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FORMAL CARDIAC REHABILITATION PROGRAMS
Following your initial, at-home recovery period of from four to six weeks, your doctor will probably do another treadmill exercise test.
This time he’ll want to push you a bit further, to see just what you can do. You and your doctor will see how well you’ve recovered thus far. And the test will provide a blueprint for the next phase of recovery.
In the past, this would be virtually the end of a planned approach to recovery. You’d be pretty much off on your own, armed only with some vague suggestions for diet, smoking and exercise.
But today you have a marvellous option at your disposal. Hospitals and other medical centres and facilities in virtually every community provide formal programs of cardiac rehabilitation. This is an optional program, and not every doctor feels that it’s necessary. I strongly disagree, hundreds of medical authorities disagree, and I vehemently hope that by the time you finish leading the next few pages you’ll disagree as well. Most importantly, I hope that you’ll opt to get into one of those programs and turn your life around once and for all.
When Dr Albert Kattus suggested the program at Santa Monica Hospital Medical Center, I grudgingly went along with it. He’d given me excellent care both before and after my second bypass, I reasoned, so why not give the program a try, at least for a little while. Even then, I thought that I’d be better off doing things on my own.
My first day was a disaster. I entered the gym and saw a lot of people I just couldn’t relate to. I was only 41 years old at the time, and I preferred to be with those my own age rather than older men and women. Some of them were well into their 70s, walking on the treadmill, cycling on stationary exercycles, working the wall pulleys.
No exercise was planned for me on that first day; rather, I filled out some forms and answered a lot of questions. Boring. Then they asked me if I could come in at 7.45 am, or whether 9.00 am would be better. Well, I thought, I don’t like either time slot. Why not 8.15 so I could sleep a bit later and then get back to the office? But, OK, OK, I’ll come in at 7.45.
My schedule called for Monday, Wednesday and Friday. That meant my first day of exercise would be the following Monday. Come in comfortable, loose-fitting clothes and sneakers, they told me. And with more than a little bit of resentment, I showed up (a little late) at just before 8.00 am. Monday, expecting to do some strenuous exercise.
Well, surprise. I couldn’t do as much as I thought. Electrodes affixed to my chest sent signals to the front desk where the nurses and exercise physiologists could continuously monitor my heart’s activity and rate. My assignment was to bounce up and down on a mini-trampoline or rebounder with handles attached to it. What kind of Mickey Mouse thing was that? But I soon found it was more than enough to get my heart up to the prescribed rate. Then it was on to the bicycle, and a little time on the treadmill. Of course there was also time for stretching exercises, something I’d really never done before, rather stupidly putting up with aches and pains instead. Oh, and I had to keep an ongoing, daily record including the date, time, resting heart rate, kind of exercise and rate reached, final resting rate after exercise, and any comments. I did not want to do that. But I did.
The amazing thing was that there I was, doing what I considered pretty wimpy things, while those grey and bald-headed men and women were doing a lot more than I could. In fact, the closer I looked, they were doing, in some cases, more than I could have done in the weeks before my bypass. Astounding. I learned that those patients had been at it for a long time, and had simply stayed on at the hospital’s gym after the formal, monitored program had ended. Hm, I thought, if they can do that well, what can I achieve if I really put my mind to it.
That was the turning point. For the next 12 weeks, I faithfully attended every session. Almost miraculously, my progress skyrocketed. In fact, I’d be walking on the treadmill or cycling and one of the nurses would shout, “Hey Bob, step it up a bit more.” Here I was, doing as much as I thought I should, and they told me I could do more. So I did, knowing confidently that they knew what they were doing and that if anything happened, they’d know what to do. After all, they were looking at my ECG every step of the way.
Within a very short time, well before completing the full 12 weeks, I knew that I was exercising a lot more than I’d normally do on my own. I wouldn’t have pushed myself that much. My anxiety would have limited my efforts.
Moreover, I knew that nothing I’d do on the outside was likely to come close to the exertion I was experiencing at the hospital. Bingo! That meant that there was nothing in my life that could cause a problem. During exercise I experienced a number of those “funny feelings” you wonder about: the left arm twinges, the tightness of the jaw and so forth. Since I was “wired” the nurses saw nothing out of the normal ECG, and 1 knew that those feelings were not heart related. So when they happened outside the hospital, I no longer feared them at all. What a feeling of freedom!
I also had the opportunity to attend a number of sessions dealing with topics that every heart patient should know more about, including stress management, diet and cholesterol reduction, controlling blood pressure, commonly prescribed heart drugs and so forth.
Very importantly, I got to know the other patients in rehab, and actually looked forward to working out with them in the mornings. It was nice to have someone to talk with, side by side on treadmills. No one there was trying to compete, or to act “macho” as might be the case in a sports club or gym. Some of those friendships have lasted through the years.
By going through the program I was able to enforce a kind of discipline that I might not have had on my own. I had my appointment at 7.45 each Monday, Wednesday and Friday morning. If I missed that time slot, I was out of luck, since I couldn’t do a “makeup” at other times when other patients were using the equipment. Little by little, it became routine, a routine I actually enjoyed.
When the 12 weeks came to an end, I decided I wanted (and needed) that kind of structure and routine. So rather than exercising on my own, I signed up for an unmonitored program whereby I came in as usual, but without the electrodes on my chest. Again, it was about an hour three times weekly, with some extra walking or cycling on the weekends. I thought I’d do that for just a few extra months.
