Outpatient Cardiovascular Rehabilitation in Croatia

    Authors

    Abstract

    Cardiovascular rehabilitation is a part of cardiologic treatment that is performed in specialized hospital or outpatient centers by a team of medical personnel using an interdisciplinary and transdiciplinary approach. Cardiovascular training with telemetric electrocardiogram monitoring under the supervision of a cardiologist, full non-invasive diagnostic testing, psychodiagnostics and psychological counseling, patient education, and non-pharmacological measures coupled with typical medication treatment are all integral components of cardiovascular rehabilitation programs. This article describes the organization of outpatient cardiovascular rehabilitation in the Republic of Croatia, which is a effective, safe, cost-effective procedure that can be tailored to the patient and reduces mortality, increases functional capacity, restores work fitness and work capacity, and improves quality of life.

    Keywords

    cardiovascular rehabilitation, secondary prevention, physical activity

    DOI

    https://doi.org/10.15836/ccar.2015.28

    Full Text

    Studies have shown that appropriate management of blood pressure in patients with arterial hypertension, optimal lipid values in patients with dyslipidemia, and glucose values in patients with diabetes and metabolic syndrome, as well as smoking cessation, optimal physical activity, and management of psychosocial factors reduce comorbidity and mortality form cardiovascular diseases, coronary heart disease (CHD) in particular. (1-3) However, despite improved treatment of CHD, an organized network of primary percutaneous intervention for treatment of acute myocardial infarction (AMI), and consistent application of evidence-based measures of secondary prevention, a significant number of persons still dies from this disease. Data from the Croatian National Institute of Public Health on the number of deaths in 2013 show that AMI is one of the most common single causes of death in Croatia, at 3456 persons (2063 men and 1393 women) or 6.9% of all mortal outcomes, followed by lung cancers (2802 deaths, or 5.6%) and colorectal cancer (2037 deaths or 4%). (4) The basis for the development of AMI, the most common cardiovascular disease, is an unhealthy lifestyle, insufficient physical activity, and smoking. These unhealthy habits first manifest with cardiovascular risk factors, followed by subclinical disease, and finally one of the clinical manifestations (angina pectoris, AMI, chronic heart failure, peripheral artery disease, stroke, or sudden cardiac death). Depending on when the phase in which the disease is noticed, various treatments can be applied ranging from changing unhealthy lifestyle habits and pharmacotherapy, i.e. primary and secondary preventive measures, which include cardiovascular (CV) rehabilitation (Figure 1). (5, 6) Figure 1. Development of coronary heart disease and prevention strategies (Adapted from Ugeskr Laeger. 2002;164:2876-81.). A holistic approach is the basis of CV rehabilitation, and includes individual risk assessment, moderated physical activity, management of CV risk factors, education and counseling, interventions focused on the psychological behavior of the patients, and work fitness assessment. (6, 7) The main goals of CV rehabilitation (5, 7) are: - Restoring the patient’s ability to function as part of a family, in society, and in work-related activities; - Encouraging the patient to change their lifestyle and take responsibility for their own health; - Slow down or prevent the progression of the disease. ## Cardiovascular Rehabilitation Continuum Traditionally, CV rehabilitation has three phases (or four, according to some authors) (1, 7). 1. During hospital treatment – in a coronary or cardiac surgery intensive care unit, early mobility therapy is applied, which includes proper positioning of the patient in bed, help with turning in bed, sitting up, and getting up from bed, as well as preparation for walking coupled with vital sign and hemodynamic value monitoring, aimed at improving oxygenation, perfusion, and muscle tone as well as prevention of complications. Patients are informed of secondary prevention measures for CV diseases, which prevents a drop in physical fitness and has a positive psychological impact. Due to application of increasingly advance methods, this period is becoming shorter (less than five days in some patients), it is extremely important to provide timely information on the state of the disease and impending recovery process; 2. During recovery – this phase of CV rehabilitation takes place in specialized institutions characterized by teamwork (an interdisciplinary and transdisciplinary approach), continuous monitoring by a cardiologist, and telemetric electrocardiogram monitoring during physical activity. It is usually performed in hospital centers over 21 days, and in outpatient centers 3-5 times a week over three months. In both cases, physical activity is gradually increased according to generally accepted principles. After non-invasive CV and psychological diagnostics, the patient is informed of the state of their disease. The patient and family are then educated and counseled on the disease as well as further treatment and behavior aimed at encouraging changes in health behavior and reducing negative psychosocial consequences of the disease; 3. Long-term maintenance – this phase takes place in so called cardiac patient clubs that are usually organized in rehabilitation centers, and lasts for the rest of the patient’s life. This phase is characterized by maintenance, and if possible improvement, of existing improvements achieved by CV rehabilitation, along with intermittent evaluations by internist-cardiologists, exercise stress test, and risk factor assessment, but with no telemetric electrocardiogram monitoring during physical activity. Patient follow up is most appropriately performed by a well-informed family physician. Long-term maintenance can also take place in sports facilities or in the patient’s home without medical supervision, which some author consider to be the fourth phase of CV rehabilitation. ## The Availability of Cardiovascular Rehabilitation in the Republic of Croatia In the Republic of Croatia, CV rehabilitation takes place in three centers: - In the hospital - Thalassotherapia Opatija – Special Hospital for Medical Rehabilitation of Heart and Lung Diseases and Rheumatism, Opatija (Referent Center for Cardiological Rehabilitation of the Ministry of Health, Republic of Croatia) - Special Hospital for Medical Rehabilitation, Krapinske Toplice, Croatia; - Outpatient - Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia. Simply looking at the number and location of rehabilitation centers in Croatia makes it clear that many patients will be unable to participate in CV rehabilitation programs due to their geographical location. Therefore, all patients with CHD or that had had AMI must be advised to take part in physical activity due to its benefits in addition to CV risk factor management. Brisk walking until slightly out of breath is usually advised. All patients must be educated on the methods and importance of heart rate control and arterial pressure, and it would be advisable to explain the talk test (exercise until the point that still allows them to speak short sentences) which would be an appropriate level of exertion for cardiac patients. (8) ## Goals of Cardiovascular Rehabilitation Programs The goals of the program do not depend on the type of center CV rehabilitation is being performed in, but are instead focused on the wellbeing of the patient, specifically on: - Reducing mortality and morbidity; - Reducing the symptoms of the disease, in particular the frequency of chest pain, shortness of breath, and fatigue; - Better exertion tolerance; - Improving work fitness; - Better blood pressure regulation, reduction of the heart rate; - Improving lipid and glucose serum values; - Reducing body weight and preventing obesity; - Smoking cessation; - Achieving a feeling of good health and reducing stress; - Improving quality of life. ## Outpatient Cardiovascular Rehabilitation in the Republic of Croatia The second phase of CV rehabilitation is part of the treatment of cardiovascular patients after acute hospital cardiologic or cardiac surgery treatment. In outpatient conditions, it usually takes place over 12 weeks in low and moderate risk patients, whereas in patients with high risk CV rehabilitation takes place in specialized hospitals. (1) The Institute for Cardiovascular Prevention and Rehabilitation has been working since 1950 in Zagreb. Outpatient cardiovascular rehabilitation (OCVR) at the Institute has been performed continuously since 1982. (7, 9-11) Patients above 18 years of age are included, and the treatment is paid for by the Croatian Health Insurance Fund based on referral by the family physician. An annual contract between the Croatian Health Insurance Fund and the Institute determines the maximum funding available for covering the bills for specialist health care. Since September 1, 2013, Croatian Health Insurance Fund introduced a special D1 referral form for ambulatory care, which covers the treatment for 365 days from its start. OCVR treatment is indicated in patients after: - Acute coronary syndrome, i.e. acute myocardial infarction; - Cardiac surgery (coronary artery bypass surgery, mechanical or biological valve implantation, valve repair, aneurism surgery, etc.); - Heart electrostimulator implantation or implantation of other medical devices with a similar function; - Percutaneous coronary intervention with stent implantation or percutaneous coronary angioplasty; - Heart transplant; - Symptomatic form of obliterating peripheral artery disease (except serious ischemia and pain at rest), etc. Patient compliance in these programs is high, ranging from 86% and 99%, except during the Croatian War of Independence, when it was below 80%. Data from international studies show 34-75% compliance. (7) Our follow up for many years found that six-year mortality in patients that went through phases 1 and 2 of CV rehabilitation was 13%, only half of which due to heart-related causes. Mortality in patients that did not take part in phases 2 and 3 of the rehabilitation was 34%, of which as much as three quarters due to cardiovascular causes. (7) The risk of physical training was extremely low: during 400 000 hours of exercise as part of OCVR we had only one cardiac arrest, one acute myocardial infarction, and one stroke, with no fatalities. (7) ## The Number of Participating Patients Approximately 450 patients attend the OCVR program annually in our Institute. Figure 2 shows the number of patients in the OCVR program from 1986 to 2014, for a total of 13009 patients. Figure 2. The number of patients taking part in outpatient cardiovascular rehabilitation at the Institute for Cardiovascular Prevention and Rehabilitation from 1986 to 2014. Most patients are referred by their cardiologist, internist, family physician, or cardiac surgeon. About a third of the patients began participation after a mail invitation based on data on patients with acute coronary syndrome from all hospitals in Zagreb, directly acquired by an employee of the Institute. Figure 3 shows the analysis of patients in OCVR programs based on primary diagnosis between 2005 and 2014. Approximately half of the patients had suffered acute myocardial infarction, and about 10% had underwent coronary artery bypass surgery. Figure 3. Analysis of patients in outpatient cardiovascular rehabilitation programs based on primary diagnosis between 2005 and 2014. In addition to OCVR, the Institute also has education programs for other medical professionals, students, and target high-risk groups (e.g. obese persons (12), vision impaired and blind persons (13), preventive CV exams for people in higher-risk age groups (14), etc). The Institute is authorized to train residents in the subspecialty of internal medicine – cardiology related to the education about rehabilitation of patients with cardiovascular disease, work fitness assessment, and CV disease prevention. In cooperation with the University of Applied Health Studies, Zagreb, we take part in the education of students for the courses on Rehabilitation of patients with heart disease and Clinical skills II in the professional undergraduate program Physical therapy and for the module Role of medical nurse in diagnostics in the specialist graduate program Clinical nursing. Health professionals