Outcomes from a Multi-disciplinary Cardiac Rehabilitation Programme: Are Angioplasty Patients Addressing Lifestyle Chan

1. Outcomes from a Multi-disciplinary Cardiac Rehabilitation Programme:Are Angioplasty Patients Addressing Lifestyle Changes? Eve Scarle, Mark Giles, Maggie Gallacher, Julian Bath, Julia Harrison, Alison Anderson Gloucestershire Cardiac Rehabilitation Service Gloucestershire Hospitals NHS Foundation Trust

2. Background • Death rates from CHD have fallen by 44% in those under 65 years old (1) • 2.6 million people in the UK living with CHD (1) • Growth of RACPC and interventional cardiology • 6,000 PTCA in 1982 increased to 54,000 in 2003 (1) • NSF for CHD (2000) (2) “Once Trusts have an effective system recruiting people who have survived an MI or undergone surgery to a high quality cardiac rehabilitation, they should then extend their rehabilitation services to people admitted to hospital with other manifestations of CHD”. (Chapter 7:4)

4. Rationale • Limited studies on first time PTCA patients with no history of MI • May feel cured by the procedure or less sick than other CHD patients- motivation to change • Evidence suggests 30-40% of individuals experience recurrent angina or a cardiac event by 2 years (4) (5) • Less compliance to behaviour changes when compared to CABG patients (3) • Low levels of CR participation (0-10%) (6) and twice as likely to drop out (7)

5. Method- Comparative Study Initial sample- baseline data n=1387 MI n=936 CABG n=285 PTCA n=166 CR programme Accepted and attended n=590 Completed initial questionnaire and attended 7 weeks rehab Measures- IPQ, SF-12, HADS, Self-efficacy, Risk factor profile Dropped out of CR Programme 13% Follow-up of patients at 6 months post cardiac event completed second questionnaire

6. Cardiac Rehab Programme • Seven sessions for two hours • Multi-disciplinary • nurse, physiotherapist, psychologist, dietitian • Exercise and education component • Based around cognitive behavioural model • Two follow-ups at six months and one year post cardiac event

7. Results • Attendance • Quality of Life (SF-12)- physical and mental • Anxiety and Depression (HADS) • Illness Perceptions (IPQ) • Risk behaviours • Self-efficacy

8. Results • SF-12 • Mental health improved in all 3 groups • Physical health better for PTCA at baseline • Improvements in physical health in MI and CABG group • HADS • Reductions in anxiety and depression scores • Greater improvement in those who had clinically meaningful scores

9. Results • Illness Perception (IPQ) • Increased timeline scores • Patients who accepted their condition to be long-term (timeline) had better diet and exercise self-efficacy scores (8). • Perceiving CHD as chronic may be instrumental in engaging individuals in making long-term changes. • MI thought consequences of illness were more serious • Following rehab PTCA patients had increased consequences scores • CR may facilitate a raising of awareness of the consequences of CHD and enhance motivation to make behavioural changes

10. Results • Self-efficacy • No group differences • Increased SE for stress reduction and dietary changes • High SE scores for stopping smoking and increasing fitness • Risk Factor Modification • No group differences • 80.4% abstinence from smoking at 6 months • Significant increases in fruit and vegetable and oily consumption, and frequency of exercise • No significant improvements in BMI

11. Study Limitations • Lack of control group • No assessment on individuals who refuse CR • Threats to internal validity • Data collection difficult with lengthy questionnaire • Need all answers for each measure at each time point • Data only available up to six months post event

12. Conclusion • No significant differences between three groups in success at CR • CR a worthwhile venture for PTCA patients • PTCA motivated to attend CR and make favourable lifestyle changes • Evidence suggests only 5-10% of PTCA patients are offered the chance to attend CR (6)

13. Future Directions • Long-term follow-up period beyond one year • Investigate individuals that refuse CR • Investigate patient activity levels outside CR • Explore alternative tools for CR • Home programme • Videos/dvds • Evening classes

14. Any Questions?

15. References 1. Heart Stats Website http://www.heartstats.org/ (2005) accessed on the 25th July 2005. 2. Department of Health (2000) The National Service Framework for Coronary Heart Disease, London: HMSO. 3. Crouse, J. and Hagaman, A. (1991) Smoking Cessation in relation to Cardiac Procedures, Amercian Journal of Epidemiology, 134 (7), pp. 699-703. 4. Hlatky, M. Charles, E. Norbrega, F. Gelmen, K. Johnstome, I. & Melvin, J. (1995) Comparison of Coronary Bypass Surgery with Angioplasty in Patients with Multi-Vessel Disease (BARI) , New England Medical Journal, 335, pp. 217-25. 5. Tuniz, D. Bernardi, G. Molinis, G. Valente, M. D’Odorico, N. Mirolo, R. Morocuttl, G. Spedicato, L. & Fioretti, P. (2004) Ambulatory Cardiac Rehabilitation with Individualised Care after Elective Coronary Angioplasty: One Year Outcome, European Heart Journal Supplements, 6 (A), A1-10. 6. Bethell, H. Turner, S. Evans, M. & Rose, L. (2001) Cardiac Rehabilitation in the United Kingdom. How Complete is the Provision?, Cardiopulmonary Rehabilitation, 21 (2), pp. 111-15. 7. Turner, S. Bethell, H. Evans, J. Goddard, J. & Mullee, M. (2002) Patient Characteristics and Outcomes of Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation, 22, pp. 253-260. 8. Lau-Walker, M. (2004) Relationship between Illness Representation and Self-Efficacy, Journal of Advanced Nursing, 48 (3), pp. 216-225. Contact details for further information: escarle@glos.ac.uk eve.scarle@glos.nhs.uk