Web Exclusives

Heart Attack Survivors Not Referred for Needed Rehab

By Jamie Santa Cruz

Fewer than one in five heart attack survivors receive the recommended cardiac rehabilitation, despite the known value of physical activity.

Current guidelines strongly recommend that patients who have survived a heart attack begin moderate exercise within two weeks after the event.1 New research from Columbia University, however, shows that fewer than one in five survivors are actually getting that needed activity.2

Previous research has suggested significantly higher rates of physical activity among heart attack survivors, but these findings were based on self-reports, which are known to be unreliable.3,4 In the new Columbia study, by contrast, researchers made use of research-grade, wristwatchlike activity monitors to collect objective measures of activity in 330 heart attack survivors during the first month after their hospitalization.

"We know that physical activity is one of those most important health behaviors for lowering cardiovascular risk," including the risk of a second heart attack, says Ian Kronish, MD, MPH, FAHA, an assistant professor of medicine at Columbia and lead author of the study. But patients are apparently not internalizing that message. Although the percentage of survivors who were achieving the recommended amount of activity increased during the five weeks of the study period, only 16% met the guideline in the end.

Exercise guidelines for patients following a heart attack mirror the guidelines for adults in general: the American College of Cardiology and the American Heart Association recommend that patients begin getting at least 30 minutes of moderate aerobic activity five days or more per week within two weeks after an acute coronary syndrome.1

Many people may actually think they are getting that much, says Jeff Goldsmith, PhD, an assistant professor of biostatistics at Columbia University and a coauthor of the study, which could help to explain why self-reports of exercise have been higher. But the new findings suggest that patients' sense of their own activity level isn't accurate. "People have a tendency to either overestimate or to shade their recollection in the direction they think is the preferred answer," Goldsmith explains.

Patient Characteristics Don't Explain Activity Level Differences
As to why so few patients are meeting the guidelines, current answers are largely speculative, according to Goldsmith. The researchers looked to see whether there were any patient characteristics that could explain which patients were more likely to exercise than others, but none of the factors they considered, including age, BMI, and preheart attack health, proved predictive. "There's not a whole lot here to suggest who is more likely to meet these guidelines," Goldsmith says.

In the past, pain resulting from catheterization could have been a factor that would have discouraged patients from beginning exercise soon after an acute coronary syndrome. However, it likely does not explain the findings in the new study, according to Kronish. The researchers checked to determine whether patients who had had a cardiac catheterization were less likely to exercise, but catheterization turned out not to be predictive. Pain could be a factor for some individual patients, he says, but it appears not to be the primary driver of the low activity rates observed in the study.

One factor that could be relevant, Kronish says, is how active patients were prior to their heart attacks. In the new study, it is not clear how much exercise patients were getting before their hospitalizations. It is possible they had previously been sedentary—a lifestyle that put them at risk for the heart attack in the first place—and they simply continued the sedentary lifestyle after discharge.

Do Patients Fear Exercise After a Heart Attack?
Although preheart attack activity level could explain some of the findings, Kronish suggests that another factor is likely in play: patients' fear of exercise. In previous decades, he says, heart attack patients used to be put on bed rest in the hospital for six weeks or longer, and patients may continue to have the impression that being active is dangerous. The evidence is only anecdotal at this point, but in his own primary care practice, he says it's common to hear patients express fear about triggering another heart attack.

There is some small basis for this fear, according to Paul D. Thompson, MD, director of the department of cardiology at Hartford Hospital and a clinical professor of medicine at the University of Connecticut Health Center, who was not involved in the new study. Previous research has shown that there is a slightly higher risk of heart attack and sudden death during exercise.5 But in the end, Thompson says, the benefits far outweigh the small risks, since the risk of a heart attack drops significantly in the hours outside of exercise.

Kronish agrees that activity is not something about which patients should worry. To avoid a danger zone, patients shouldn't immediately launch into marathon training after an acute coronary syndrome, but moderate activity is not of concern. "Patients' fear about it is completely out of proportion to the risk," he says. "It's not like it's zero risk, but the risk is so small and the benefits are so much greater that we recommend that people get back to physical activity right away."