of all profiles take part in constant medical training. Daily results are regularly published on national and international conferences, as well as periodically in indexed journals. A list of published articles is available on the Institute’s webpage. (15) ## Contents and Organization of the Program The organization of OCVR at the Institute is based on the principle of holistic rehabilitation, in line with European guidelines. (16) The OCVR program accepts patients within 12 months from their acute cardiologic state, living up to 50 km from the Institute, requiring less than 60 minutes of transit time. The program takes place during the morning shift, three to five times a week over three months, which allows for 42 to 64 sessions. The activities included in the OCVR program in the institute are: - Cardiorespiratory and vascular therapy – individually tailored medical gymnastics and functional aerobic training controlled by telemetric electrocardiogram monitoring along with heart frequency and arterial pressure measurements; - Non-invasive CV diagnostics; - Non-pharmacological management of risk factors and evidence-based cardiologic therapy for secondary prevention of CHD; - Education of the patient and family; - Psychodiagnostic processing and counseling. Apart from a holistic approach, “optimal dosage” is important in CV rehabilitation as well, to allow the implementation of all the measures. It has been proven that effective OCVR should include at least 36 sessions, which ensures a preventive effect on long-term outcomes (mortality and incidence of myocardial infarction) over the four years. (17) After an initial examination and evaluation, the patient is placed into one of five existing intensity level groups based on the extent of the disease, heart function, age, functional status, and comorbidities. The general state of the CV and locomotor system is improved through measured training that also improves the patient’s self-confidence. An appropriate psychological approach is used to ascertain possible psychological risk factors, help modify inappropriate behaviors, and develop relaxation and stress-reduction exercises. In particular, we aim to relieve the fear and depression that are almost always present after an acute cardiologic event. Education helps patients form healthy lifestyle habits and avoid factors that led to the disease, as well as improve treatment compliance. The social goals include achieving an independent lifestyle, returning to work and everyday duties, and resuming familial and social roles. (7, 9-11) The organization process of the OCVR program at our Institute can be summarized in seven basic steps: [list-style:none] 1. 0 – identifying and referring the candidate to a CV rehabilitation center: via doctor recommendation or mail invitation. 2. 1 – application processing: initial familiarization of the patient with a cardiologist and the contents of the OCVR program. 3. 2 – initial patient evaluation: assessing risk and intensity groups after: Analysis of the patient’s medical documentation; History and clinical examination with anthropometric measurements; 12-lead electrocardiogram and exercise stress test; Filling out an application form for OCVR; Filling out questionnaires on perceived health control sources (ZLK-90-2) and depression anxiety level assessment using the Hospital Anxiety and Depression Scale (HAD); Additional targeted tests (24 hour ambulatory blood pressure measurement, 24 hour ambulatory electrocardiographic monitoring, transthoracic echocardiography, additional laboratory tests, psychodiagnostics, and examination by a physical medicine specialist). 4. 3 – creating an individualized OCVR plan: the type, intensity, duration, and frequency of cardiorespiratory and vascular therapy are individually tailored to the patient, as well as the scope of non-invasive CV diagnostic, psychodiagnostic processing and counseling, and education plan. In general, 70-80% of the ergometric exertion levels serve as a basis for the training, taking into consideration the possibility of peripheral artery disease, cerebrovascular disease, the capabilities of the locomotor system, comorbidities, and the patient’s preferences. 5. 4 – implementation of the OCVR program. 6. 5 – final evaluation of the patient and recommendations: targeted tests before discharge, final assessment of anxiety and depression based on the HAD scale, guidance from cardiology consultation. 7. 6 – discharge and follow up: data collected during OCVR is stored in an integrated software system for medical documentation processing and printed on the discharge letter, which lists all test results, non-pharmacological treatment recommendations, pharmacological treatments, and suggested further examination and follow up. As the D1 referral form is valid for 365 days, patients who are so inclined are provided with cardiologic evaluation and follow-up examinations during that period. After the OCVR program, patients are invited to participate in long-term maintenance at the Institute (Heart Patient Club). (7) Patients are assessed for risk and assigned intensity groups, in line with OCVR principles. This phase is voluntary, and the expenses are shared between the patient and the Institute. The focus is on continuing medicinal gymnastics training twice a week, with no telemetric electrocardiogram monitoring. This option can be used by 150 to 200 patients annually, over the course of one or more months. ## Education of the patient and family/partner Education of the patient and family/partner is performed by all members of the rehabilitation team both individually and in groups, using advice, workshops, and lectures from the fields of cardiology, physical medicine and rehabilitation, psychology, and psychiatry. Weekly education of patients participating in OCVR takes place in the lecture hall of the Service for outpatient rehabilitation and lasts 45 to 60 minutes. A twelve-lecture cycle is held four times per years, dealing with the following topics: - Importance of heart and blood vessel diseases. CV risk factors. - Anatomy of the heart and blood vessels. Basics of heart physiology and blood flow. The most important places for the appearance of atherosclerotic changes. Atherosclerotic plaque. Coronary heart disease and its forms. - Proper dieting. Healthy food preparation. - Arterial hypertension – increased blood pressure. Dyslipidemia – increased levels of lipids in the blood. Metabolic syndrome – a common illness today. Diabetes. - Smoking and cardiovascular health. - Physical activity and CV disease. - Diseases of the locomotor system and CV diseases. - Body mass index. Waist circumference. Non-invasive CVD diagnostics. - Psychological factors relevant to CHD. Managing stress. - Cardiovascular medication and intervention. Prevention of CV disease. - Occupational therapy interventions in CV patients. - Everyday lives of CV patients. Lectures for the families/partners of enrolled patients take place once a month, lastin 60-90. They cover the following topics: - Everyday lives of CV patients. - Psychological factors relevant to CHD development. - Occupational therapy interventions in CV patients. Although the educational activities cannot be reimbursed from the Croatian Health Insurance Fund since April 2014, the Institute’s education team has continued their activities in line with recommendations and the needs of the patients. (18) Targeted education is performed with small groups of patients (up to five) in workshops lasting for 45 minutes: - Proper measurement of heart frequency and blood pressure. - Screening of “Passport for Life” – a video recommended by the Croatian Cardiac Society followed by conversation, counseling, and written recommendations on the import and management of CV risk. ## Diagnostic services All diagnostic services in OCVR are indicated by the cardiologist depending on the clinical picture, the primary disease, and comorbidity. Diagnostic services include: - Examination by a cardiologist - Examination by a physical medicine specialist - Psychodiagnostics, psychological counseling, and psychosocial education - Anthropometric measurements - Measuring heart rate and blood pressure - 12-lead electrocardiogram - Exercise stress test - Telemetric electrocardiogram monitoring - 24 hour ambulatory blood pressure measurement - 24 hour ambulatory electrocardiographic monitoring - Transthoracic echocardiography - Color Doppler ultrasonography of the carotid and vertebral arteries - Transcranial Doppler ultrasonography of the vertebral arteries - Doppler ultrasound of lower limb arteries - Doppler ultrasound of lower limb veins - Basic laboratory diagnostics from vein blood samples: ESR, full blood count, Tr, CRP, fibrinogen, glucosis, total cholesterol, LDL, HDL, triglycerides, urates, creatinine, potassium, bilirubin, AST, ALT, GGT, AF, blood iron, CK, and LDH - Expanded laboratory diagnostics – PV, INR, CK-MB, troponin T, NT-proBNP, D-dimer values, APTV, urea, sodium, OGTT, HbA1c, microalbuminuria, thyroid hormones, urine testing - Vital function monitoring (blood pressure, heart rate, electrocardiogram, oxygen saturation) and application of urgent medication treatment - Cardiovascular consultation - Recommendation for consultation examinations – psychiatrist, diabetologist, vascular surgeon, and other specialties - Myocardial scintigraphy under loading in a collaborating institution The decision on longitudinal follow-up of the results of individual diagnostic procedures during AKVR is made by a cardiologist, depending on the indication. ## The outpatient cardiovascular rehabilitation team The members of the outpatient cardiovascular rehabilitation team at the Institute are: cardiologists, a physical medicine specialist with additional training in cardiovascular rehabilitation, a clinical psychologists, bachelors of nursing, physical and work therapy and nurses and physical therapists, and other medical personnel as needed. The bachelors of nursing and physical therapy have additional training in diet therapy. Experts performing cardiovascular consultation are also considered part of our team. (7, 9, 11, 19) As in other European centers (20), the leader, organizer, and coordinator of the OCVR program at the Institute is a cardiologists with additional training in emergency medicine, who is constantly present in the OCVR facilities. The rehabilitation presses takes place in an atmosphere of active team-work and is not divided within particular fields, aiming at an interdisciplinary, and if possible transdisciplinary, approach. Continuous education and exchange of information of the whole team takes place on regular weekly meetings. Considering the nature of the diseases these patients suffer from, the risk of serious CV complications is always present, which necessitates adequate diagnostic and treatment equipment and constant readiness for emergency interventions. All team members are trained in performing advanced resuscitation procedures in case of cardiopulmonary arrest. The role of the cardiologist – the internist-cardiologists takes part in all OCVR activities – patient selection, individual risk evaluation, non-invasive CV diagnostics, monitoring patients during medical gymnastics and training, recommending and correcting medication treatment based on test results, counseling and education of patients and families, and cardiologic consultation. After the patient has finished the OCVR program, the cardiologist performs the final evaluation of the procedure, reassessing risk for every patient and providing a final overview in the discharge letter. The role of the physical medicine specialist – after cardiologic status evaluation, the physical medicine specialist takes a detailed working anamnesis, performs a clinical examination, and assesses the locomotor status in order to make OCVR as successful for every patient. When further examination is needed, it is requested (X-ray of the cervical, thoracic and lumbar spine, X-ray of the hips or knees; densitometry, etc.). During the examination, the medical documentation related to the locomotor system as well as neurological and neurosurgical documentation is analyzed, in addition to the findings of other specialists that could influence the OCVR process. Finally, the team jointly issues recommendations for medical gymnastics and physical therapy. If there are problems with parts of the locomotor system during OCVR, a control examination is perform and the new medical data is analyzed, and the patient and physical therapists are given further