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Acute care, immediate secondary prevention, and referral 

Acute care, immediate secondary prevention, and referral
Chapter:
Acute care, immediate secondary prevention, and referral
Author(s):

Ugo Corrà

and Bernhard Rauch

DOI:
10.1093/med/9780199656653.003.0021
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date: 16 April 2021

Summary

Preventive cardiology (PC), as performed in various cardiac rehabilitation (CR) settings, is effective in reducing recurrent cardiovascular events after both acute coronary syndromes and myocardial revascularization. However, the need for newly structured PC programmes and processes to provide a continuum of care and surveillance from acute to post-acute phases is still evident. Phase I CR is becoming more and more important, serving as a bridge between acute therapeutic interventions and phase II CR. After clinical stabilization, phase I CR ideally involves multifaceted and multidisciplinary interventions, including post-acute clinical evaluation and risk assessment, general counselling, supportive counselling, early mobilization, discharge planning, and referral to phase II CR. All these interventions are important and contribute equally to achievement of the preventive target, which is to effectively reduce lifelong cardiovascular risk and guarantee an individual full participation in social activities. All the interventions within phase I CR should be supervised and provided in a comprehensive manner involving several healthcare professionals. For explanatory purposes, these components are analysed and described separately.

Introduction

Despite remarkable progress in diagnosis and therapy, acute events such as coronary syndromes (ACS), decompensated heart failure, and major arrhythmia, still pose a huge challenge in cardiovascular medicine. Whereas in-hospital mortality of patients has markedly decreased since 1990, medium- and long-term prognosis strongly depends on the risk constellation, including age, left ventricular function, persistent ventricular arrhythmias, diabetes, and other risk factors and comorbidities. In a German survey, 1-year mortality after acute myocardial infarction (MI) was as low as 3.2% in a low-risk population but increased to as much as 25% in high-risk patients [1]. Individual risk management therefore remains a major challenge, and this chapter will concentrate on the first steps to be considered during the early days in hospital after surviving an ACS and/or after a myocardial revascularization (MR) intervention. The basic items described here should be considered in the post-acute management of all cardiovascular patients.

Preventive cardiology and cardiac rehabilitation in the acute setting

Improvements in diagnostic and therapeutic procedures as well as increasing economic pressure and competition have led to a continuous shortening of the in-hospital stay after an acute event. By contrast, there are a growing number of old, increasingly frail patients with multiple morbidities who require intense clinical supervision and care. Optimal coordination between inpatient and outpatient care is an increasing challenge for healthcare providers. Furthermore, the long-term success of any acute or elective cardiac intervention strongly depends on the sustained implementation of preventive measures. Accordingly cardiac rehabilitation (CR) plays a major role as a bridge between the acute treatment and outpatient care.

Recent scientific data have demonstrated that preventive cardiology (PC) as performed in various CR settings is effective in reducing recurrent cardiovascular events after both ACS and MR [213]:

  • Phase I CR (described in this chapter) represents the earliest preventive intervention beginning right after the acute event during the hospital stay.

  • Phase II CR is a structured and comprehensive therapeutic intervention starting early after hospital discharge. It may be performed in various settings (outpatient, inpatient, centre-based, or home-based) depending on clinical, administrative, or logistic circumstances (see Acute care, immediate secondary prevention, and referral Chapters 22 and 23).

  • Phase III CR represents the long-term outpatient supervision of patients’ adherence to prescribed risk control measures and is usually the responsibility of general practitioners and cardiologists. Special phase III prevention programmes have been established in some countries to support long-term secondary prevention [7,14]

This classification may not represent clinical practice in all European countries as implementation, organization, and structure differ considerably for various reasons [14]. In the future phase I and phase II CR may become merged because of the need for newly structured cardiovascular prevention programmes that are able to provide a continuum of care and surveillance from the acute to the post-acute phase.

In-hospital phase I rehabilitation: core components

Inpatient phase I rehabilitation should begin as soon as possible after clinical stabilization of the patient [15]. It comprises a complex, multifaceted, and multidisciplinary intervention. (Acute care, immediate secondary prevention, and referral Box 21.1). All these interventions are important and make an equal contribution to achievement of the preventive target [16]. In-hospital phase I CR is therefore the first step in the lifelong programme of preventive cardiology and should be regarded as a bridge to phase II rehabilitation programmes.

