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This article appeared in The Home News Tribune.
May 6, 2008
Make exercise part of the prescription for congestive heart failure
By Sanjiv Prasad • Correspondent
My patient has congestive heart failure, so his heart is not effectively pumping blood. His body's need for blood and oxygen isn't being met. As a result, he is chronically tired and short of breath. The simplest activities exhaust him. His feet, ankles and legs are swollen, and it's difficult for him to walk.
When I suggest an exercise program as part of his treatment, he shoots me a skeptical look.
"You want me to exercise?" he incredulously asks. "I can't even walk."
His reaction is understandable.
I wasn't suggesting he join a gym or start a rigorous walking program. Rather, I recommended a cardiac rehabilitation program — a program of monitored exercise, nutritional counseling, education and support designed for people with heart problems, including congestive heart failure.
Such programs can be found in hospitals, such as the Nicholas Quadrel Healthy Heart Center for Cardiopulmonary Rehabilitation at Robert Wood Johnson University Hospital in Rahway, or a program can be home-based.
More than 20 years ago, patients who suffered heart attacks were prescribed bed rest, and heart failure patients were told to restrict their activity. But since the 1990s, numerous studies have shown exercise not only is safe, but also beneficial.
In addition to improving exercise capacity and duration, regular exercise training results in fewer subsequent cardiac events and fewer additional hospitalizations. Regular exercise increases stamina and improves quality of life for people with congestive heart failure, or CHF.
Cardiac rehabilitation is good for heart patients and improves their sense of well-being. Yet programs of supervised exercise are underutilized in the United States. The challenge is how to get a person who barely can walk to start a rehabilitation program — and just as important, stay with it.
This becomes especially challenging when Medicare, the federal insurance for the elderly, doesn't cover cardiac rehabilitation for people with CHF.
Scope of the problem
More than 5 million people live with congestive heart failure, a condition in which the heart isn't pumping enough blood. More than 500,000 new cases are diagnosed each year. Heart failure is the reason for 12 million to 15 million office visits each year and 6.5 million hospital days each year. It is the single most costly cardiovascular illness in the U.S., with treatment costs estimated at more than $33 billion.
Heart failure isn't one disease, but the result of a number of conditions, often occurring at the same time. These include coronary artery disease, high blood pressure, diabetes, heart valve disease, disease of the heart muscle itself or the result of a heart defect. A past heart attack that has damaged the heart can result in heart failure.
As a result of the heart not pumping effectively, the body doesn't get enough blood and oxygen. Blood backs up in the veins and fluid builds up causing swelling in the ankles and legs, a condition called edema. Fluid also can build up in the lungs, causing pulmonary congestion.
The signs of CHF include shortness of breath — even when lying down — swelling in the legs and weight gain. Confusion or the inability to think clearly also can be a sign.
The symptoms of CHF — chronic fatigue, exercise intolerance and shortness of breath — make even the idea of exercise a hard sell. Meanwhile, the body compensates by producing certain hormones that over time worsen their condition. We can decrease these harmful effects with beta blockers, diuretics, inhibitors and exercise.
Benefits of exercise
If exercise is so beneficial, why aren't all CHF patients exercising?
Perhaps it's because physicians don't recommend cardiac rehab to their patients. Sometimes physicians are so focused on medication, they don't remember to strongly recommend it. Patients' attitudes about exercise and changing their lifestyles also play a part.
Reimbursement is another factor. Current Medicare policy covers supervised rehabilitation for patients with a recent diagnosis of a heart attack, coronary bypass surgery or stable angina pectoris. But it does not cover rehabilitation for a diagnosis of CHF, so many would have to pay out of pocket — which can be about $15 per hour — for a program three times a week, or about $17 a monitored program.
That can add up. But with a physician's guidance, a patient can create his or her own home-based exercise program.
Exercise keeps a CHF patient out of the hospital and improves quality of life. If a patient can't join a supervised cardiac rehab program, a guided exercise program should be part of the prescription.
Sanjiv Prasad, MD, FACC, is a cardiologist at Robert Wood Johnson University Hospital in Rahway. He has offices in Clark and Springfield.
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