recommendations on dealing with the emerging issues, after which the OCVR program continues. During the OCVR program, the range of movement and general status at first and last examination is monitored. Medical gymnastics take place under the supervision of a bachelor of physical therapy and a physical therapist, as well as bachelor of occupational therapy.. Exercises include standing, sitting, and lying down on a mat, wall ladders, riding a bicycle using legs or arms and walking on a treadmill. During training, therapeutic correction includes individual exercises for the neck and shoulders in front of the mirror, individual exercised for lumbosacral spine, specialized exercises for the hips and knees, instructions to individual patients on proper sitting, working, lying, and reading positions, and appropriate footwear. Supervision of patients in the exercise room during AKVR is continual, with necessary correction in therapy. The role of the psychologist – after CV processing, the psychologist performs five groups of tasks in OCVR: psychodiagnostics, patient counseling, education, group therapy based on behavioral-cognitive principles, and participating in cardiovascular consultation. Psychodiagnostics includes two types of activity – testing and conversation/interviews. Testing is focused on the evaluation of the patient’s emotional state (general /Cornell Medical Index/ and individual elements – anxiety /STAI/ and depression /BDI/) and health locus of control /HLK-90/, as well as assessment of current personality functioning (Wartegg, projection test). The interview check for a wide range of emotional, cognitive, physical, social, and professional functionality in the patient, in addition to assessment of the capacity to face the illness and prediction about the communication with health personnel. This assessment generally takes place during a one-time conversation and testing, but heteroanamnestic evaluation is sometimes required. The contents and scope of the counseling depends on the patient, their primary disease, comorbidities, and possible psychological difficulties. (21) Counseling usually takes place during the interview, and if needed in additional weekly sessions. The psychologist gives two lectures on psychological risk factors for CHD as part of the regular lecture cycle for patients and their families. Patients attending OCVR are offered to take part in a small, closed relaxation and weight-reduction groups. The relaxation group teaches the following skills: diaphragmatic breathing, facilitating relaxation, adequate communication skills, anger management, assertiveness, problem-solving schemes, recognizing and coping with manipulation, etc. The weight reduction group focuses on the control of the stimuli which lead to eating, and the control of alimentary processes. Gradual reduction of daily energy intake values coupled with proper ingredient choices and combinations depending on individual risk factors. Both groups meet once a week. The psychologist takes part in cardiovascular consultation and informs other members on the psychological risk factors and characteristics of the particular patient’s personality. The Institute also provides education for psychology students from the Faculty of Philosophy and Centre for Croatian studies. The role of cardiovascular consultation – expert cardiovascular consultation is provided by representatives of the Cardiology Departments of various hospitals in Zagreb and the employees of the Institute (cardiologists, a psychologist, a bachelor of nursing). A session generally takes place once a week. A patient is presented to the consultants based on medical documentation: - When cardiovascular consultation is required to assess the health of the patient and reach a decision on further diagnostics and treatment; - When it is necessary to secure appointments for differential management in the hospital setting. Cardiovascular consultation provides other suggestions for the AKVR Service. (7) With respect to the prescribed decision, the consultation does not take part in the final decision on work ability, i.e. temporary work disability. The role of the bachelor of physical therapy/physical therapist – physical therapy begins with the application of SOAP (Subjective, Objective, Assessment, and Plan) and ICF (The International Classification of Functioning, Disability and Health) assessment models, setting up and planning goals, and evaluation and monitoring of the effectiveness of the effects of the therapy. (22) Physical therapy assessment (subjective and objective) is defined as: - Anthropometric measuring (height, weight, body mass index, waist circumference, hip circumference, hip and waist circumference ratio); - Educating the patient on heart rate and blood pressure monitoring during everyday activities; - Measuring heart rate and blood pressure before, during, and after training; - Telemetric electrocardiogram monitoring; - Recognizing CV issues and comorbidities; - Recognizing the need for further diagnostics; - Filling out the list of problems; - Consultation with a cardiologists and other members of the rehabilitation team; - Adjusting physical therapy. The physical therapist applies the appropriate cardiorespiratory and vascular therapies: - Medical gymnastics consisting of: Gradual introduction to training through easy breathing, warm up, and stretching exercises; Full training – aerobic exercises/activities of targeted intensity, frequency, and duration; Cooling down – gradual cessation of activity; Functional training consisting of predominantly aerobic activities using exercise machines: driving a leg or arm bicycle, walking on a treadmill; - In cooperation with the physical medicine specialist, the physical therapists educates the patients and advises them on health measures aimed at developing and maintaining maximal functional capacity and mobility. The physical therapists focuses on individual responses and tolerance, noticing symptoms of deterioration which are noted in the patient’s OCVR chart. Medical gymnastics and functional training are performed in groups of optimally ten patients, and 14 patients at most. Cardiorespiratory training is supervised using telemetric electrocardiogram monitoring that is generally performed on admission, in the middle, and the end of the program and during changes in exertion intensity, and more often in indicated cases. When necessitated by comorbidity or invalidity, training is performed on an individual basis. The role of the bachelor of occupational therapy/occupational therapist – the role of the bachelor of occupational therapy consist of occupational therapy (OT) evaluation and treatment. (23, 24) The first and most important step in OT assessment with is a result of a testing process and conversation. Every procedure requires an individual approach to each patient. The tests used are Canadian measure of occupational performance, Questionnaire on management/facing stress, and the Hospital Anxiety and Depression Scale. The occupational therapist much gain insights in three areas through conversation with the patient: - How the disease influences the patient’s life – when does the patients state deteriorate, which factors lead to deterioration, how long do the changes last, which symptoms manifest and in which cases, etc. - Which coping strategies (negative and positive) does the patient use; - A detailed evaluation of occupational performance (the patients areas of activity are assessed: work, rest, free time, and socialization, with the goal of forming picture of how the patient combines these areas). Assessment by a work therapist requires additional conversation with family members. Occupational therapy procedures include education and counseling that takes place individually or in smaller groups through application of the OT approach (educational approach, compensated approach, functional approach, biomechanical approach, cognitive-behavioral approach, and human occupation model). Each of these approaches is an integral part of OCVR and includes several factors, ultimately leading to increased functional capacity and improved quality of life. It is important for counselling to increase the capacity for life after rehabilitation, after which it is important to reintegrate the patient into everyday activities in their community. An integral part of the counseling is education on adapting the home and workspace to the patient’s needs.. The role of the bachelor of nursing/medical nurse – the work of medical nurses in OCVR takes place in an atmosphere that fosters an inter- and transdiciplinary approach to each patient. This approach is rooted in the basic medical care that is the determinant of the role of the medical nurse, and as such includes an active relationship with the patient through the creation of a positive and motivational atmosphere during the whole OCVR process. The medical nurse is the person that connects the cardiologist and the patient during the rehabilitation program. The bachelor of nursing takes part in the work of the OCVR team, performing tasks related to organization, diagnostics, treatment, monitoring, and education: - Organizational tasks: enrollment for possible inclusion in the program, signing up for the date of program start, preparing required documentation at admission, arrangement for the diagnostic procedures - Diagnostic/monitoring procedures: in case of problems during AKVR, the nurse takes anamnestic data, monitors vital signs, and consults with the cardiologist - Treatment procedures: in case of problems with AKVR, the nurse administers the prescribed therapy and takes part in the care and observation of the patient until they are transferred to a hospital - Education procedures: on topics related to their expertise and competencies, the medical nurse performs individual and group counseling sessions with patients on the importance of rehabilitation, taking medication regularly, and adhering to the cardiologists recommendations, gives advice on CV risk factors (25) both orally and in written form, and leads topical lectures and workshops in weakly patient education sessions. The medical nurse is also manages the availability and expiration dates of medication and the availability and functionality of equipment necessary for the whole OCVR procedure. ## Direct Medical Expenses of Outpatient Cardiovascular Rehabilitation In most European countries, less than half of the patients with indications for CV rehabilitation actually attend a CV rehabilitation program. (20) There are few publications on OCVR program expenses: - According to data from the United Kingdom (26), the direct medical expenses for OCVR programs were 5007 HRK per patient. - Data from Germany published in 2009 (27), where stationary CV rehabilitation is prevalent (28), shows that the direct medical expenses for outpatient CV rehabilitation was 4629 HRK lower than the cost of stationary CV rehabilitation, while both had the same influence on quality of life (10910.28 ± 2427.08 HRK per patient for outpatient programs versus 15533.28 ± 2727.57 for stationary programs). - The average bill per OCVR patient, directed to the Croatian Health Insurance Fund, was approximately 3500 HRK for a patient that trains three times a week over three months, analysis and procedure cost included. This is significantly more economical than the cost of stationary CV rehabilitation (DBL 08; cost per day of treatment in 2014: 574.14 HRK), especially for patients at low and moderate risk that are common in OCVR. ## Conclusion Outpatient cardiovascular rehabilitation has been proven to be an effective treatment to continuously apply after pharmacological and invasive and/or surgical treatment of the acute phase of the disease. This treatment allows clinically stable patients to lead active lives in their places of residence, thanks to the efforts of a rehabilitation team of medical workers. Cardiovascular rehabilitation is long-term treatment that increases functional capacity, allows the patient to be fit for work, and improves quality of life. This form of cardiologic treatment is, in Croatia as in other countries, adaptable and economical, but underused because it is ignored by medical professionals themselves, but also due to possible remoteness of available rehabilitation centers. Outpatient cardiovascular rehabilitation has for 33 years only been available to patients residing in the city of Zagreb and Zagreb County. Therefore, there is a need to organize rehabilitation centers in other Croatian cities as well.

