Heart failure

Cardiac rehabilitation for heart failure

People with heart failure may be referred for cardiac rehabilitation. Rehabilitation programmes are provided by specialist staff. A cardiac rehabilitation programme (also called Cardiac Rehab) usually includes the following basic areas: supervised exercise sessions, education and relaxation and emotional support. The goals of cardiac rehabilitation are to help people regain strength, to prevent their condition from worsening and to reduce their risk of future heart problems.

We asked Helen Jackson, Advanced Nurse Practitioner in heart failure, to help explain cardiac rehabilitation programmes for people with heart failure.

Brian explains how his referral to a cardiac rehabilitation programme came about.

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Age at interview: 76

Sex: Male

Age at diagnosis: 70

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I’ve seen Dr [name of GP] regularly who’s prescribed medication and I have a chat with him now and again and I think it must have been about three or four months ago, I talked to him about my physical, my lack of physical activity, is there anything I can do? And he has put me in touch with an outfit, I think run by the local hospital in [name of town] whereby they do exercise programmes for heart patients. Now the other patients in that group have other problems; coronary problems, and they’ve had by-pass operations and that sort of thing.

I’m in this group of about ten or twelve patients because of my heart failure [clock chimes] and there’s a couple of nurses and a couple of guys who are expert PT instructors and they can work out a programme which is just appropriate to your personal condition and I’m going there twice a week at the moment and I’m getting a bit of exercise under very close supervision because they want to avoid the patient getting any distress overdoing it a bit and in my case, overdoing it is very easy . But I am already, after just a few weeks beginning to feel some benefit.

Helen, a specialist nurse, talks about cardiac rehabilitation programmes available for heart failure patients

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Sex: Female

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If people have cardiac problems that require the defibrillator they will be plugged into a cardiac rehab service and the cardiac rehab service generally focus on the lifestyle side of things: So how to keep your heart healthy; How to reduce the risk of a further event, whatever that might be whether it’s been a heart attack or just a heart rhythm problem.

So the cardiac rehabilitation service is for patients who have come into hospital with a cardiac event and they would like further information and support about keeping their heart as healthy as possible. So it varies across the country as to what service there is but in our local area we have education sessions that run. So that is coming to a group session and listening to people giving information about keeping a healthy heart. So that could be experts in exercise physiology, so giving exercise and activity advice. It could be a pharmacist. It could be a nurse talking about medications. It could be talking about diet, exercise those sorts of things. So there are those education classes. Those are available usually for people with, who have had heart attacks, heart surgery and heart failure. So people who have devices would certainly be included in that service. It would be available to them. [This is available in Oxfordshire, but access to cardiac rehab for all these groups will vary around the country].

There are also exercise classes that are available. Sometimes they are provided in hospitals. Sometimes they are provided in local leisure centres. So in Oxfordshire there is a hospital-based cardiac rehab class and there are also four leisure centres around the county that provide these exercise sessions. And those sessions are staffed by exercise physiologists so people who have had specialist training in exercise in conjunction with heart disease. So they do know about the conditions and cardiac nurses, very experienced cardiac nurses. They carry with them a full emergency kit so that if any problems should arise with the heart during the exercise programme that they have equipment there to help the patient and get them quickly to hospital if that is necessary.

Ok. So and these programmes are for how long?

The length of the programmes vary but generally they are between 8 and 12 weeks and the ideal is that after that 8 or 12 weeks that the person can be introduced to someone who can carry on with their lifelong exercise programme based in local gyms and that is referred to as Phase 4 cardiac rehabilitation.
Phase 3 cardiac rehabilitation is where someone has had an admission to hospital with a cardiac problem and then they are starting a rehab programme based on that.

Rehab programmes vary; some specialise in heart failure, others are more general and will include people with heart failure as well as those recovering from heart attack or heart surgery. There are hospital-based rehab classes as well as classes organised in leisure centres. Cardiac rehab classes are also held at GP surgeries, community centres and residential homes. Community-based cardiac rehabilitation classes should be run by a trained instructor, who has experience of running exercise classes for cardiac patients.

