Cardiac rehabilitation is shown to be effective for improving morbidity and mortality and reducing subsequent events in patients with varying heart complications. However, researchers at the University of Ottawa Heart Institute (UOHI) contend that cardiac rehab programs do not benefit all patients equally. Those who fare worse are often overweight, obese and severely obese – a fact that researchers say could become a big problem without tailored interventions to meet the needs of the growing number of at-risk patients enrolling in this setting.
In a recently published paper appearing in the June issue of the Canadian Journal of Cardiology, Dr. Tasuku Terada et al. investigate the psychosocial and cardiometabolic health of outpatients who completed a three-month cardiac rehab program at the UOHI, one of the largest and most advanced programs in Canada. The medical records of 582 outpatients were included and analyzed. Body Mass Index (BMI) scores were recorded at the start of the program. Patients were categorized as either “normal” weight (117), overweight (264), obese (126) or severely obese (75).
"[...] we sought to determine whether patients with varying BMI experience the same benefits from cardiac rehabilitation in terms of their psychosocial and cardiometabolic health."
- Dr. Tasuku Terada, Postdoctoral Research Fellow, UOHI
“Specifically, we sought to determine whether patients with varying BMI experience the same benefits from cardiac rehabilitation in terms of their psychosocial and cardiometabolic health,” explains Dr. Terada, a Postdoctoral Research Fellow working in the Exercise Physiology and Cardiovascular Health Laboratory at the UOHI, and the paper’s lead author.
The investigation found that when measured at baseline, patients with severe obesity had lower Physical Component Summary (PCS) scores when compared against those with “normal” BMI. PCS is a multi-item measure used to evaluate a person’s health-related quality of life based on their physical function, role limitations caused by physical problems, bodily pain, and general health. Similarly, patients with severe obesity experienced elevated levels of anxiety and depression, higher glycated hemoglobin A1C and triglycerides, and lower high-density lipoprotein cholesterol. Higher rates of chronic pain at baseline were also reported in these individuals.
“This data tells us that patients living with obesity and severe obesity are entering the cardiac rehabilitation setting with worse psychosocial and cardiometabolic profiles than those with lower body mass index,” says Dr. Jennifer Reed, a Scientist in the Division of Prevention and Rehabilitation, and Director of the Exercise Physiology and Cardiovascular Health Laboratory at the UOHI. “This means they are at heightened risk for subsequent cardiovascular events.” Dr. Reed is the paper’s senior author.
What’s more: after completing the three-month cardiac rehabilitation program, despite achieving a greater percent of weight reduction, patients with obesity and severe obesity were found to have made smaller gains in their PCS scores when compared to patients with lower BMI.
Terada and Reed conclude from their research that patients would benefit from enhanced care in the cardiac rehab setting.
“We’re only going to see the magnitude of this problem increase,” Reed says. “We’re going to see more and more patients with obesity and severe obesity enrolling in cardiac rehabilitation programs each year. Psychological health will continue to be an issue for these patients. This means we need to be thinking more about the programs we offer for patients who are obese and severely obese. The status quo is not enough.”
In its June issue, the Canadian Journal of Cardiology also published an editorial which supports these conclusions. In it, the authors call for the critical improvement of Canadian cardiac rehab programs.
“The article is a strong reminder that individuals with obesity who undergo cardiac rehabilitation are faced with the struggle of overcoming two comorbid chronic medical conditions and might require a greater level of individualized treatment to optimize recovery and longevity,” the editorial reads. “The results by Terada et al. make it abundantly clear that a single approach to cardiac rehabilitation will not work similarly for every patient. Rather, efforts should be made to move toward the precision treatment of cardiac patients by providing interventions that are individually tailored to the patient’s unique risk factor profile and preferences.”
Reed agrees.
“We need to spend quality time with patients, it’s important we ask them what physical activities they would enjoy and continue doing,” she told The Beat. “Given their physical concerns or limitations, there are certain activities these patients are going to be more comfortable with than others. When it comes to physical activity for heart health, ‘Some is better than none, and more is better than some.’ ”
Terada adds: “We cannot simply keep prescribing the same recommendations for everyone and expect they will improve similarly. If you look at the data, it is clear that this just isn’t the case.”
Both Terada and Reed say a focus on stronger, tailored interventions to encourage healthy lifestyle behaviours such as regular physical activity and healthy eating strategies after cardiac rehab is a step in the right direction. The Heart Institute’s Prevention and Wellness Centre has published a number of tools and resources on its website, including a physical activity guide for patients in cardiac rehabilitation, and tips for healthy eating.
“Patients come in all shapes and sizes,” said Dr. Terada. “We need to be doing more to ensure the future of cardiac rehab does too.”