Physicians Undervalue Physical Activity
Although part of the explanation for failure to meet activity guidelines likely lies with patients, physicians probably also play a role. Specifically, Kronish says, many physicians are not communicating the importance of exercise to patients. "We tend to emphasize the need for taking medications—especially if people have stents put in. … I don't think we spend as much time educating and advising patients how important it is to either begin or resume regular exercise. We're biased toward emphasizing medication over other health behaviors that are really important," he says.

Part of the reason for this bias is that medical schools provide little training on exercise, meaning that physicians may not be comfortable advising patients on the topic. And there are no spokespeople available to champion exercise to physicians after they leave medical school. "Every day there's somebody who tries to get in my office to tell me about a new medicine and how to use that new medicine," Thompson says. "But there's nobody to go out there and push exercise. There's no exercise salesperson that comes into my office and tells me, 'You know, you really ought to send your patients to get cardiac rehab.'"

Perhaps in consequence, many physicians don't refer their patients for exercise-based cardiac rehabilitation. Previous research has suggested that referral rates fall under 20% for women and older patients, who are less likely than men to be referred.6-8 Without a referral, "most patients don't know what to do," Thompson says.

Barriers to Cardiac Rehabilitation and Future Possibilities
Unfortunately, even when physicians do refer patients for cardiac rehabilitation, several barriers—especially the barrier of inconvenience—may prevent patients from fully taking advantage. Since going in person to a rehabilitation center may mean patients often have to travel a long distance multiple times a week, the effort may appear too great.

Fortunately, new technology will likely soon obviate this particular barrier. With the advent of wearable activity monitors such as Fitbit, Goldsmith explains, there is now the possibility that rehabilitation specialists could monitor patients virtually and offer counseling over the phone or via Skype, increasing convenience and accessibility. Although such programs remain in the future at this point, Goldsmith says there is "big interest in developing new kinds of interventions."

Advice for Physicians
For now, Kronish says, the main takeaway for physicians is to spend more time discussing the significance of exercise with heart patients and addressing potential misperceptions and fears. "Given the low percentage of patients who were exercising, physicians should assume that few of their patients are exercising and that all of their patients would benefit from some discussion about the patient's views about physical activity."

Some patients may struggle with how to make an exercise program a reality in their daily lives, Kronish says, so physicians should engage in what the counseling field would refer to as "action planning"—essentially, working together with a patient to find out what would make sense for that individual. This might include discussions of various types of activity options, best times of day to do them, and whether there is anyone the patient can recruit as an exercise partner, such as a spouse, a child, or a friend.

Regarding the type of activity to recommend, Thompson says patients should generally focus on moderate aerobic activity, such as brisk walking. More vigorous exercise such as jogging is also safe for most people, but vigorous exercise merits a discussion with a cardiologist to ensure the activity's safety. It's worth noting that excessive exercise doesn't necessarily bring more benefit. According to Thompson's own research, people who engage in heavy exercise after a heart attack typically did not do as well as those who opted for only moderate exercise.9 "Just looking at epidemiologic data, you get the most out of doing some; you get diminishing returns as you do more and more," he explains.

Finally, Kronish says, physicians should be sure to bring up the topic of exercise again in subsequent visits. "Following up with patients to ask them how they're doing and giving them feedback over time [lets] the patient know it's something you view as important—important enough to bring up again in a follow-up visit," he says.

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

1. Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;57(19):e215-e367.

2. Kronish IM, Diaz KM, Goldsmith J, Moise N, Schwartz JE. Objectively measured adherence to physical activity guidelines after acute coronary syndrome. J Am Coll Cardiol. 2017;69(9):1205-1207.

3. Murphy BM, Worcester MU, Goble AJ, et al. Lifestyle and physiological risk factor profiles six weeks after an acute cardiac event: are patients achieving recommended targets for secondary prevention? Heart Lung Circ. 2011;20(7):446-451.

4. Prince SA, Adamo KB, Hamel ME, Hardt J, Connor Gorber S, Tremblay M. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J Behav Nutr Phys Act. 2008;5:56.

5. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.

6. Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2002;105(14):1735-1743.

7. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001;345(12):892-902.

8. Perk J, Veress G. Cardiac rehabilitation: applying exercise physiology in clinical practice. Eur J Appl Physiol. 2000;83(4-5):457-462.

9. Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol. 2016;67(3):316-329.