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    Cardiologia Croatica
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    Outpatient Cardiovascular Rehabilitation in Croatia

    Review Article
    Issue1-2
    Published
    Pages28-42
    PDF via DOIhttps://doi.org/10.15836/ccar.2015.28
    cardiovascular rehabilitation
    secondary prevention
    physical activity

    Authors

    Mario Ivanuša*ORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Kristina Narančić SkorićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Srećka Glavaš VražićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Dubravka Kruhek LeontićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Marija HeinrichORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Lidija Mažuran BrkljačićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Gabrijela ĆurićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Goran KrstačićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia

    *Correspondence email: mivanusa@gmail.com

    Abstract

    Cardiovascular rehabilitation is a part of cardiologic treatment that is performed in specialized hospital or outpatient centers by a team of medical personnel using an interdisciplinary and transdiciplinary approach. Cardiovascular training with telemetric electrocardiogram monitoring under the supervision of a cardiologist, full non-invasive diagnostic testing, psychodiagnostics and psychological counseling, patient education, and non-pharmacological measures coupled with typical medication treatment are all integral components of cardiovascular rehabilitation programs. This article describes the organization of outpatient cardiovascular rehabilitation in the Republic of Croatia, which is a effective, safe, cost-effective procedure that can be tailored to the patient and reduces mortality, increases functional capacity, restores work fitness and work capacity, and improves quality of life.

