Forty years ago if you had a heart attack, the standard treatment was to lie in bed for 6 weeks.
That was the prescription for my father and he chaffed under it. He had the nurses put a board at the bottom of his bed so he could pass the hours pushing against it to keep the tone and power in his legs. He had learned to do that from prior experience.
He had fallen from the top of the barn where he had perched to repair a track and had broken his back. He lay on the barn floor until a neighbour happened by and picking him up, threw him into the back of his truck and drove him to the city hospital. He had spent that summer in a body cast flat on his back and had lost massive muscle tone.
Yet he had stood up, walked and regained his former indomitable strength. He was a carpenter and a farmer and his life was rooted in physical labour. As he described it, in the winters he got soft, put on ten or so pounds all of which he shed once sowing and ploughing began. There was never a suggestion that he would not resume this pattern after his heart attack, nor did he entertain any slowing down of the demands of maintaining the farm aside form maybe expecting a little more help from his daughter.
When you had a heart attack twenty years ago, the expectation of getting out of bed early was a quantum shift in management. But it took Dr. Terry Kavanagh to move it to the next level and actually start a cardiac rehabilitation program after the event in order to make the heart muscle perform better and be stronger and more able to respond to physical demands- in other words, to work. To prove his point he even trained men after their bypass surgeries, treatment had advanced to replacing clogged arteries with clean ones, to run the storied Boston marathon.
Now of course, we put a router through these clogged vessels and brace them with stents and you are out of hospital in less than 2 days.
Ten years ago, we understood the value of a cardiac rehabilitation program in the bigger picture of restoring fitness and thus quality of life to a patient who had had a ‘cardiac event’.
But getting patients to buy into the program, especially the unfit and more especially women was at times a conundrum. We said it was because we had become ‘too soft’ and had lost the edge that having some degree of physical prowess bestows in any adversity. As for women, we said they were often older, sicker and had never attended to their own care needs as much as caring for others and that they remained focused on tending to spouses or grandkids.
So that is why the study in the American Journal of Medicine from Dr. Shannon Dunlay and her crew in Minnesota is so important for all the boomers as they cross the 65 year old threshold.
Dr. Dunlay is a cardiologist whose study follows just under 3000 patients over the past 20 years after they had heart attacks. On entry, which is to say after their heart attacks, the average age was 67 years. But what this study concerned itself with was cardiac rehabilitation – who did it and or how long, and who didn’t, and what changed over time.
It turns out the Minnesota population is a rather good one to look at. They are mostly homogenous, settled, don’t tend to move and have health care.
Because of this the study has been able to follow these patients for an average of seven years and for just under 50 per cent of them until their death.
And here is why this study matters to us.
First the study affirmed that cardiac rehab resulted in reductions of readmission to hospital, not only for heart events, but any event that lead to readmission by almost 25 per cent. Further it showed that there was an amazing 42 per cent reduction in mortality in those who had followed a cardiac rehab program. That reduction in all cause mortality persisted over the 7.6 years that the subjects were followed on average. It may not seem much but remember they were 67 years old on entry.
Even more telling, was who didn’t enter the study. Patients who were admitted to nursing home facilities, often with a lot of other medical issues didn’t enter and more than half of the women didn’t enter. That percentage didn’t change over the whole of the study duration. The number of elderly people attending increased over the time of the study but that was countered by the number of younger people who didn’t.
Current smokers were the only group that showed no reduction in the readmission or mortality data and they were also the group that had 13 per cent who attended less than 5 of the rehab sessions.
The most significant point in this study though is that the participants began their sessions on average between 7-9 days post event. We know in Canada that the average time to enrollment in such a program is six weeks. In Minnesota 76 per cent of the enrollees attended at least one session and the average number attended was 14.
The value of this report serves to underscore not only what we already know intuitively but may point us in the directions where our energies will be most fruitful.
Early is better and the earlier rehabilitation can start – after all there is no smoking in a hospital – the better.
We get people out of bed in a flash after surgeries – why not into a gym to do the walk?
Why not provide women patients with a personal trainer like physio? Wouldn’t it send a different message about self-care?
We are quick and getting quicker about treatment on the fly – as I like to say “Don’t drop your bag you’re not staying” puts us at risk of loosing sight that the event itself is the greatest motivator in changing behaviour.
It is not stents or drugs that will sustain these changes, that is blatantly clear from Dr. Dunlay’s study. It is rather activity, not smoking, mindful diet that will preserve us, sustain us, extend us as upright seniors.
Dunlay, Shannon M. et al. AJM, Vol 127, Issue 6, 538-546. Participation in Cardiac Rehabilitation, Readmissions and Death After Acute Myocardial Infarction.