For logistical reasons, in clinical practice not all in-hospital phase I CR components outlined in Acute care, immediate secondary prevention, and referral Box 21.1 can be delivered to all patients. However, this form of intervention represents a major component of in-hospital care, and provides safe access to a phase II CR programme for all eligible patients.

Post-acute clinical evaluation and risk assessment

The post-acute clinical evaluation and risk assessment should be based not only on the available information about the coronary anatomy but mainly on a careful examination of the acute medical and/or surgical records. It should include a review of the clinical history, the level of physical activity before the acute event, the actual clinical signs and symptoms, physical and functional examination, as well as results of technical diagnostic tests such as electrocardiogram (ECG) and ECG monitoring, echocardiography, and laboratory examinations [16,17]. In this way the severity of coronary artery disease, myocardial damage, arrhythmic burden, comorbidities, and potential frailty are evaluated to assess the individual cardiovascular risk burden and prognosis and to determine subsequent short- and long-term evidence-based treatment [18].

Importantly, every member of the therapeutic team should be well informed about the clinical status and all risk factors. This is a prerequisite for a complete counselling intervention and adequate prescription of a physical activity and exercise programme. A detailed description of clinical evaluation and risk assessment is outlined in Acute care, immediate secondary prevention, and referral Chapter 5.

General counselling

Patients with ACS or after MR differ in their desire for information, including advice about their illness, its causes, and prognosis, treatment options, potential lifestyle changes, activity levels, and disease management in daily life. In addition, individual beliefs and attitudes as well as psychosocial factors may influence the coping process. Negative emotions (denial, fear, anger) may affect compliance, and patients’ adherence should be addressed during CR.

Interventions correcting misconceptions are important to improve knowledge and reduce emotional stress in patients, partners, and family members. Of note, patients’ needs are both diverse and specific, depending on issues such as age, gender, ethnicity, and educational and social level [19]. Thus, the approach should be tailored to the patient, as a unique person. Moreover, patients often have difficulties in understanding and accepting detailed and complicated information, and their receptivity and understanding may be limited by physical illness and psychological or cognitive barriers. Information should therefore be provided in a clear and simple way, based on a patient’s personal characteristics and needs. Reassurance, individual support, and empathy should underpin all discussions.

General counselling is based on detailed knowledge of all members of the healthcare team about the individual patient’s risk profile as well as social background. All members of the team should have regular meetings to discuss clinical cases and to coordinate therapeutic interventions. Counselling of patients by a team member should be restricted to his or her speciality; medical aspects, as well as summarizing information and advice, is the responsibility of the cardiologist. Medical and social aspects are always interrelated and influence one another to a considerable extent. It is not generally sufficient to prescribe medication and lifestyle changes without knowing the potential promoters and barriers in the patient’s social life.

Thus, during phase I CR, counselling should be initiated after a careful consideration of the patient’s pre-existing knowledge and individual needs (Acute care, immediate secondary prevention, and referral Box 21.2). This could be accompanied by general information on the nature of cardiovascular disease and risk factor management using audio or video resources. Post-discharge telephone counselling may reinforce patients’ adherence to medication and lifestyle changes. However, these interventions do not confer sustained emotional or physical benefit, rather they help to increase patients’ and family members’ knowledge and involvement as a bridge to phase II CR.

Psychological and social support

As well as the risk of premature death, many patients may experience a significant loss of independence and a decline in physical function during the first year following an acute cardiovascular event.

In addition, after ACS or MR patients are in a clinically and psychologically critical condition and experience difficulties in understanding and accepting the ‘new’ situation and the potential consequences for their future and life expectancy. Life-threatening situations may have occurred and survival of the acute phase is considered the primary goal, whereas efforts for long-term cardiovascular prevention and lifestyle changes may be felt to be secondary at this stage. Patients therefore need to be supported to cope with their situation. Early mobilization to regain physical independence and individual self confidence is a prerequisite for coping, but clear medical information about the causes and consequences of the disease and psychological support also are required.

During the acute hospital stay structured psychological interventions are not feasible in most cases, but may be started within phase II CR. In addition, hospital discharge is too early in most cases to provide sufficient social and vocational counselling. Social counselling during phase I CR should therefore reinforce patients’ participation in phase II CR, which, apart from implementation of secondary prevention, supports vocational and social reintegration.

