Rehabilitation for Heart Attack

The key to bringing 'heart' patients back to normal life, therefore, is rehabilitation, both physical and mental. The process should start in hospital, where you are encouraged to be mobile as early after the attack as possible, and to be optimistic about your future physical abilities. Video sessions showing how former patients have recov­ered, and visits from former patients, are extras that many hospitals are now providing.

Within three to four weeks of your attack, or five or six weeks after bypass surgery or angioplasty, you will be introduced to a scheme of gradually increasing exercise, planned for you by your physiotherapist and doctors. The amount you will be asked to do is based on your performance on a careful treadmill or bicycle test, monitored by ECG to assess the extent of any residual heart problem.

If this test finds that your angina is worsening, or that there is a tendency to arrhythmia or heart failure, then you will be sent back for further treatment to your hospital physician. If not, you can start on the exercise program.

The aim of the exertion is to speed up your heart rate to 85 per cent of your 'predicted maximum'. For most people this turns out at around 195 minus your age, so that if you are 50 years old you would expect to exercise enough to raise your pulse to 145 beats per minute. This is not because you should not go further, but because there is no need to; you will achieve as much benefit by keeping under the limit as by going all out.

The kind of exercise matters. It should emphasize movement, rather than power. Coronary rehabilitation groups in Britain, most of which are based in hospital physiotherapy departments, usually employ circuit training. This mixes stationary cycling with stepping up and down, jogging on a mini-trampoline, and a series of arm and leg exercises using light dumbbells.

This variety is important, not only because it helps avoid boredom, but because it spreads the exertion across a range of muscle groups, Timbering up' the whole body for eventual return to work and other activities. Cycling and jogging are popular with some groups, but they all feel that a warm-up with easy callisthenics and a 'warm-down' with a game - preferably non-competitive -leads to enthusiasm for a return visit. The whole session lasts for between 20 and 30 minutes.

You should attend training sessions like these three or four times a week: twice a week is the minimum. At this rate, your fitness will improve very quickly; trying to do more will be of no extra benefit and carries risks of muscle injuries or, if your heart is not quite back - to normal, of inducing arrthythmias.

Each person attending one of these cardiac rehabilitation groups has different needs and abilities. The rule is to start off with very light exercise, and build up over succeeding sessions, increasing the exercise load according to the heart rate from the previous session. Partners such as spouses should be encouraged to attend and join in; this gives them an idea of how much exercise can be done, and may stop well-meaning but overprotective care at home.

For the first three weeks or so, all the exercise sessions must be supervised by a professional. From then on, you will be encouraged to do home exercises as well, on the same pattern, and keeping your pulse rate to that 85 per cent of maximum. The 'circuit' can include jogging on the spot, stepping up and down two steps and swinging 3 kg dumbbells. It should then extend to outdoor walks, of, say, one to two miles (l 1/2 to 3 km), which can be further extended to a jog in two or three more weeks.

The length of most hospital-organized rehabilitation varies from around six to twelve weeks, depending on the resources available and the numbers of patients. It takes about this time to sort out the different needs of those with little or no heart damage from those with need for more care. It also gets the patients used to regular exercising, and to get into the frame of mind that exercise like this is for ever, and not just to get over that particular attack.

Rehabilitation works on several levels. It brings people back to fitness as quickly and pleasantly as possible. It gives them confidence that they can return to a full life - often in a fitter state than they were before their attack. The exercise itself, combined with the new-found confidence, helps to dispel the depression and anxiety that naturally comes with the realization that you have had a heart attack. The new attitudes to life are a bonus, as are the new friends you meet in the group.

The friends are a help in another way. They, like you, will be trying to give up all the bad habits that led to their heart attack. They will be trying to lose weight, to give up smoking, to change their eating habits in the right direction - often all at once. Tension, anxiety and depression all have to be faced, openly. It is much easier to do all this along with others in the same boat than to try to go it alone.

Cardiac self-help groups often carry on meeting long after the hospital has had to wish them goodbye. They become 'self-help clubs' in which they share in their exercise, recreation and friendship. They can be a powerful source of support in times of need.

Many general hospitals provide coronary rehabilitation pro­grammes for their heart attack patients. Dr H. J. N. Bethell, a general practitioner from Hampshire, England, described the one set up by his local hospital, in a British Medical Journal article in 1988 (297, 120). He calculated then that it trained about 100 patients back to health a year, at a cost of £53 per rehabilitated patient. This is less than the cost of half a day in hospital.

These economics must surely be worth it. No hospital should be without a rehabilitation program: if yours has none, perhaps a little pressure on the authorities by the patients and their relatives may help to change their point of view!

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