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EPIDEMIOLOGY OF HEART DISEASE
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Cardiovascular disease continues to be the leading cause of mortality in the United States for men and women, accounting for one third of all deaths. Nearly 16.3 million Americans have a history of coronary artery disease and 7.9 million have suffered a myocardial infarction. Direct and indirect costs of this condition approach $190.3 billion annually. That is $95.5 billion in direct costs (physicians and other professionals, hospital services, medication, and home health care) and $94.8 billion in indirect costs (lost productivity and mortality). Medical costs for coronary heart disease are projected to increase by 200% over the next 20 years, augmenting the need for widespread availability of cost-effective secondary prevention.
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As cardiovascular disease is a substantial cause of disability, physiatrists must be well-versed in all aspects of cardiac rehabilitation. Numerous analyses of evidence-based medical studies have shown cardiac rehabilitation programs to be a safe and effective therapeutic intervention. These secondary prevention programs enhance quality of life and functional status, improve processes of care, and reduce recurrent myocardial infarction, hospitalization, and long-term mortality. Increasingly, cardiac rehabilitation patients have complex medical profiles; thus the need for physiatry involvement is growing. As medical specialists, physiatrists can contribute their unique knowledge and understanding of comprehensive functional assessment to this large patient population, which is in need of such expertise.
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OVERVIEW OF CARDIAC REHABILITATION
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Cardiac rehabilitation consists of comprehensive long-term services involving medical evaluation, prescribed exercise, cardiac risk factor modification, health education, counseling, and behavioral interventions. Its short-term goals are to control cardiac symptoms, enhance functional capacity, limit unfavorable psychological and physiologic effects of cardiac illness, and boost psychosocial and vocational status. The long-term goals are to alter the natural history of coronary artery disease, stabilize or reverse the progression of atherosclerosis, and lessen the risk of sudden death and reinfarction.
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Indications for cardiac rehabilitation are listed in Table 23–1. Cardiac rehabilitation is considered reasonable and necessary in patients with any of the listed indications within the past 12 months. Additionally, patients with congestive heart failure, sustained ventricular tachycardia or fibrillation, and those who are survivors of sudden cardiac death may be candidates for rehabilitation on a case-by-case basis. Overall, more than 18 million Americans meet the requirements for cardiac rehabilitation.
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Cardiac rehabilitation is divided into three phases:
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