Why aren’t female heart attack survivors showing up for cardiac rehab?

~ Carolyn Thomas

by Carolyn Thomas  ♥ @HeartSisters

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.

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
  • educated
  • married
  • self-sufficient
  • 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.

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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

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NOTE FROM CAROLYN:   I wrote much more about the cardiac rehabilitation and other proven ways to help avoid a future cardiac event in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 20% off the list price).

See also:

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)

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Published by Carolyn Thomas

24 thoughts on “Why aren’t female heart attack survivors showing up for cardiac rehab?”

  1. I didn’t even KNOW cardiac rehab existed before this! My heart attack and peripartum cardiomyopathy was 16 years ago and my (male) cardiologist never mentioned it as an option. I am sure it would have helped me a lot. I got NO support or follow up. I got Lasik. and the only advice he gave me was to avoid stairs. Women with heart disease really need more help with stuff like this 🙂 Doctors need to be educated, too.

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  2. To Kathleen and Rachel – so glad you both connected here in this helpful fashion. Thanks for that link to the article on your brother, Rachel. Such a tragic story.

    Good luck to you both.

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  3. That’s a great question.
    Living Proof has produced an at-home Cardiac Rehab Fitness DVD that offers women (and men) the benefits of a cardiac rehab program at home.

    * CAROLYN’S CAUTIONARY NOTE and DISCLAIMER: This DVD sells online for $25 Cdn and is neither endorsed nor reviewed by Heart Sisters. I’m including this comment and link here only for those interested in learning more! Remember that cardiac rehabilitation programs are normally supervised by cardiac staff for your safety while exercising.

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    1. Great advice, Mary. WomenHeart is the ‘National Coalition For Women With Heart Disease’. This organization is a strong voice for women living with or at risk of cardiovascular disease, working in both education and advocacy on our behalf.
      Cheers,
      C.

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      1. Hello Carolyn,

        Knowing it is your Heart Anniversary- I want to congratulate you for what you have learnt and done for yourself and others in past two years.

        Women like you will make a huge difference in our society in help empowering women and educating them to prevent heart disease. Keep up the good work.
        Thank you for your postings.
        Keep spreading the good word.
        Proud sister

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  5. At 54 years old, I had a “cardiac event” about 2 months ago. I’ve been in cardiac rehab for 5 weeks and am planning to end participation at 6 weeks. I realize changes in lifestyle are necessary and that exercise is important, however I am not being given the tools for life outside rehab. Frankly, I am still trying to get an explanation about what actually did happen and what are the chances of it happening again.

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    1. Thanks for your comment, Denise. You are in very early days since your cardiac event – no wonder you’re still trying to get your brain wrapped around the overwhelming shock of what hit you.

      It sounds like your cardiac rehab program is mostly exercise-based. As the study above confirms: “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.”

      Your cardiologist is likely your best source of info about the specifics of your own case – keep researching as much as you can, and then ask your doc questions until you are confident that you know as much as possible. You’re about to become an expert on your own cardiac health.

      cheers,
      C.

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  6. At 28 years old I had a cardiac arrest. I was religious in my attendance of cardiac rehab while off work, but I had to go back to work unlike the majority of the 50-70 year old generally male crowd that I was pounding the treadmill with. I managed to make it a priority for a number of years and paid out of pocket for rehab. Now 12 years on and with a small child, I’m struggling to make it a few times a month. This is a combination of my choices, not making it a priority, and that rehab hours often don’t account for those of us back in the work place.

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    1. A cardiac arrest at age 28!? Yikes. That is just way too young.You’re so right – when you are off on sick leave, cardiac rehab can seem like part of the overall recuperation therapy so it just gets scheduled. But once you return to work and an increasingly busy “normal” life again, rehab can easily slide. My rehab programs ran only in the mornings – so anybody going back to work either had to miss work two mornings a week, or skip rehab.

      Good luck to you – hope the New Year will bring many more opportunities – if not to an official rehab program, then at least to the gym!
      cheers,
      C.