But then the progress I was making in my increasing level of fitness really kicked in, and I was feeling terrific. Dr Kattus simply beamed when he did my next treadmill test, calling my recovery phenomenal. I wondered if I could do that much in just a few months, what would be possible in a year? So I stuck with it. And continued for another year after that.
Why did I finally leave the hospital program? I found that I wanted to do even more, and I was being limited by the available time slots and the length of time I could work out on any given piece of equipment. It was time to move on, to graduate to an independent setting. I joined a place called Sports Club LA because they had a limited membership, which meant I wouldn’t have to wait in line for equipment. My early habits have stuck with me, and I now make physical exercise my first appointment of the day Monday through Friday, five days a week without fail. But I’ll get into some specifics on continuing exercise and conditioning in the next chapter.
It turns out that the program of cardiac rehabilitation I went through was pretty typical of those available all over the country. The 12-week length is standard, with three hour-long sessions per week. Some concentrate exclusively on the exercise segment, while a large number include educational segments to focus on other lifestyle modifications necessary to achieve total recovery.
There’s a bit of controversy regarding the monitoring aspect. Some programs use the chest electrodes allowing continuous ECG monitoring only for higher-risk patients, while others utilise the system of wireless transmittal known as telemetry for all patients. Personally, having gone through it myself, I’m glad I had the electrodes. They gave me the confidence I needed.
Who’s eligible for entering a cardiac recovery program? Anyone who’s had a heart attack, bypass or other cardiac surgery, angioplasty, or confirmed existence of heart disease with or without the symptoms of angina and claudication. All programs call for an exercise treadmill test documenting the safety of such an approach. We’ll get into the safety aspects shortly, but for now suffice it to say that cardiac rehabilitation is warranted for all heart patients except those with significant damage done to the heart muscle, severe arrhythmias and extremely high blood pressure. As we’ll see, even patients with heart failure have done well. Both men and women benefit, in all age categories.
While doing the research for this book, I visited a number of cardiac rehabilitation programs both large and small. Certainly the size of the hospital, medical centre or outpatient centre will have a lot to do with the level of sophistication that the program can attain. But that’s not always true. Sometimes a very small hospital can set up a very effective and well-equipped approach.
Everyone I spoke with echoed the same thoughts about their patients. The drop-out rate is very low because the participants quickly see the benefits. According to Dr Michael Lawlor, exercise physiologist and Director of Cardiac Rehabilitation and Fitness Programs at the Heart Institute of the Desert in Rancho Mirage, California, almost everyone says: “I’ve never felt better, not just OK, but fantastic!” Barbara Else, RN, director of the rehab program at Cedars-Sinai Hospital in Los Angeles, points out that “the faster we get somebody in, the faster they start to feel good about themselves”.
Dr Lawlor notes that the majority of people just don’t know what it’s like to feel really terrific. “If at one time you were in good physical condition you know what it’s like to be in good shape, to feel great,” he says. “But if you’ve never been physically fit, it’s almost impossible to relate to what it can feel like.”
Virtually all the rehab directors agree on one thing. Once a person gets beyond the first six weeks, no one wants to quit. Time and again, I’ve spoken with men and women at the start of their rehab program and told them how they were going to love it once they got past the first few weeks’ hump. They’d grunt “Yeah, sure.” But then a month later I’d see them again, or they’d call on the phone and say, “Bob, you were right. I never thought I could feel this good this fast!”
But the benefits of cardiac rehabilitation can be objectively measured as well as subjectively felt. Here are some of those benefits:
Counteract the effects of inactivity. There’s nothing that can compare with a structured program to bring back your body’s vigour.
Improve functional capacity. Both your lungs and heart will work more efficiently, reducing the strain on the cardiovascular system. This can increase the level of day-to-day activities you want to participate in without getting tired and with lessened heart symptoms.
Improve cardiovascular efficiency. As your heart pumps more oxygen-rich blood to tissues with less effort, your heart rate and blood pressure begin to come down. The body appears to be more capable of stripping the oxygen off the blood’s haemoglobin, as well.
Increase in collateral circulation. Just as a railroad might lay new tracks around a blockage, your arteries can form new branches around areas of blockage, providing a new supply of oxygen-rich blood to the heart muscle. The more one exercises, the more one begins to see the development of such collateral circulation.
Reduce heart disease risk factors. Sedentary behaviour has, itself, been identified as a risk factor in the development and progression of heart disease. But exercise can also help in efforts to maintain or attain ideal weight, to control blood sugar for those with diabetes, and to regulate cholesterol levels. Not only will exercise help reduce the “bad” LDL cholesterol, but it will also raise the levels of the “good” HDL type.
A number of well-controlled studies both in the United States and abroad have demonstrated the advantages of cardiac rehabilitation. The Journal of the American Medical Association published a review of 10 trials with cardiac rehabilitation and found a 24 per cent reduction in all causes of death and a 25 per cent cut in cardiovascular mortality. These studies involved 2202 patients in comprehensive rehab programs compared with 2145 who were not in programs.
Thus we have the evidence that enrolling in a formal cardiac rehabilitation can actually save your life. In one way, that should be reason enough. But, as mentioned earlier, we have both physical improvements and psychological well-being as bonuses.
As I said, that evidence comes from around the world. A five-year Swedish program found that the incidence of future heart attacks was cut almost in half, and the number of all cardiac events was reduced by nearly 40 per cent.
*69/85/2*

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