Brian talks about the care he gets during exercise sessions and his trust in the staff’s expertise.

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Age at interview: 76

Sex: Male

Age at diagnosis: 70

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Well they’re checking blood pressure and pulse. And while you’re exercising they’re continually going from patient to patient, talking to them to make sure they can talk. Apparently, when you exercise in this condition you know, feeling a bit of fatigue, bit of breathlessness is normal and what, what they actually want to achieve but there’s a point where you lose your breath and you can’t actually speak. Now they want to make sure you don’t reach that stage. So they keep coming round saying, “Are you alright?” and you’ve got to talk to them and if they detect any struggling to speak then they, they’re assuming that you’ve done a bit too much and slow you down.

Were you apprehensive?

No, not at all actually I suppose I’m one of these fortunate people in that, trust me I’m a doctor is not a joke to me. I trust people who have expertise. I mean I used to have some expertise myself, you see [laughs]. Not in medical matters but in other things and I do, I simply trust them, you know, they they’re expert in, in what they’re doing and it would be silly for me to have any doubts about their ability or their commitment to what they’re doing, they’re very committed and, and very helpful.

Specialist nurse Helen explains that cardiac rehabilitation exercise programmes are individualised and tailored to people with different heart problems

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They [exercise programmes] are very individualised?

Very and the exercise programme, perhaps exercise is not quite the right word in a sense because for some people if it’s a young person that a heart attack has happened to that it may be very appropriate for them to be running on a treadmill or cycling very hard in the gym with the team helping support them gradually increase what they are doing with the knowledge that they have people who understand their condition around them and can deal with anything that might happen and that it is safe prescription of exercise. But also there might be people in that class who have quite severe heart failure and can just about manage to potter around the house. But it is still appropriate for them in some situations because the exercise programmes are very tailored to the individual. They might only be able to manage seated exercise but even so it is still worth doing because it will help keep upper body strength and general movement ability. It is very important to keep mobile when you are very debilitated with heart failure. So a huge range of abilities can benefit from cardiac rehabilitation.

And your nurse can advise the patient?

That’s right. So at each class, the class begins with a check-in with the person. ‘How are you today? What’s been going on with you for the last week?’ and/or however long it’s been since their last session. Checking their blood pressure, their pulse and generally seeing whether they feel that they are suitable to exercise today. If not it might involve contacting the GP with the patient’s permission if they think that medication changes might need to happen. So it’s a really useful check on how they are doing as well as a useful exercise facility.

Those who had experienced cardiac rehab generally felt it was worthwhile, though some remarked that those with heart failure were usually outnumbered by people who had had heart attacks. Several people went to exercise and relaxation classes once or twice a week and one woman described a relaxation technique called 'stop, drop and flop' she had learned in class. Several people said that rehab classes had been important to them in the beginning and had helped them understand more about heart disease.

She describes her cardiac rehab programme which includes a session of relaxation.

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Age at interview: 69

Sex: Female

Age at diagnosis: 67

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I do also go to the hospital every week, twice a week on a Tuesday and a Friday for exercises, and that's through the Cardiology Department Rehabilitation, because I had a session of rehabilitation after my illness was diagnosed at my local hospital and that went on for 7 to 8 weeks and a spin off from there was that I had to carry on with exercises, and that is controlled... with a nurse, who is aware of each one of our conditions and our shortcomings and she knows I have low blood pressure and I can keel over, so she stops me doing certain exercises in case I land flat on my face! But its all very reassuring and very good, if you can make the effort to go to the hospital or to a gym or wherever you have to go to, and do the exercises twice a week you know for an hour each time, it's very good and you feel better for it.

