After a cardiac event, a 2-6 month program called cardiac rehabilitation can help survivors gradually improve their physical fitness, learn about nutrition, meet other heart patients, and get support to quit smoking, lose weight or make other heart-healthy lifestyle changes to improve heart health. Cardiac rehab can reduce mortality by 25-40%, reduces angina symptoms, increases functional capacity, improves lipid (cholesterol) levels, reduces smoking by 25%, enhances psychological well-being, and improves exercise tolerance for all – including the elderly, frail or people with congestive heart failure.
Cardiac rehabilitation really works! We know that completing a program of cardiac rehab can be very effective in reinforcing improved habits. A 2001 University of Calgary research team lead by Dr. Kathryn King found that six months after finishing cardiac rehab, participants demonstrated higher health maintenance expectations and overall behaviour performance scores – and these indicators continued to improve over time.
But when I did a 4-month stint at cardiac rehabilitation after my own heart attack, I was vastly outnumbered by male participants, and was also one of the youngest in the group by at least two decades. Where did all the women go?
I subsequently learned that only 20% of all patients entering structured rehabilitation programs are women, despite the fact that we experience almost half of all cardiac events.
In fact, men are twice as likely to be referred for cardiac rehab by their physicians. Cardiac rehab attendance is only possible when physicians actually refer their heart patients to rehab. Yet referral rates remain shockingly low – estimated at only 20% of all eligible patients. See also: Failure to refer: why are doctors ignoring cardiac rehab?
Many women who are referred tend to become rehab dropouts. And even if they do eventually complete the full program, their attendance throughout tends to be sporadic compared to male participants.
Dr. Chris Blanchard is a health psychologist at Dalhousie University in Halifax who studied 1,200 Maritimers to figure out why women are up to 30% more likely to quit these programs than men.
Out of a typical 20-session cardiac rehab program, Dr. Blanchard found that men will attend 80% of sessions, compared to women who will show up only 50-60% of the time. If these sessions are home-based, male adherence stays at around 80%, but that of women plummets to 30%.
Here are some reasons that Dr. Blanchard and other experts have come up with to explain this:
- Some women don’t like to exercise in a regimented way.
- When women do attend rehab sessions, many say they don’t like working out alongside so many men – there’s often a one-to-five ratio. To address this concern, some programs are now offering female-only rehab sessions.
- Women put themselves low on their priority lists. “They are caretakers for other people, and they undersell themselves,” Dr. Blanchard says. “That’s the biggest gender discrepancy I’ve seen. This is extremely dangerous because research shows that 30 minutes of physical activity a day leads to a 20% increase in patient survival. So if we know that women are doing less physical activity, then we know that they’re potentially placing themselves at increased risk for death. That’s a huge impact.”
- Women seem to be at higher risk of suffering serious psychological issues than men following a heart attack, including functional complaints, more sleep disturbances, greater anxiety/depression, and a generally lower quality of life than men.
- A 1998 study reported in the Nurses Research journal found that most of the women enrolled in cardiac rehab programs were exercising well below the recommended guidelines for exercise after an acute cardiac event. “One possible explanation for this finding is that cardiac events generally occur in women who tend to have more severe pathology with poorer prognoses. Participation in rehabilitation decreases with age and with patients with more severe pathology.”
- Women reported more difficulty traveling to and consistently attending cardiac rehab programs.
- Many women don’t find the rehab programs relevant to their needs, suggesting that women may find programs more appealing if there is a strong psychological emphasis, rather than exercise being the main focus, as is currently the case.
- The physical components of cardiac rehab and women’s perception of their physical abilities may hinder their participation in rehab programs.
- Dr. Kathryn King adds that rehab participation may depend on how quickly the survivor returns to ‘normal’ routines. Her study participants who resumed role-related activities early and more completely apparently did not see the need to “rehabilitate”, and did not value the known benefits of cardiac rehab in preventing another cardiac event.
- UPDATE: To this list, I’d add an important factor as reported by the American Heart Association in the journal Circulation in 2012: “Doctors themselves are a significant obstacle to cardiac rehabilitation participation. Only 20% of all eligible heart patients are referred by their physicians to cardiac rehab.” (1)
No matter what reason women may have for not taking advantage of rehab programs they know will save lives, consider once more that men are twice as likely to be referred by physicians in the first place despite similar clinical profiles compared to women.
Many hospitals have now implemented automatic referrals to cardiac rehab to address this failing of the medical profession.
A quantitative review of 32 studies describing almost 17,000 people enrolled in cardiac rehabilitation programs was reported in the journal Heart in 2005. Researchers found that the main predictor of participation in a cardiac rehabilitation program was the physician’s endorsement of such a program.
Patients are more likely to participate in cardiac rehabilitation programs when they are:
- actively referred by a physician
- able to easily access programs.
Patients are less likely to participate in cardiac rehabilitation programs when they:
- have to travel long distances to participate in a cardiac rehab program
- experience guilt over family obligations
- are not told to register for rehab by their physicians
- cannot afford the fees/insurance co-pays of attending and completing a full series (can be thousands of dollars)
Learn more about cardiac rehabilitation from the Heart and Stroke Foundation.
1) Arena, R et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings. A Science Advisory From the American Heart Association. Circulation. January 30, 2012
NOTE FROM CAROLYN: I wrote more about the importance of cardiac rehabilitation for women diagnosed with heart disease in my new book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, November 2017).
- The surprising reasons heart patients don’t go to cardiac rehab
- Do we need to change the name of cardiac rehab?
- ‘Women-Only’ cardiac rehab curbs depression in women heart attack survivors
- Failure to refer: why are doctors ignoring cardiac rehab?
- Survivorship bias: When we focus only on success
- Study: “91% discharged from hospital without care plan”
- Why your heart needs work – not rest! – after a heart attack
- Returning to Exercise (and Training) After Heart Surgery (THE best and most comprehensive overview on this topic I’ve seen yet, written by cardiologist and triathlete Dr. Larry Creswell; especially useful for heart patients who have been regular exercisers before their cardiac event and are wondering how to safely resume their routine)