COVID and Cardiac Rehabilitation: Rehab During a Pandemic

By Dr. Uyen Lam, Kosowsky Cardiovascular Rehabilitation and Prevention Center 

Cardiovascular disease (CVD) remains a major public health concern with high financial burden. While overall cardiovascular mortality has decreased with advancement in medical therapies, cardiovascular disease remains the greatest cause of morbidity and mortality in the developed world.  Enserro, et al studied potential causes and found the percentage of patients with ideal cardiovascular health in the past 20 years has declined ¹.

The study was based on the American Heart Association (AHA) Cardiovascular Health (CVH) Score that weighed a person’s BMI, smoking status, serum cholesterol levels, fasting blood glucose, blood pressure, quality of dietary choices, and physical activity level. Of the 3460 studied participants, researchers found decreased presence of ideal CVH scores in the past 20 years. Uncontrolled modifiable risk factors increase the risk of developing CVD ¹.

In the last decade, preventive initiatives such as Life’s Simple 7 and Million Hearts 2022 have been implemented to curb cardiovascular disease. Cardiac rehabilitation (CR) plays an integral role in these initiatives and is paramount to a patient’s recovery after a cardiovascular event. This comprehensive program provides patients with the tools and knowledge necessary to live a healthier lifestyle and improve their quality of life after a cardiac event. Even in the era of modern medicine, CR has proven to reduce cardiovascular related deaths and hospital admission by 20-30% when compared to standard therapy and has been a Class 1a recommendation by the ACC/AHA ^2,3.

Applications to Practice

The Bernard D. Kosowsky Cardiac Rehabilitation and Prevention Center at St. Elizabeth’s Medical Center – Steward Medical Group opened December 2019. As a center of excellence that provides extensive cardiovascular services, the program is crucial to complement the quality care we provide patients. Unfortunately, as the program was expanding, the COVID-19 pandemic surged. Mitigation strategies such asocial distancing measures have had a dramatic impact on all operations resulting in closure of many outpatient practices, moratoria on elective procedures, redeployment of staff, and furloughs. Many CR in the Steward Health family have faced the difficult decision to temporarily suspend operations to protect patients and dedicate resources towards fighting the pandemic.

CR professionals know the value of these comprehensive programs. Suspending cardiac rehabilitative service may also convey a sentiment of patient abandonment. Despite clear data showing positive outcomes, including mental and physical recovery after cardiac event, reduced cardiovascular mortality, and reduced cardiac related admissions participation remains low and has fallen significantly during the pandemic.

Pre-COVID-19, nationally only about 25-30% of eligible patients participate in CR programs ². While the Center for Medicaid & Medicaid Services (CMS) carved out an exception for many practices, CR was excluded from delivery of telehealth services despite data showing home-based CR offered similar long-term outcomes for clinically stable low to moderate risk participants ². Currently 180,000 CMS beneficiaries attend CR. Unfortunately, appeals to include temporary CR services at home by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) have been rejected by CMS.

The Kosowsky Cardiac Rehabilitation and Prevention Center remained open during this time of uncertainty to continue to provide critical support for patients. There is a direct correlation of number of CR sessions attended to improved cardiovascular outcomes.

It is important to capture the initial phase where patients feel most vulnerable. Disruptions in routines impact one’s trajectory toward making positive lifestyle changes that have a lasting health impact. Dr. Joseph Carrozza, Chief of Cardiology and Mr. Jon Gardner, Administrative Director of Cardiovascular Medicine both deemed CR an essential service to our patients and provided full support if uncompromising guidelines were practiced to protect the patients, staff, and community.

According to the AACVPR, approximately 29% of CR programs in the United States remained open during the COVID-19 pandemic ⁵. Patients with cardiovascular disease are at increased risk for developing severe complications from COVID-19. SARSCoV-2 is an unpredictable virus and many patients can be asymptomatic carriers. Several safety measures were taken into consideration with the decision to keep the Kosowsky Cardiovascular Rehabilitation and Prevention Center open.