Yes I do feel tired. I do feel tired quite easily. I don't know whether its just that I'm getting older... next year I shall be 70, so I think maybe that's my you know... something I should accept and think well why shouldn't I feel tired, I've got every right to be tired (laughter), you know I should sort of just sit down and pick up the paper or just have a snooze. Part of the... weekly exercise we do at the hospital, they tell us we should have half an hour each day of doing nothing what they call it 'stop, flop and drop', and absolutely unwind and its stop, flopping and dropping. It does the trick. So I say to myself, well come along, just do that then and I've got half an hour and put everything out of your mind and it really is magnificent because you do unwind and you feel sort of a new life and rejuvenation and you feel you can carry on the rest of the day what you have to do so its important. So I do feel tired, and then I think well I should 'stop, drop and flop' and it works.

She describes the rehabilitation programme at her hospital.

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Age at interview: 68

Sex: Female

Age at diagnosis: 48

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And we're fortunate enough at our hospital to have a cardiac rehab department where patients go for 7 weeks. There's 2 sessions a week, 14 sessions in all. 7 sessions in all but it's divided into 14 different sections and everybody who comes away from that has a handout, details of all sort of things, you know, lifestyles and risks, health risks. It's a long time since I've been so I don't know quite what they do now but when I used to help out there we even used to have a bread-making morning, which was great fun because not only was it getting you motivated but it was social as well. That was very good. But they do an hour's exercise and then an hour lecture and as I say, everybody that comes out from a lecture has always got a handout.

Brian explains that his cardiac rehabilitation programme includes circuit training, a gym session and relaxation.

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Age at interview: 76

Sex: Male

Age at diagnosis: 70

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So, what type of exercise have you been given?

Well, I suppose two types mainly. One is what they call circuit training where you move from station to station approximately one minute per station and at each station you do a different level of exercise. Now some of it is using weights which for the fitter people are like up to 5 kilos and for somebody like me at the beginning, maybe just 1kilo. Some of the exercises involve bending and stretching, some of them involve running or walking on the spot, but what you do is you move from station to station, a different exercise every minute and you’d start off with about eight of these and then they gradually build it up week by week until you’re doing about twelve.

OK

And the other form of exercise is in the gymnasium where you operate a treadmill and also a bicycle. The advantage of those two pieces of equipment which never having been in a gym in my life before, I didn’t know but they can be set at different levels appropriate to the person who’s operating them and I started at what I assume was the bottom level for about six minutes and after only two or three weeks, I’m now up above that level. I’m now able to operate those machines for nine minutes whereas initially I was exhausted after six. I can now do it for nine at a slightly higher setting. So I’ve had quite a bit of benefit. But those are the two types, circuit exercises and gym, two items in the gym.
Sounds quite a lot

And it takes two hours by the way because in between you have warming up exercises, cooling down exercises and also a lesson in how to relax, which isn’t very helpful to me, I can’t relax [laughs].

As Robert explained, socialising with fellow participants could be as much of a benefit as the supervised exercise. Some who had completed a rehab course had then paid to join the gym to keep going. Not everyone stayed the course; one man said he had only gone once but felt it had given him hope to hear what others had achieved. Another person said that even though he didn't go to classes he sometimes called in to see the rehabilitation nurse at his local hospital or rang her for help and advice.

Robert started cardiac rehab 24 years ago; he has since joined the gym and attends on the same day as the rehab classes so he can socialise with the other people.

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Robert started cardiac rehab 24 years ago; he has since joined the gym and attends on the same day as the rehab classes so he can socialise with the other people.

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Age at interview: 73

Sex: Male

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But we also have a heart rehabilitation group, which means that you go to the gym. And I’ve done that since 1991. And now, I do my own thing, but when I first started it was done by a retired GP and a nurse who used to take your blood pressure before the exercising, give you a set of exercises to do, and then take your blood pressure at the end. That doesn’t happen now. And that was when, officially, the GP, the heart, the heart group did part four of the rehabilitation course, after my heart attack in ’91. Now they don’t do that. It’s done by professionals at the hospital or somewhere around, from the hospital, because they have, they have rehabilitation nurses. And you go through a system of four stages, I think. So now, I mean I just go to the gym and I know what I can do and what I can’t do. And it’s, it’s mainly things like walking on the treadmill and a little bit of weights, exercising the tummy, things like that. You know, cycling, general things like that really. Do about an hour and a half. That’s sufficient.