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      1. Thanks Carolyn. We lost my brother at 24 years old just 2.5 years earlier to a cardiac event. Too young, too young.

        I’ve subscribed to this blog so hopefully it is enough of a kick in the behind to see your posts and take action. Thanks for your response.

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        1. I just saw this comment from 3 years ago while clicking through other links. And would like to be sure that this woman, her family and their docs have considered Hypertrophic Cardiomyopathy (HCM) and have done the necessary screening.

          My own case was misdiagnosed for over 6 years, and that was after I had suggested that HCM would account for my symptoms and test rests, including a relatively clear angiogram.

          Look around the website of the Hypertrophic Cardiomyopathy Association. There are many stories like hers. HCM is a genetic condition – under-diagnosed and often misdiagnosed. Family history of sudden cardiac death is a major red light marker. Sudden major cardiac “events” including cardiac arrest in otherwise healthy active people is another. Leading cause of death among young athletes, for example.

          But many, many docs, including cardiologists, do not recognize it. My own echos were misread until a recent one fell into the hands of a cardiologist who not only recognized it, but saw that it was consistent with all previous echoes.

          I would urge growfamilygrow (and anyone to whom this sounds familiar) to check out the Hypertrophic Cardiomyopathy Association website. They are a wonderful resource with excellent materials. Locating HCM specialists is critical.

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            1. Kathleen and Carolyn,

              Thank you both. My brother’s autopsy results actually mentioned that his heart appeared enlarged along with some other issues and so my initial talks with my primary care and then the cardiologists prior to my own cardiac arrest was regarding HCM.

              I am interested though to pursue this again, have recently been irritated by my cardiologist’s lack of interest in even taking my pulse or following up on a stress test after an ER visit (one of five in 15 years – so not an overly needy patient) so perhaps with a new cardiologist a review of materials. If I could just find a copy of the autopsy.
              Cheers,
              Rachel

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              1. Perhaps I’m misinterpreting, but that you explain that you’re not “an overly needy patient” suggests to me that too many doctors, and, indeed, a certain cardiac rehab program I have just quit, continue to read specific questions and concerns as a threat to THEM, not an attempt, as intelligent women, to save our lives as best we can.

                The program I quit was solely exercise-based, and I felt like a hamster in a wheelcage. The equipment is designed for men. Irritating as hell.

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  7. I guess part of the reason would be is that women tend to think that housework might compensate for workout and some basically might not have time to leave all the house chores to their husbands, so I guess it’s a matter of not being convenient! But for some, they just simply hate to work out. Your blog is very informative. Thanks for posting!

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  8. Carolyn,

    Thank you so much for your comments on my blog. I have sick sinus syndrome and I really enjoyed reading through your site! I can always use more tasty, heart healthy recipes.

    Katie

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    2. I am a 48 year old woman who was diagnosed with cardiomyopathy two years ago and received a pacemaker a year ago. My cardiologist recommended cardiac rehab, but my insurance would not cover it. My insurance only covers cardiac rehab in the event of a heart attack, and not heart muscle disease.

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        1. It makes sense (though not medical sense) if Jacqueline lives in the US.

          Here we have the health care business with competing profit centers, and insurance companies call the shots on all sorts of medical decisions. In recent years I’ve noticed that they are waging a campaign against physical therapy and rehab programs, on the grounds that “they are endless” and “with dubious benefit.” Right now they would rather pay for pills and gadgets – less labor-intensive.

          In California, for example, under the new workers compensation system an injured worker gets no more than 24 PT visits no matter what the injury. PT has been tremendously beneficial to me in improving long-term function and reducing pain, but it’s taken years of consistent work.

          I would bet that I’m one of the few who pays for PT out of pocket rather than swallow more pills. Lots of people are truly miserable and docs have been given little choice but to prescribe pain pills. The agency that won’t approve my PT constantly renews my RX card. And now we are seeing articles about the increase in addicts as a result, only the focus is to rail against the docs and patients, not the policies that have driven them.

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