    Full Text

    Studies have shown that appropriate management of blood pressure in patients with arterial hypertension, optimal lipid values in patients with dyslipidemia, and glucose values in patients with diabetes and metabolic syndrome, as well as smoking cessation, optimal physical activity, and management of psychosocial factors reduce comorbidity and mortality form cardiovascular diseases, coronary heart disease (CHD) in particular. (1–3) However, despite improved treatment of CHD, an organized network of primary percutaneous intervention for treatment of acute myocardial infarction (AMI), and consistent application of evidence-based measures of secondary prevention, a significant number of persons still dies from this disease. Data from the Croatian National Institute of Public Health on the number of deaths in 2013 show that AMI is one of the most common single causes of death in Croatia, at 3456 persons (2063 men and 1393 women) or 6.9% of all mortal outcomes, followed by lung cancers (2802 deaths, or 5.6%) and colorectal cancer (2037 deaths or 4%). (4)

    The basis for the development of AMI, the most common cardiovascular disease, is an unhealthy lifestyle, insufficient physical activity, and smoking. These unhealthy habits first manifest with cardiovascular risk factors, followed by subclinical disease, and finally one of the clinical manifestations (angina pectoris, AMI, chronic heart failure, peripheral artery disease, stroke, or sudden cardiac death). Depending on when the phase in which the disease is noticed, various treatments can be applied ranging from changing unhealthy lifestyle habits and pharmacotherapy, i.e. primary and secondary preventive measures, which include cardiovascular (CV) rehabilitation (Figure 1). (5, 6)

    Figure 1. Development of coronary heart disease and prevention strategies (Adapted from Ugeskr Laeger. 2002;164:2876-81.).

    A holistic approach is the basis of CV rehabilitation, and includes individual risk assessment, moderated physical activity, management of CV risk factors, education and counseling, interventions focused on the psychological behavior of the patients, and work fitness assessment. (6, 7)

    The main goals of CV rehabilitation (5, 7) are:

    • Restoring the patient’s ability to function as part of a family, in society, and in work-related activities;
    • Encouraging the patient to change their lifestyle and take responsibility for their own health;
    • Slow down or prevent the progression of the disease.

    Cardiovascular Rehabilitation Continuum

    Traditionally, CV rehabilitation has three phases (or four, according to some authors) (1, 7).

    1. During hospital treatment – in a coronary or cardiac surgery intensive care unit, early mobility therapy is applied, which includes proper positioning of the patient in bed, help with turning in bed, sitting up, and getting up from bed, as well as preparation for walking coupled with vital sign and hemodynamic value monitoring, aimed at improving oxygenation, perfusion, and muscle tone as well as prevention of complications. Patients are informed of secondary prevention measures for CV diseases, which prevents a drop in physical fitness and has a positive psychological impact. Due to application of increasingly advance methods, this period is becoming shorter (less than five days in some patients), it is extremely important to provide timely information on the state of the disease and impending recovery process;
    1. During recovery – this phase of CV rehabilitation takes place in specialized institutions characterized by teamwork (an interdisciplinary and transdisciplinary approach), continuous monitoring by a cardiologist, and telemetric electrocardiogram monitoring during physical activity. It is usually performed in hospital centers over 21 days, and in outpatient centers 3-5 times a week over three months. In both cases, physical activity is gradually increased according to generally accepted principles. After non-invasive CV and psychological diagnostics, the patient is informed of the state of their disease. The patient and family are then educated and counseled on the disease as well as further treatment and behavior aimed at encouraging changes in health behavior and reducing negative psychosocial consequences of the disease;
    1. Long-term maintenance – this phase takes place in so called cardiac patient clubs that are usually organized in rehabilitation centers, and lasts for the rest of the patient’s life. This phase is characterized by maintenance, and if possible improvement, of existing improvements achieved by CV rehabilitation, along with intermittent evaluations by internist-cardiologists, exercise stress test, and risk factor assessment, but with no telemetric electrocardiogram monitoring during physical activity. Patient follow up is most appropriately performed by a well-informed family physician. Long-term maintenance can also take place in sports facilities or in the patient’s home without medical supervision, which some author consider to be the fourth phase of CV rehabilitation.

    The Availability of Cardiovascular Rehabilitation in the Republic of Croatia

    In the Republic of Croatia, CV rehabilitation takes place in three centers:

    • In the hospital - Thalassotherapia Opatija – Special Hospital for Medical Rehabilitation of Heart and Lung Diseases and Rheumatism, Opatija (Referent Center for Cardiological Rehabilitation of the Ministry of Health, Republic of Croatia) - Special Hospital for Medical Rehabilitation, Krapinske Toplice, Croatia;
    • Outpatient - Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia.

    Simply looking at the number and location of rehabilitation centers in Croatia makes it clear that many patients will be unable to participate in CV rehabilitation programs due to their geographical location. Therefore, all patients with CHD or that had had AMI must be advised to take part in physical activity due to its benefits in addition to CV risk factor management. Brisk walking until slightly out of breath is usually advised. All patients must be educated on the methods and importance of heart rate control and arterial pressure, and it would be advisable to explain the talk test (exercise until the point that still allows them to speak short sentences) which would be an appropriate level of exertion for cardiac patients. (8)

    Goals of Cardiovascular Rehabilitation Programs

    The goals of the program do not depend on the type of center CV rehabilitation is being performed in, but are instead focused on the wellbeing of the patient, specifically on:

    • Reducing mortality and morbidity;
    • Reducing the symptoms of the disease, in particular the frequency of chest pain, shortness of breath, and fatigue;
    • Better exertion tolerance;
    • Improving work fitness;
    • Better blood pressure regulation, reduction of the heart rate;
    • Improving lipid and glucose serum values;
    • Reducing body weight and preventing obesity;
    • Smoking cessation;
    • Achieving a feeling of good health and reducing stress;
    • Improving quality of life.

    Outpatient Cardiovascular Rehabilitation in the Republic of Croatia

    The second phase of CV rehabilitation is part of the treatment of cardiovascular patients after acute hospital cardiologic or cardiac surgery treatment. In outpatient conditions, it usually takes place over 12 weeks in low and moderate risk patients, whereas in patients with high risk CV rehabilitation takes place in specialized hospitals. (1)

    The Institute for Cardiovascular Prevention and Rehabilitation has been working since 1950 in Zagreb. Outpatient cardiovascular rehabilitation (OCVR) at the Institute has been performed continuously since 1982. (7, 9–11) Patients above 18 years of age are included, and the treatment is paid for by the Croatian Health Insurance Fund based on referral by the family physician. An annual contract between the Croatian Health Insurance Fund and the Institute determines the maximum funding available for covering the bills for specialist health care.

    Since September 1, 2013, Croatian Health Insurance Fund introduced a special D1 referral form for ambulatory care, which covers the treatment for 365 days from its start.