That’s fantastic. And how often, how many time a week…?

Twice a week, at least. I can go as many times as I like, ‘cos I’ve joined the gym now. We’ve all joined at a special rate because we are heart patients…

Right.

…which is nice of them.

Yeah.

And although I do tend to go on days when they’re there, the rest of them, so we can all meet socially at the gym as well, [laughs] chat about things.

Roger joined a gym after he finished the cardiac rehab programme but has since left to save money and walks instead.

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Age at interview: 68

Sex: Male

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Well, basically it’s just doing lots of exercises without straining too much, you know, treadmill stuff, that sort of thing and bikes. I was in there for about, just over an hour a day when I was in there, which was all right. But it keeps you fit. So but the only problem with that is, is getting to the hospital. It’s a bit of a pain; the parking and that is a problem. Yeah, I did once that one finished, I did start to go to the gym. But, I thought, well this is silly, because I am paying nearly four pound a time just to go on a treadmill. I might as well go for a walk. So I didn’t, I done it a few times and then I thought, no, no, I will go for a walk, which is what I do now.

Not everyone who wanted it was offered cardiac rehab; for instance a woman who was recovering from surgery thought that rehab and some form of home-based follow-up would have helped improve her confidence. Another woman was told she was unsuitable for rehab, which had made her very angry at first until nurses explained exactly why. Later she joined a local patient support group and found it extremely helpful (see ‘Support groups’).

She felt she needed some follow-up and rehabilitation to help her manage her heart failure at home.

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Age at interview: 59

Sex: Female

Age at diagnosis: 55

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I think as part of the follow-up programme someone perhaps that could come and see you at home and just see how you're managing and just sort of how it's affecting your daily life.

You know, not just the physical but the traumatic effect it's had on you and what it's actually done to your confidence, because that's the big thing. It does just knock your confidence for six... you know, in just doing simple, everyday things really.

I had a really bad experience about, it was a couple of months after, it may have been longer, a few months after I'd had it done. One Saturday morning my husband was out and I was feeling really well and I am quite hard working when I get going, and I'd decided to do something like clean the car, do the windows and do something else. And at lunchtime I felt terrible, my heart, my pulse rate had gone up mad and I was just feeling really ill and didn't quite know what to do really. It was really sort of panicky and in fact we did go, we got an emergency appointment with the GP, who in fact, wasn't my regular GP who actually just sort of sent me home really and told me to stop one drug. In fact on reflection I should have gone and had an ECG at the hospital, I think.

But it would have been nice to have somebody I could have, that perhaps knew a bit more about heart disease that I could have called. I mean what I did have as support because there wasn't a rehab programme in my area, was I knew there were 2 local ones and I was given the phone number of one of them and I did actually ring that number twice. The first time about, I was still really worried because I was painkillers after 6 weeks and as I said before, I don't like taking tablets so I was really worried that I was getting hooked on these, but I mean that was great because I was greatly reassured that it is still going to be painful for some people, you know and you need to take them for as long as you're getting the pain so don't worry, continue to take them.

And the other thing I rang up about is when I did start going to a gym was to ask about my pulse rate and how high could it go? And they were really good because they actually got hold of the person that was able to work that out for me, and she rang me back and said you know you can go between these levels. So it was there, distantly something by the phone. But it would be quite nice to have something in the area that you know was much more easily accessible, that you could either get to easily by bus or car or that they would come out. I think that would make quite a difference to the healing.

Last reviewed April 2016.
Last updated April 2016.