Figure 1 details our extensive screening questions addressing symptoms, confirmed diagnosis of COVID-19, or direct exposure with COVID-19 patients that are asked prior to every exercise session. Temperatures assessment is now part of routine vital sign measurement for patients before starting their exercise.  All patients and staff are required to wear masks throughout their entire exercise session. A limit of four to five patients per cardiac rehab session allowed enforcement of proper social distancing during both educational activities and exercise. Patients are asked to disinfect equipment with provided sanitation wipes after use, a standard even before the pandemic. Following every session staff will disinfect all common areas of the facility including chairs, door handles, conference room, telemonitors, patient lockers’, and the waiting area. Finally, before patients leave, proper hand hygiene is again reinforced by staff. Patients are reminded to stay home if any of the above symptoms are perceived and will be tested for COVID-19 prior to their return to the program. New enrollees into the program undergo screening but are also COVID-19 tested prior to their first gym session.

During this period of anxiety and uncertainty, positive feedback from patients has reinforced the decision that CR remains an essential form of medical therapy. During the COVID-19 pandemic two new patients enrolled in the program, a third of patients continued to attend religiously, and two patients graduated the program. Patients’ provided the following testimonials as to why they continued to attend CR despite current circumstances.

A new patient shared, “I was referred by my cardiologist due to left bundle branch block.  [Cardiac Rehab] works really well. I feel great after each session and the staff are very professional and knowledgeable. Great place”.

Another stated, “I wanted to get started regardless of the circumstances. I abide by social distancing outside of coming to cardiac rehab and wear a mask.  Once I start something, I like to complete it. I started cardiac rehab 20 years ago and never finished and would like to complete this program. My cardiologist encouraged me to do so.  It is well organized and not demanding”.  

A few previously enrolled patients shared, “I wanted to do something good for myself, I can use the discipline and of course the terrific help”.  “Because I felt my cardiac rehab was beneficial for my general health”.  

Most patients who have continued coming have enjoyed a sense of normalcy that has benefited their physical and emotional health. For those who wished to pause their program during this time, the center offered home based resources and an online exercise class.  AACVPR conducted a survey of program directors.  Approximately 38% of CR centers across the U.S. were offering home based or innovative delivery for their patients ^5,6.  Patients who chose not to attend center-based CR received bi-weekly telehealth calls and offered a weekly virtual exercise class via Zoom every Friday.  Virtual exercise classes included a warmup, strength training exercises using readily available household items, balance and core exercises, and a final cool down with stretching.  Positive feedback was received from participants regarding the virtual classes. Unfortunately, a large portion of elderly patients lacked resources and while interested were unable to overcome technological challenges.

Summary

            Moving forward, the Kosowsky Cardiac Rehabilitation will continue to abide by national and Massachusetts regulations regarding the pandemic. Face coverings and social distancing will become the new normal for our practice until further treatments are available where safety is ensured.  The number of patients per session will continue to be limited with ample time between sessions to allow proper sanitizing practices. New incoming patients will have COVID-19 testing at intake and undergo screening questionnaire prior to each CR session. The pandemic also provides an opportunity for innovation including development of a more robust home-based program and use of mobile phone technology to deliver educational content for those unable to attend CR in person. Having a cardiac event in any circumstance often leaves patients apprehensive about their recovery and their future. Hopefully with these measures in place our practice can continue to provide a safe, healing environment for patients.

Special thanks to Dr. Joseph Carrozza for providing edits.

References

1. Enserro, DM., Vasan, RS., and Xanthakis, V. Twenty-Year Trends in the American Heart Association Cardiovascular Health Care Score and Impact of Subclinical and Clinical Cardiovascular Disease: The Framingham Offspring Study. Journal of American Heart Association. 2018;17:1-9.
2. Thomas, R., Beatty, A., Beckie, T., et al. Home-Based Cardiac Rehabilitation – A Scientific Statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019;140:e69-e89.
3. Suaya, J., Stason, W., Ades, P., Normand, S., and Shepard, D. Cardiac Rehabilitation and Survival in Older Coronary Patients. Journal of American College of Cardiology. 2009; 54:25-33.
4. Virani, S., Alonso, A., Benjamin, E., et al. Heart Disease and Stroke Statistics – 2020 Update: A Report from the American Heart Association. Circulation. 2020;141: e139-e596.
5. American Association of Cardiovascular and Pulmonary Rehabilitation. COVID-19 and Telehealth. 2020, May 18. http://www.aacvpr.org/covid19/telehealth.
6. Malloy, Terri. Six Ways Home-Based Cardiac Rehab Keeps Patients Safe, Healthy during COVID-19. Mayo Clinic, Mayo Foundation for Medical Education and Research. 2020, April 2. newsnetwork.mayoclinic.org/discussion/six-ways-home-based-cardiac-rehab-keeps-patients-safe-healthy-during-covid-19/.

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