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Getting On With Life after a Heart Attack

Cardiac rehabilitation, together with supervised exercise and counseling, can cut the danger of death. Nevertheless, fewer than 20% of patients get the therapy.

Americans who have had a stroke or a hip replacement take for granted that they would require a few weeks or months of rehabilitation to relearn speech or movement and to figure out how to care for own selves.

However when people have a major heart problem, usually they leave the hospital with nothing more than a bottle of aspirin and a couple of prescriptions. They get very little training and education in how to eat, exercise, handle stress and otherwise pick up their lives and care for their damaged tickers. A study in the Oct. 9 journal Circulation found that among 267,427 Medicare recipients who had suffered a heart attack or had coronary artery bypass surgery, only around 18% had even one sitting of cardiac rehabilitation within a year of their hospital release.

Approximately 1.2 million people suffer a heart attack every year (roughly 40% of them pass away), and about half a million of them have had a previous heart attack, according to the American Heart Assn. For more than a decade, proof has been accumulating cardiac rehabilitation can lessen the danger of passing away from a second heart attack by as much 30%.

Known as secondary prevention, rehabilitation after a heart attack or other severe cardiac problem is designed to reduce the risk of further heart damage, or even death, while the patient returns to a life as normal as far as possible. It provides heart-strengthening, supervised exercise, together with nutrition and stress counseling and social support.

Moreover, it works. A review of studies in the May 15, 2004, American Journal of Medicine found that patients who had exercise-based rehabilitation for heart disease had greater falls in blood pressure and total cholesterol and lived longer than patients who did not obtain rehabilitation. The American Heart Assn., in a 2002 scientific statement, calls rehabilitation the most excellent way to provide education, counseling and behavioral interventions to reduce future risk.

Medicare and most private insurers pay for rehabilitation therapy. Yet, in most of the country taking in California, fewer than 1 in 5 heart patients receive such services. For some, it is for the reason that their physicians never wrote a referral. Others get the recommendation but never follow through.

Patty Block of Long Beach is one who has decided cardiac rehabilitation is worth her time, despite the everyday jobs of helping to care for her husband, who has Parkinson's disease, as well as her 96-year-old mother. Ever since her Sept. 13 heart attack, she has been going to the Long Beach Memorial Medical Center Cardiac Rehabilitation Center for one-hour sessions three times a week.

She says, "I'm 67, and I'm just not ready to have my heart go out on me now." She's had nutrition counseling and is starting to learn how long, and at what pace, to walk on the treadmill and pedal on the stationary bicycle, all the while hooked up to an electrocardiograph whose squiggly readings are watched by a nurse.

The use of this therapy differs considerably in the United States, according to the latest Circulation study. With only 6.6% of heart patients getting rehabilitation, Idaho has the lowest rate of follow-up therapy in the country; Nebraska, with 53.5% of heart patients getting the therapy, has the highest rate.

In addition, according to the Circulation report, in California, with 29 centers listed with the American Assn. of Cardiovascular and Pulmonary Rehabilitation, only 2,642 of 14,389 eligible heart patients in 1997, the year studied, received cardiac rehabilitation after a heart attack or bypass surgery.

Researchers were at a loss to give explanation on the wide geographic variations in follow-up therapy. Donald Sheppard, an author of the study and professor of health policy at Brandeis University says, "It's recommended more vigorously in some parts of the country, particularly the Midwest." It could be that medical training in some areas promotes prevention more than in other areas, he said, though the study did not address that.

How hard a doctor pushes for rehabilitation is the best predictor of whether a patient will follow up, according to research published in the May 1992 issue of Archives of Internal Medicine? Dr. Philip Ades, director of cardiac rehabilitation and preventive cardiology at the University Of Vermont College Of Medicine, is an author of the Circulation study. He was also the lead author of the 1992 study in which he asked 262 heart patients 62 and older to rate how strongly their doctor suggested cardiac rehabilitation. He says, "If the physician was strong in recommending rehabilitation, 70% of patients participated. If it was a weak recommendation, only 2% participated."

In New York, the recommendation rate to cardiac rehabilitation is around 13%, says Murray Low, director of cardiac rehabilitation at 4 hospitals in New York and Connecticut, and president of the American Assn. of Cardiovascular and Pulmonary Rehabilitation. He says, "Do you realize how outrageous that is? We spend millions putting in stents, bypassing arteries. Then we say, 'See you in six months.' The patient goes home and leads the same lifestyle that led to the problem in the first place."

There are other obstructions to the therapy, says Dr. Randal Thomas, director of the Cardiovascular Health Clinic at the Mayo Clinic. Some patients are not conscious of the benefits of rehabilitation; others see it as little more than a gym membership; and some simply would have to travel too far to reach a center. "The benefits of cardiac rehabilitation are on the same level as aspirin, beta blockers and statins, about a 30% reduction in mortality."

Dr. Henry Van Gieson, a Long Beach cardiologist, says he advices cardiac rehabilitation for nearly all of his heart attack and bypass patients. After a heart scare, he says, "patients start seeing themselves as fragile and vulnerable. When you see a patient in your office a week or a month later, there is no way you can do an adequate job of doing all of the counseling they need. This is a great way to take that first step back to recovery."

One of his patients, Maurice Greeson, 65, of Long Beach makes twice-weekly trips to Long Beach Memorial. He has used up his insurance coverage of cardiac rehabilitation; following bypass surgery in February 2006, but continues the therapy, paying $45 a month himself. Because he has been doing well for more than a year, his therapy is less deeply supervised. He says, "This was a lifestyle change, big time. This place is relaxed and friendly but with underlying professionalism."

Greeson is one of a small percentage of people, who continue rehabilitation long after they have gotten answers to their questions, about how long and hard to walk, what to eat and when they can recommence sex.

Greg Jones, program director of the Long Beach center says, "They feel safe. In addition, it is very social. People make friends with other people who have the same problems they do. You see a patient who might have been depressed. Then they meet some other patients, and there's a different person than walked in here the first day."



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