.
Patient information based on the latest NICE guidance on cardiac rehabilitation and
includes information on exercise and sessions covering a range of topics including
health education and information. Also encourages partners or carers to be involved
in cardiac rehabilitation.
Cardiac rehabilitation—a personal view from Philip Boorman
I am a 65 year old retired air traffic controller, and had been treated for hypertension
and high cholesterol since 1998. I had experienced mild chest pains in the past, which
I could always walk through, but more severe pains in December 2014 led me to seek
advice from my general practice, which resulted in a referral to the Fast Track Chest
Pain Clinic. Ironically, while I was waiting for my outpatient appointment, I experienced
a bout of more severe pain at home and was rushed to hospital, where I was told that
I had had a heart attack.
Treatment in hospital was first class, and a single stent was fitted. My first contact
with the cardiac rehabilitation team was a home visit by a rehabilitation nurse. She
was suitably encouraging, but the cynic in me thought that she was probably encouraging
to everyone. However, her advice was sound, and I followed it to the letter. Rehabilitation
sessions at the gym started about eight weeks after my heart attack and not only proved
to be physically demanding and rewarding (no stopping for at least 50 minutes) but
also helped to rebuild my slightly flagging confidence. The programme included “teach-ins”
on lifestyle, relaxation, diet, and exercise regimens, and I am extremely grateful
for the opportunity to attend.
Will I have another heart attack? I don’t know, but I do know that cardiac rehabilitation
has fast-tracked me back to a normal life and given me the knowledge that the chances
of another heart attack are greatly reduced. It is also helpful to know that I will
have regular follow up by my GP and see the practice nurse in the cardiac clinic at
least once a year.