Recommendations for counselling on mobilization and physical activity

In-hospital phase I CR is the first step in regaining physical independence and individual self-confidence. The risks and complications of prolonged immobilization affect almost all organ systems and may have severe psychological consequences (Acute care, immediate secondary prevention, and referral Table 21.1). The primary purpose of early mobilization is to prevent such complications. Additional goals are to regain cardiovascular fitness and functional abilities and to increase comfort and psychological well-being. Early remobilization is therefore now common practice in the care of hospitalized patients and may be implemented through a broad range of activities as outlined in Acute care, immediate secondary prevention, and referral Box 21.3. The following limitations, however, should be considered:

  • Scientific data on early remobilization are rare, and there are no evidence-based guidelines on how to perform early remobilization most effectively in clinical practice. A systematic review of experimental data from studies conducted in the 1970s and 1980s showed a trend towards an increased survival of ACS patients receiving early mobilization relative to those who did not [20]. More research is necessary to determine the minimum standards for safe and effective remobilization.

  • The scientific uncertainty may translate into clinical practice and lead to unjustified delays in remobilization of patients. Some of these uncertainties concern safety and monitoring issues as well as the correct adjustment of the programme intensity. Cardiovascular risks like recurrent ischaemia, heart failure, and arrhythmias have to be taken into account as well as comorbidities, puncture sites, and wound healing or Dressler’s syndrome after heart surgery.

  • Underuse of a structured early remobilization may also be the result of economic pressure and time constraints. Patients with multiple morbidities, advanced obesity, and/or frailty may be particularly affected by those restrictions.

Table 21.1 Risks and complications of immobility.

Respiratory

  • Retention of secretions and decreased respiratory excursions

  • Atelectasis and pneumonia

Cardiovascular

  • Orthostatic hypotension

  • Hypovolaemia

  • Deep-vein thrombosis, local and systemic embolism

Musculoskeletal

  • Muscle mass reduction and wasting

  • Joint contractures

  • Bone demineralization (osteoporosis)

  • Heterotopic ossification

Gastrointestinal

  • Decreased motility

  • Constipation

Neurological

Polyneuropathy

Endocrine

  • Hyperglycaemia with insulin resistance

  • Catabolism

Genitourinary

  • Urinary stasis

  • Renal calculi

Psychological

  • Depression

  • Delirium

Source: Amidei C, Mobilization in critical care: a concept analysis. Intensive and Critical Care Nursing 2012; 28: 73–81.

Amidei C, Mobilization in critical care: a concept analysis. Intensive and Critical Care Nursing 2012; 28: 73–81.

Despites these limitations and potential restrictions, a few recommendations on how to handle early remobilization in clinical practice are available [21] (Acute care, immediate secondary prevention, and referral Box 21.4).

Amidei C, Mobilization in critical care: a concept analysis. Intensive and Critical Care Nursing 2012; 28: 73–81.

Discharge planning

Transitions of care are defined as ‘a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care in the same location’ [22]. Correctly performed care transitions are associated with significant reductions in readmissions and total healthcare costs [23]. Patients and medical institutions taking over care therefore have to be informed and instructed in a very clear way about long-term medication and the individual’s most important lifestyle changes. The importance of these instructions has been highlighted by the following studies:

  • Among 5353 patients post-MI, those on optimal medication (including five guideline recommended drugs; 46%) had a significantly lower risk of death after 1 year compared with those taking no drugs or one drug only (adjusted OR 0.260, 95% CI 0.179–0.379, p < 0.001) [24].

  • Among 18 835 patients in 41 countries post-ACS, those who reported persistent smoking and non-adherence to diet and exercise had a 3.8-fold (95% CI 2.5–5.9) increased risk of a cardiovascular event (myocardial infarction, stroke, or death) compared with those who never smoked and who modified their diet and exercise [18].

The importance of starting patients on appropriate secondary prevention at the time of hospital discharge cannot be over-emphasized, as secondary prevention treatment tends to decrease rather than increase after hospitalization [25,26]. In the EUROASPIRE III survey of secondary prevention in 22 countries, 95% of patients were on antiplatelet drugs at the time of discharge, 82.5% on beta-blockers, and 81% on statins, but these proportions had decreased within 6–36 months after discharge. After this time period less than half of the patients were meeting risk factor targets such as for blood pressure (44%) and lipid (48.5%) control [27]. Attending CR, however, was associated with an increased likelihood of meeting risk factor targets [28].