    OCVR treatment is indicated in patients after:

    • Acute coronary syndrome, i.e. acute myocardial infarction;
    • Cardiac surgery (coronary artery bypass surgery, mechanical or biological valve implantation, valve repair, aneurism surgery, etc.);
    • Heart electrostimulator implantation or implantation of other medical devices with a similar function;
    • Percutaneous coronary intervention with stent implantation or percutaneous coronary angioplasty;
    • Heart transplant;
    • Symptomatic form of obliterating peripheral artery disease (except serious ischemia and pain at rest), etc.

    Patient compliance in these programs is high, ranging from 86% and 99%, except during the Croatian War of Independence, when it was below 80%. Data from international studies show 34-75% compliance. (7)

    Our follow up for many years found that six-year mortality in patients that went through phases 1 and 2 of CV rehabilitation was 13%, only half of which due to heart-related causes. Mortality in patients that did not take part in phases 2 and 3 of the rehabilitation was 34%, of which as much as three quarters due to cardiovascular causes. (7)

    The risk of physical training was extremely low: during 400 000 hours of exercise as part of OCVR we had only one cardiac arrest, one acute myocardial infarction, and one stroke, with no fatalities. (7)

    The Number of Participating Patients

    Approximately 450 patients attend the OCVR program annually in our Institute. Figure 2 shows the number of patients in the OCVR program from 1986 to 2014, for a total of 13009 patients.

    Figure 2. The number of patients taking part in outpatient cardiovascular rehabilitation at the Institute for Cardiovascular Prevention and Rehabilitation from 1986 to 2014.

    Most patients are referred by their cardiologist, internist, family physician, or cardiac surgeon. About a third of the patients began participation after a mail invitation based on data on patients with acute coronary syndrome from all hospitals in Zagreb, directly acquired by an employee of the Institute.

    Figure 3 shows the analysis of patients in OCVR programs based on primary diagnosis between 2005 and 2014. Approximately half of the patients had suffered acute myocardial infarction, and about 10% had underwent coronary artery bypass surgery.

    Figure 3. Analysis of patients in outpatient cardiovascular rehabilitation programs based on primary diagnosis between 2005 and 2014.

    In addition to OCVR, the Institute also has education programs for other medical professionals, students, and target high-risk groups (e.g. obese persons (12), vision impaired and blind persons (13), preventive CV exams for people in higher-risk age groups (14), etc).

    The Institute is authorized to train residents in the subspecialty of internal medicine – cardiology related to the education about rehabilitation of patients with cardiovascular disease, work fitness assessment, and CV disease prevention. In cooperation with the University of Applied Health Studies, Zagreb, we take part in the education of students for the courses on Rehabilitation of patients with heart disease and Clinical skills II in the professional undergraduate program Physical therapy and for the module Role of medical nurse in diagnostics in the specialist graduate program Clinical nursing.

    Health professionals of all profiles take part in constant medical training. Daily results are regularly published on national and international conferences, as well as periodically in indexed journals. A list of published articles is available on the Institute’s webpage. (15)

    Contents and Organization of the Program

    The organization of OCVR at the Institute is based on the principle of holistic rehabilitation, in line with European guidelines. (16) The OCVR program accepts patients within 12 months from their acute cardiologic state, living up to 50 km from the Institute, requiring less than 60 minutes of transit time. The program takes place during the morning shift, three to five times a week over three months, which allows for 42 to 64 sessions.

    The activities included in the OCVR program in the institute are:

    • Cardiorespiratory and vascular therapy – individually tailored medical gymnastics and functional aerobic training controlled by telemetric electrocardiogram monitoring along with heart frequency and arterial pressure measurements;
    • Non-invasive CV diagnostics;
    • Non-pharmacological management of risk factors and evidence-based cardiologic therapy for secondary prevention of CHD;
    • Education of the patient and family;
    • Psychodiagnostic processing and counseling.

    Apart from a holistic approach, “optimal dosage” is important in CV rehabilitation as well, to allow the implementation of all the measures. It has been proven that effective OCVR should include at least 36 sessions, which ensures a preventive effect on long-term outcomes (mortality and incidence of myocardial infarction) over the four years. (17)

    After an initial examination and evaluation, the patient is placed into one of five existing intensity level groups based on the extent of the disease, heart function, age, functional status, and comorbidities. The general state of the CV and locomotor system is improved through measured training that also improves the patient’s self-confidence. An appropriate psychological approach is used to ascertain possible psychological risk factors, help modify inappropriate behaviors, and develop relaxation and stress-reduction exercises. In particular, we aim to relieve the fear and depression that are almost always present after an acute cardiologic event. Education helps patients form healthy lifestyle habits and avoid factors that led to the disease, as well as improve treatment compliance. The social goals include achieving an independent lifestyle, returning to work and everyday duties, and resuming familial and social roles. (7, 9–11)

    The organization process of the OCVR program at our Institute can be summarized in seven basic steps:

    1. 0 – identifying and referring the candidate to a CV rehabilitation center: via doctor recommendation or mail invitation.
    2. 1 – application processing: initial familiarization of the patient with a cardiologist and the contents of the OCVR program.
    3. 2 – initial patient evaluation: assessing risk and intensity groups after: Analysis of the patient’s medical documentation; History and clinical examination with anthropometric measurements; 12-lead electrocardiogram and exercise stress test; Filling out an application form for OCVR; Filling out questionnaires on perceived health control sources (ZLK-90-2) and depression anxiety level assessment using the Hospital Anxiety and Depression Scale (HAD); Additional targeted tests (24 hour ambulatory blood pressure measurement, 24 hour ambulatory electrocardiographic monitoring, transthoracic echocardiography, additional laboratory tests, psychodiagnostics, and examination by a physical medicine specialist).
    4. 3 – creating an individualized OCVR plan: the type, intensity, duration, and frequency of cardiorespiratory and vascular therapy are individually tailored to the patient, as well as the scope of non-invasive CV diagnostic, psychodiagnostic processing and counseling, and education plan. In general, 70-80% of the ergometric exertion levels serve as a basis for the training, taking into consideration the possibility of peripheral artery disease, cerebrovascular disease, the capabilities of the locomotor system, comorbidities, and the patient’s preferences.
    5. 4 – implementation of the OCVR program.
    6. 5 – final evaluation of the patient and recommendations: targeted tests before discharge, final assessment of anxiety and depression based on the HAD scale, guidance from cardiology consultation.
    7. 6 – discharge and follow up: data collected during OCVR is stored in an integrated software system for medical documentation processing and printed on the discharge letter, which lists all test results, non-pharmacological treatment recommendations, pharmacological treatments, and suggested further examination and follow up.

    As the D1 referral form is valid for 365 days, patients who are so inclined are provided with cardiologic evaluation and follow-up examinations during that period.

    After the OCVR program, patients are invited to participate in long-term maintenance at the Institute (Heart Patient Club). (7) Patients are assessed for risk and assigned intensity groups, in line with OCVR principles. This phase is voluntary, and the expenses are shared between the patient and the Institute. The focus is on continuing medicinal gymnastics training twice a week, with no telemetric electrocardiogram monitoring. This option can be used by 150 to 200 patients annually, over the course of one or more months.

    Education of the patient and family/partner

    Education of the patient and family/partner is performed by all members of the rehabilitation team both individually and in groups, using advice, workshops, and lectures from the fields of cardiology, physical medicine and rehabilitation, psychology, and psychiatry.

