Cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic in Rochester, Minnesota, has this important advice for all heart patients:
“If your doctor recommends cardiac rehabilitation, go.
“If you’re not referred, ask.
“And if you ask, and are told ‘You don’t need it’ – find a new cardiologist!”
Based on what we already know about the shockingly low rates of physician referral to this life-saving treatment (as low as 20% of all eligible heart patients) we might expect a flurry of doctor dumping if heart patients follow Dr. Sharonne’s advice to seek out physicians who are more appropriately informed.
According to The American College of Cardiology (ACC):
“Women with coronary artery disease who completed a 12-week cardiac rehabilitation program were two-thirds less likely to die compared to those who were NOT referred to the program.
“In addition, the mortality benefits of this evidence-based program derived for patients with angina, or for those recovering from heart attack, coronary artery bypass graft or implanted stents appear to be much more striking in women than in men with the same condition, yet referrals and attendance among women fall short.”
So why aren’t all cardiologists recommending this evidence-based treatment program to their patients with the same enthusiasm they’re mustering to recommend a fistful of cardiac drugs to every survivor?
As I’ve written here:
“Doctors themselves are a significant obstacle to cardiac rehabilitation participation, as described in this 2012 American Heart Association report published in the journal Circulation(1):
“Given the well-documented benefits of participation in cardiac rehabilitation, it is surprising how few eligible patients are referred to rehab. A number of recent surveys have reported referral rates in the order of 20%.(2, 3) The under-utilization of cardiac rehab is particularly apparent:
- in women
- in those with low socioeconomic status
- in African-Americans
- in the elderly
“Each of these groups represents those who are significantly more likely to die within five years following a first heart attack.(4)”
As the ACC report explains, even a brief endorsement of cardiac rehabilitation by a physician has been shown to improve patient participation in this important exercise/education follow-up program. In fact, physician endorsement is one of the strongest predictors of full participation in cardiac rehabilitation.
PLEASE NOTE, Doctors: checking off a little tickbox on a discharge form or clicking a button on a computer screen is NOT an endorsement. An endorsement is taking 11 seconds to say something like this out loud to your patient:
“Cardiac rehabilitation is a terrific program for heart patients that has been proven to improve quality of life and reduce your risk of having another cardiac event – and I’d really love you to participate in this program.”
Dr. Gina Lundberg, a Preventive Cardiologist & Clinical Director of the Emory Women’s Heart Center in Atlanta, tweeted this message to her colleagues:
“Women go to Cardiac Rehab when I encourage them. Many MDs don’t encourage women to attend. MD bias problem!”
Her Tweet was aimed at her like-minded colleagues Dr. Sarah Samaan (@) and Dr. John Erwin III (@HeartOTxHeartMD), both Texas cardiologists who seem equally keen on getting more heart patients to experience the lifesaving benefits of cardiac rehab therapy.
Their ongoing online discussion topic: why do so few heart patients participate in a cardiac rehabilitation program? (Their secondary discussion topic: Do we need to change the name of cardiac rehab?)
We know that physicians’ failure to refer is a major (and utterly preventable) reason. As I quoted him here, Oregon cardiologist Dr. James Beckerman is blunt in his assessment of such failure:
“It is bad medicine to withhold life-saving treatments, and many physicians are selling their patients short.”
And if Dr. Gina herself can somehow convince her own heart patients to attend cardiac rehabilitation, what possible excuse can there be for all those physicians who are NOT referring 80% of all eligible heart patients?
But we know that there are also other practical issues that discourage cardiac rehab participation. A number of researchers have investigated why women in particular are not only less likely to attend, but also more likely to become rehab dropouts compared to our male counterparts. Reasons include:
- unavailable or unaffordable child care
- can’t get time off work
- transportation issues
- no evening/weekend programs available
- reluctance to exercise in front of men
- lack of awareness of rehab program’s benefits
But a physician’s failure to refer in the first place should never be the reason that any eligible heart patient doesn’t go to cardiac rehabilitation. See also: Why aren’t women heart attack survivors showing up for cardiac rehab?