The core components of discharge planning are given in Acute care, immediate secondary prevention, and referral Box 21.5. It is important to involve the patient and relatives/caregivers in discharge planning as soon as possible, including the core components of outpatient care and subsequent phase II CR. While discharge policies, protocols, and practices have to consider the individual’s needs and be sensitive to different requirements, standardized discharge protocols should be developed to promote consistency of clinical practice between specialists and general practitioners and to reinforce the appropriate use of clinic resources. A structured and comprehensive discharge letter can be regarded as a prerequisite for an effective continuation of healthcare and to guarantee consistency within an individual’s care. Standardized templates for discharge letters and other communications are available to promote efficiency and consistency of clinical practice—an example is given in Acute care, immediate secondary prevention, and referral Box 21.6.

Adapted from CADPACC (1995) [33].

Referral to phase II cardiac rehabilitation

Referral to phase II CR should be a primary aim for all patients recovering from acute cardiovascular disease [16]. Participating in a CR programme yields well-established benefits (reduction in cardiac and non-cardiac mortality as well as reduced morbidity and cardiac risk factors). CR plays a crucial role in secondary prevention, helping individuals to return to a productive and satisfying life.

Regrettably, referral to phase II CR is unsatisfactory in most European countries, with patchy distribution and large disparities in staffing and uptake. The low service uptake depends on environmental factors like the availability of CR centres and/or support from the healthcare system, as well as on patient characteristics like age, gender and ethnicity, social factors, clinical conditions (i.e. comorbidities), and psychological factors [9,2931].

In addition, lack of information and support from physicians and other healthcare professionals during the hospital stay can have a negative impact on participation in CR [32]. Physicians themselves therefore need to be better educated about the benefits of CR.

The patient’s perspectives and attitudes are also important. As already mentioned, an increasing number of patients with ACS only experience a short hospital stay. For this reason patients often do not feel that they are suffering from a serious disease. Participation in CR may therefore be felt to be unnecessary. Moreover, entering a CR programme may make the situation seem more serious, which is difficult for some patients to accept.

Automatic referral to phase II CR using electronic patient records or standard discharge orders in combination with individual and personal information and reinforcement appears to be the best way to get a high admission rate to phase II CR [33,34].

Conclusions

In patients after ACS or MR, phase I CR during the hospital stay serves as a bridge between the acute therapeutic interventions and a fully comprehensive secondary prevention intervention such as phase II CR. Ideally phase I CR is structured and follows an evidence-based programme, including psychological support, individual information, structured physiotherapeutic programmes, and early supervised exercise training. During phase I CR, patients should be informed about the importance and the contents of secondary prevention with respect to cardiovascular risk reduction and social reintegration. On the basis of this information patients should automatically be referred to phase II CR, ideally with a choice about the most appropriate rehabilitation setting for them.

Further reading

Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 2011; 124: 2951–60.Find this resource:

Bjarnason-Wehrens B, McGee H, Zwisler AD, et al. Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010; 17: 410–18.Find this resource:

Goel K, Lennon R, Tilbury R, et al. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation 2011; 123: 2344–52.Find this resource:

Grace SL, Chessex C, Arthur H, et al. Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario. Can J Cardiol 2011; 27: 192–9.Find this resource:

Hammill B, Curtis L, Schulman K, et al. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121: 63–70.Find this resource:

Giannuzzi P, Temporelli L, Marchioli R, et al; for the GOSPEL Investigators. Global secondary prevention strategies to limit event recurrence after myocardial infarction. Arch Intern Med 2008; 168: 2194–204.Find this resource:

Piepoli M, Corrà U, Benzer W, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010; 17: 1–17.Find this resource:

Piepoli MF, Corrà U, Adamopoulos S, et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery. Eur J Prev Cardiol 2012; 21: 664–81.Find this resource:

Rauch B, Riemer T, Schwaab B, et al; for the OMEGA study group. Short-term comprehensive cardiac rehabilitation after AMI is associated with reduced 1-year mortality: results from the OMEGA study. Eur J Prev Cardiol 2014; 21: 1060–9.Find this resource:

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