    Weekly education of patients participating in OCVR takes place in the lecture hall of the Service for outpatient rehabilitation and lasts 45 to 60 minutes. A twelve-lecture cycle is held four times per years, dealing with the following topics:

    • Importance of heart and blood vessel diseases. CV risk factors.
    • Anatomy of the heart and blood vessels. Basics of heart physiology and blood flow. The most important places for the appearance of atherosclerotic changes. Atherosclerotic plaque. Coronary heart disease and its forms.
    • Proper dieting. Healthy food preparation.
    • Arterial hypertension – increased blood pressure. Dyslipidemia – increased levels of lipids in the blood. Metabolic syndrome – a common illness today. Diabetes.
    • Smoking and cardiovascular health.
    • Physical activity and CV disease.
    • Diseases of the locomotor system and CV diseases.
    • Body mass index. Waist circumference. Non-invasive CVD diagnostics.
    • Psychological factors relevant to CHD. Managing stress.
    • Cardiovascular medication and intervention. Prevention of CV disease.
    • Occupational therapy interventions in CV patients.
    • Everyday lives of CV patients.

    Lectures for the families/partners of enrolled patients take place once a month, lastin 60-90. They cover the following topics:

    • Everyday lives of CV patients.
    • Psychological factors relevant to CHD development.
    • Occupational therapy interventions in CV patients.

    Although the educational activities cannot be reimbursed from the Croatian Health Insurance Fund since April 2014, the Institute’s education team has continued their activities in line with recommendations and the needs of the patients. (18)

    Targeted education is performed with small groups of patients (up to five) in workshops lasting for 45 minutes:

    • Proper measurement of heart frequency and blood pressure.
    • Screening of “Passport for Life” – a video recommended by the Croatian Cardiac Society followed by conversation, counseling, and written recommendations on the import and management of CV risk.

    Diagnostic services

    All diagnostic services in OCVR are indicated by the cardiologist depending on the clinical picture, the primary disease, and comorbidity. Diagnostic services include:

    • Examination by a cardiologist
    • Examination by a physical medicine specialist
    • Psychodiagnostics, psychological counseling, and psychosocial education
    • Anthropometric measurements
    • Measuring heart rate and blood pressure
    • 12-lead electrocardiogram
    • Exercise stress test
    • Telemetric electrocardiogram monitoring
    • 24 hour ambulatory blood pressure measurement
    • 24 hour ambulatory electrocardiographic monitoring
    • Transthoracic echocardiography
    • Color Doppler ultrasonography of the carotid and vertebral arteries
    • Transcranial Doppler ultrasonography of the vertebral arteries
    • Doppler ultrasound of lower limb arteries
    • Doppler ultrasound of lower limb veins
    • Basic laboratory diagnostics from vein blood samples: ESR, full blood count, Tr, CRP, fibrinogen, glucosis, total cholesterol, LDL, HDL, triglycerides, urates, creatinine, potassium, bilirubin, AST, ALT, GGT, AF, blood iron, CK, and LDH
    • Expanded laboratory diagnostics – PV, INR, CK-MB, troponin T, NT-proBNP, D-dimer values, APTV, urea, sodium, OGTT, HbA1c, microalbuminuria, thyroid hormones, urine testing
    • Vital function monitoring (blood pressure, heart rate, electrocardiogram, oxygen saturation) and application of urgent medication treatment
    • Cardiovascular consultation
    • Recommendation for consultation examinations – psychiatrist, diabetologist, vascular surgeon, and other specialties
    • Myocardial scintigraphy under loading in a collaborating institution

    The decision on longitudinal follow-up of the results of individual diagnostic procedures during AKVR is made by a cardiologist, depending on the indication.

    The outpatient cardiovascular rehabilitation team

    The members of the outpatient cardiovascular rehabilitation team at the Institute are: cardiologists, a physical medicine specialist with additional training in cardiovascular rehabilitation, a clinical psychologists, bachelors of nursing, physical and work therapy and nurses and physical therapists, and other medical personnel as needed. The bachelors of nursing and physical therapy have additional training in diet therapy. Experts performing cardiovascular consultation are also considered part of our team. (7, 9, 11, 19)

    As in other European centers (20), the leader, organizer, and coordinator of the OCVR program at the Institute is a cardiologists with additional training in emergency medicine, who is constantly present in the OCVR facilities. The rehabilitation presses takes place in an atmosphere of active team-work and is not divided within particular fields, aiming at an interdisciplinary, and if possible transdisciplinary, approach. Continuous education and exchange of information of the whole team takes place on regular weekly meetings.

    Considering the nature of the diseases these patients suffer from, the risk of serious CV complications is always present, which necessitates adequate diagnostic and treatment equipment and constant readiness for emergency interventions. All team members are trained in performing advanced resuscitation procedures in case of cardiopulmonary arrest.

    The role of the cardiologist – the internist-cardiologists takes part in all OCVR activities – patient selection, individual risk evaluation, non-invasive CV diagnostics, monitoring patients during medical gymnastics and training, recommending and correcting medication treatment based on test results, counseling and education of patients and families, and cardiologic consultation. After the patient has finished the OCVR program, the cardiologist performs the final evaluation of the procedure, reassessing risk for every patient and providing a final overview in the discharge letter.

    The role of the physical medicine specialist – after cardiologic status evaluation, the physical medicine specialist takes a detailed working anamnesis, performs a clinical examination, and assesses the locomotor status in order to make OCVR as successful for every patient. When further examination is needed, it is requested (X-ray of the cervical, thoracic and lumbar spine, X-ray of the hips or knees; densitometry, etc.). During the examination, the medical documentation related to the locomotor system as well as neurological and neurosurgical documentation is analyzed, in addition to the findings of other specialists that could influence the OCVR process. Finally, the team jointly issues recommendations for medical gymnastics and physical therapy. If there are problems with parts of the locomotor system during OCVR, a control examination is perform and the new medical data is analyzed, and the patient and physical therapists are given further recommendations on dealing with the emerging issues, after which the OCVR program continues. During the OCVR program, the range of movement and general status at first and last examination is monitored.

    Medical gymnastics take place under the supervision of a bachelor of physical therapy and a physical therapist, as well as bachelor of occupational therapy.. Exercises include standing, sitting, and lying down on a mat, wall ladders, riding a bicycle using legs or arms and walking on a treadmill. During training, therapeutic correction includes individual exercises for the neck and shoulders in front of the mirror, individual exercised for lumbosacral spine, specialized exercises for the hips and knees, instructions to individual patients on proper sitting, working, lying, and reading positions, and appropriate footwear. Supervision of patients in the exercise room during AKVR is continual, with necessary correction in therapy.

    The role of the psychologist – after CV processing, the psychologist performs five groups of tasks in OCVR: psychodiagnostics, patient counseling, education, group therapy based on behavioral-cognitive principles, and participating in cardiovascular consultation. Psychodiagnostics includes two types of activity – testing and conversation/interviews. Testing is focused on the evaluation of the patient’s emotional state (general /Cornell Medical Index/ and individual elements – anxiety /STAI/ and depression /BDI/) and health locus of control /HLK-90/, as well as assessment of current personality functioning (Wartegg, projection test). The interview check for a wide range of emotional, cognitive, physical, social, and professional functionality in the patient, in addition to assessment of the capacity to face the illness and prediction about the communication with health personnel. This assessment generally takes place during a one-time conversation and testing, but heteroanamnestic evaluation is sometimes required.

    The contents and scope of the counseling depends on the patient, their primary disease, comorbidities, and possible psychological difficulties. (21) Counseling usually takes place during the interview, and if needed in additional weekly sessions. The psychologist gives two lectures on psychological risk factors for CHD as part of the regular lecture cycle for patients and their families.

    Patients attending OCVR are offered to take part in a small, closed relaxation and weight-reduction groups. The relaxation group teaches the following skills: diaphragmatic breathing, facilitating relaxation, adequate communication skills, anger management, assertiveness, problem-solving schemes, recognizing and coping with manipulation, etc. The weight reduction group focuses on the control of the stimuli which lead to eating, and the control of alimentary processes. Gradual reduction of daily energy intake values coupled with proper ingredient choices and combinations depending on individual risk factors. Both groups meet once a week.