But here are some examples from Real Live Patients who shared their own experiences with (or sadly, without!) cardiac rehabilitation:
♥ “I so wish I had had rehab. I went to the introductory meeting and the therapists told me that all patients had to be referred by their doctor. My doctor refused to refer me, saying it would not do me any good, and was angry that the therapists had told me it would be helpful. I begged for a referral, saying I would pay out-of-pocket, but he still refused.” (heart attack, sudden cardiac arrest, ICD implanted)
♥ “My cardiologist did not even suggest it, they did not talk about it at the hospital. I found out about it from a relative, asked for a referral and my cardiologist said ‘Fine, but I think it is a waste of time personally.’ “(heart attack)
♥ “I was referred to cardiac rehab, however my insurance would not cover it so I only went a few times. I found this to be so odd because my bill from my STEMI (heart attack) was about $250,000. That they would cover this and not the recovery and prevention of the next one leaves me scratching my head. I work managing medical billing so I am not sure why this was so surprising to me but it was. With all of the studies surrounding the benefits of cardiac rehab, it just seems so ridiculous.” (heart attack)
♥ “I did not get to go. I asked my cardiologist and it was covered through my insurance, but he said to just exercise and eat a balanced diet. I later asked him why he refused to send me, and he said it was because of my age; they had no one else going at the time under 70 and he was afraid it would cause further depression. I knew 47 was young to have a heart attack. I think it would have helped me immensely with the fear.” (heart attack)
♥ “Some doctors are negative and think cardiac rehabilitation is not needed. It amazes me that any cardiologist would discourage anyone from 12 weeks of cardiac rehab if you are eligible. For those who have been discouraged, find a new doctor who is aware of the importance of cardiac rehab. There is no room for ego in participating or encouraging someone to do something to increase their physical and emotional well-being.” (heart attack, SCAD*)
♥ “Not everyone has insurance which covers cardiac rehab. Some people have insurance which can only partially cover it, and even that can be steep. For myself, the rehab was $150 per session, and my insurance covered $100 of that cost. For 36 sessions, it cost me $1,800. Thank goodness I could afford it, but it was a shocking amount of money, especially after the cost of my hospitalization/heart attack. But in the U.S., only those with decent health plans will be able to attend cardiac rehab, it really is a therapy for the haves versus the have-nots. For me, worth every single cent I paid. It was my oasis in a time of fear. I regained my confidence in my body and in my health while at rehab.” (heart attack)
♥ “I would love to attend cardiac rehab, but trying to work full-time and having so many doctor appointments, there is no time left. My job is already in jeopardy because of being off work so much. Cardiac rehab is 3 times a week for 10 weeks and it is all during work hours. I wish they had more convenient hours for people who have to work 8 to 5. I know my heart is important, but if I don’t have my job I couldn’t pay for the cardiac rehab. Vicious circle.” (heart attack)
♥ “My doc is 70 years old. He told me he reads every night to keep up on the latest information, so I don’t think exercise or cardiac rehab is a big mystery to any doctor in this day and age. I think (doctors’ reluctance to refer) might be stubbornness or fear of change. Unfortunately this harms women. I started cardiac rehab 18 days after my SCAD, cardiac arrest, and four stents – five days in the hospital. I now go three times a week.” (heart attack, SCAD*, cardiac arrest, four stents)
♥ “Where does doctors’ bias against cardiac rehab come from? I think arrogance, actually. Cardiologists sometimes think that it is all about them, that they are fixing you, you do not need the other stuff. They think cardiac rehab is some kind of fluffy do-good yoga and meditation program rather than a serious educational and exercise program designed to give heart patients a better chance at avoiding a repeat. Honestly, I think sometimes they believe you just need the office visits, the meds and you are good to go.” (three heart attacks)
♥ “I only attended for about six sessions. It was good, but I had to pay $60 for each session and find a babysitter each time I went, so I had to stop because I couldn’t afford it.” (SCAD*)
♥ “If doctors aren’t ‘prescribing’ cardiac rehab for those who need it, how would the patient ever know about it?” (sudden cardiac arrest)
♥ “I think cardiologists and other healthcare providers still need to be educated, or educate themselves about the benefits of cardiac rehabilitation. Then perhaps they will properly educate and motivate their patients to attend. Lastly, the nurses and others who actually run the programs must educate patients to make the necessary decisions to make time for their own recovery and not drop out of the programs.” (coronary artery disease, stents)
♥ “I did cardiac rehab for about four weeks and checked myself out. It was BORING! I am a fitness instructor so even though my insurance was paying for it, I knew I could do what they were doing at my own gym and be with my friends and people my own age.” (sudden cardiac arrest)
♥ “Cardiac rehab would have been such a help after my difficult recovery. I slept in a chair for 5 months because of lung complications. I had difficulty breathing and could barely walk. It was a long road back and I was scared to death.” (aortic valve surgery)
♥ “Went to rehab for only a few weeks before I quit. It turned out to be an Old Boys Club. VERY disappointing. I was the only woman there, much younger than anybody else (in my early 40s) and some of the men in my group were in their 80s! I was still working, had young kids at home, stressed out about how on earth I was ever going to manage going back to work, raising my boys, running a household again, all while coping with this scary angina pain. Wish our rehab program had included more than just exercise but also help with the emotional pain too. I’ve also heard about woman-only cardiac rehab groups, would have LOVED that.” (coronary microvascular disease)
♥ “From personal experience, I was NOT one of those patients who ever received a referral. I even asked my cardiologist to refer me to rehab so I could get stronger. Nope. He wouldn’t do it for whatever reason.” (heart attack)
* SCAD is Spontaneous Coronary Artery Dissection
.Thanks to all of my heart sisters who took the time to share their opinions and stories!
NOTE FROM CAROLYN: I wrote much more about cardiac rehabilitation and other ways to improve your chances of survival 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 the JHUP code HTWN to save 20% off the list price).
(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
(2) Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:1653-1662
(3) Boyden T et al. Can increasing referral to cardiac rehabilitation improve participation? Prev Cardiol 2010;13:198-202
(4) Roger VL, et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee. Heart disease and stroke statistics – 2011 update. a report from the American Heart Association. Circulation 2011;123:e18-e209
Q: If you’re a heart patient who did not attend or complete a supervised cardiac rehabilitation program, tell us why
I was interviewed for this US News article: “Cardiac Rehab: Boosting Your Heart Recovery“
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)