    The psychologist takes part in cardiovascular consultation and informs other members on the psychological risk factors and characteristics of the particular patient’s personality.

    The Institute also provides education for psychology students from the Faculty of Philosophy and Centre for Croatian studies.

    The role of cardiovascular consultation – expert cardiovascular consultation is provided by representatives of the Cardiology Departments of various hospitals in Zagreb and the employees of the Institute (cardiologists, a psychologist, a bachelor of nursing). A session generally takes place once a week. A patient is presented to the consultants based on medical documentation:

    • When cardiovascular consultation is required to assess the health of the patient and reach a decision on further diagnostics and treatment;
    • When it is necessary to secure appointments for differential management in the hospital setting.

    Cardiovascular consultation provides other suggestions for the AKVR Service. (7) With respect to the prescribed decision, the consultation does not take part in the final decision on work ability, i.e. temporary work disability.

    The role of the bachelor of physical therapy/physical therapist – physical therapy begins with the application of SOAP (Subjective, Objective, Assessment, and Plan) and ICF (The International Classification of Functioning, Disability and Health) assessment models, setting up and planning goals, and evaluation and monitoring of the effectiveness of the effects of the therapy. (22) Physical therapy assessment (subjective and objective) is defined as:

    • Anthropometric measuring (height, weight, body mass index, waist circumference, hip circumference, hip and waist circumference ratio);
    • Educating the patient on heart rate and blood pressure monitoring during everyday activities;
    • Measuring heart rate and blood pressure before, during, and after training;
    • Telemetric electrocardiogram monitoring;
    • Recognizing CV issues and comorbidities;
    • Recognizing the need for further diagnostics;
    • Filling out the list of problems;
    • Consultation with a cardiologists and other members of the rehabilitation team;
    • Adjusting physical therapy.

    The physical therapist applies the appropriate cardiorespiratory and vascular therapies:

    • Medical gymnastics consisting of: Gradual introduction to training through easy breathing, warm up, and stretching exercises; Full training – aerobic exercises/activities of targeted intensity, frequency, and duration; Cooling down – gradual cessation of activity; Functional training consisting of predominantly aerobic activities using exercise machines: driving a leg or arm bicycle, walking on a treadmill;
    • In cooperation with the physical medicine specialist, the physical therapists educates the patients and advises them on health measures aimed at developing and maintaining maximal functional capacity and mobility.

    The physical therapists focuses on individual responses and tolerance, noticing symptoms of deterioration which are noted in the patient’s OCVR chart. Medical gymnastics and functional training are performed in groups of optimally ten patients, and 14 patients at most. Cardiorespiratory training is supervised using telemetric electrocardiogram monitoring that is generally performed on admission, in the middle, and the end of the program and during changes in exertion intensity, and more often in indicated cases. When necessitated by comorbidity or invalidity, training is performed on an individual basis.

    The role of the bachelor of occupational therapy/occupational therapist – the role of the bachelor of occupational therapy consist of occupational therapy (OT) evaluation and treatment. (23, 24) The first and most important step in OT assessment with is a result of a testing process and conversation. Every procedure requires an individual approach to each patient. The tests used are Canadian measure of occupational performance, Questionnaire on management/facing stress, and the Hospital Anxiety and Depression Scale. The occupational therapist much gain insights in three areas through conversation with the patient:

    • How the disease influences the patient’s life – when does the patients state deteriorate, which factors lead to deterioration, how long do the changes last, which symptoms manifest and in which cases, etc.
    • Which coping strategies (negative and positive) does the patient use;
    • A detailed evaluation of occupational performance (the patients areas of activity are assessed: work, rest, free time, and socialization, with the goal of forming picture of how the patient combines these areas). Assessment by a work therapist requires additional conversation with family members.

    Occupational therapy procedures include education and counseling that takes place individually or in smaller groups through application of the OT approach (educational approach, compensated approach, functional approach, biomechanical approach, cognitive-behavioral approach, and human occupation model). Each of these approaches is an integral part of OCVR and includes several factors, ultimately leading to increased functional capacity and improved quality of life. It is important for counselling to increase the capacity for life after rehabilitation, after which it is important to reintegrate the patient into everyday activities in their community. An integral part of the counseling is education on adapting the home and workspace to the patient’s needs..

    The role of the bachelor of nursing/medical nurse – the work of medical nurses in OCVR takes place in an atmosphere that fosters an inter- and transdiciplinary approach to each patient. This approach is rooted in the basic medical care that is the determinant of the role of the medical nurse, and as such includes an active relationship with the patient through the creation of a positive and motivational atmosphere during the whole OCVR process. The medical nurse is the person that connects the cardiologist and the patient during the rehabilitation program.

    The bachelor of nursing takes part in the work of the OCVR team, performing tasks related to organization, diagnostics, treatment, monitoring, and education:

    • Organizational tasks: enrollment for possible inclusion in the program, signing up for the date of program start, preparing required documentation at admission, arrangement for the diagnostic procedures
    • Diagnostic/monitoring procedures: in case of problems during AKVR, the nurse takes anamnestic data, monitors vital signs, and consults with the cardiologist
    • Treatment procedures: in case of problems with AKVR, the nurse administers the prescribed therapy and takes part in the care and observation of the patient until they are transferred to a hospital
    • Education procedures: on topics related to their expertise and competencies, the medical nurse performs individual and group counseling sessions with patients on the importance of rehabilitation, taking medication regularly, and adhering to the cardiologists recommendations, gives advice on CV risk factors (25) both orally and in written form, and leads topical lectures and workshops in weakly patient education sessions.

    The medical nurse is also manages the availability and expiration dates of medication and the availability and functionality of equipment necessary for the whole OCVR procedure.

    Direct Medical Expenses of Outpatient Cardiovascular Rehabilitation

    In most European countries, less than half of the patients with indications for CV rehabilitation actually attend a CV rehabilitation program. (20) There are few publications on OCVR program expenses:

    • According to data from the United Kingdom (26), the direct medical expenses for OCVR programs were 5007 HRK per patient.
    • Data from Germany published in 2009 (27), where stationary CV rehabilitation is prevalent (28), shows that the direct medical expenses for outpatient CV rehabilitation was 4629 HRK lower than the cost of stationary CV rehabilitation, while both had the same influence on quality of life (10910.28 ± 2427.08 HRK per patient for outpatient programs versus 15533.28 ± 2727.57 for stationary programs).
    • The average bill per OCVR patient, directed to the Croatian Health Insurance Fund, was approximately 3500 HRK for a patient that trains three times a week over three months, analysis and procedure cost included. This is significantly more economical than the cost of stationary CV rehabilitation (DBL 08; cost per day of treatment in 2014: 574.14 HRK), especially for patients at low and moderate risk that are common in OCVR.

    Conclusion

    Outpatient cardiovascular rehabilitation has been proven to be an effective treatment to continuously apply after pharmacological and invasive and/or surgical treatment of the acute phase of the disease. This treatment allows clinically stable patients to lead active lives in their places of residence, thanks to the efforts of a rehabilitation team of medical workers. Cardiovascular rehabilitation is long-term treatment that increases functional capacity, allows the patient to be fit for work, and improves quality of life.

    This form of cardiologic treatment is, in Croatia as in other countries, adaptable and economical, but underused because it is ignored by medical professionals themselves, but also due to possible remoteness of available rehabilitation centers. Outpatient cardiovascular rehabilitation has for 33 years only been available to patients residing in the city of Zagreb and Zagreb County. Therefore, there is a need to organize rehabilitation centers in other Croatian cities as well.

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