Cardiovascular disease (CVD) is an umbrella term for all diseases of the heart and circulation including coronary heart disease, stroke, heart failure, atrial fibrillation (AF), congenital heart disease and inherited heart conditions. There are an estimated 7 million people living with cardiovascular disease in the UK with coronary heart disease being the single biggest killer in the UK.
An ageing and growing population and improved survival rates from cardiovascular events could see these numbers rise still further. Coronary Heart Disease (CHD) occurs when coronary arteries become narrowed by a build-up of atheroma, a fatty material within their walls. The pain or discomfort felt from such narrowing is called angina and if a blockage occurs it can cause a myocardial infarction (heart attack). Most CHD deaths are caused by a myocardial infarction.
Healthy eating, regular exercise and smoking cessation are important elements in the prevention of further cardiovascular events. For those who have a myocardial infarction, undergo revascularisation or have heart failure, attending a comprehensive cardiovascular prevention and rehabilitation programme has been strongly recommended in recent scientific research papers and has become part of routine cardiology care in the UK over the last few years. The physical activity and exercise component of a programme is an integral part both in the early stages of recovery and also in the longer term. The role of an exercise professional, who must be able to demonstrate that they have the appropriate training, qualifications and skills, is important in delivering effective long-term exercise programmes and in maintaining long-term exercise habits.
Cardiovascular disease (CVD) continues to be a leading cause of mortality and morbidity in the UK with almost 160,000 individuals dying from CVD every year in the UK. Coronary heart disease (CHD) is the single biggest killer in the UK and is responsible for nearly 70,000 deaths in UK each year, an average of 190 people each day, or one death around every eight minutes. Most deaths from CHD are caused by a heart attack. An estimated 915,000 people alive in the UK today (640,000 men and 275,000 women) have survived a heart attack. More than 2.3 million people in the UK are living with some form of coronary heart disease (CHD) and more than 500,000 with heart failure.
Risk factors for CVD, both modifiable and non-modifiable are well established and lifestyle interventions which target the modifiable risk factors have been shown to have many benefits including reducing cardiovascular mortality, reducing hospital admissions and improvements in health related quality of life.
Physical inactivity is a key preventable risk factor of CVD and is considerably more prevalent than other major risk factors. Increasing overall levels of sustained in physical activity and avoidance of prolonged sedentary behaviour are associated with reduction of CVD risk. In addition low physical fitness is a strong independent predictor of CVD events. The mechanisms by which physical activity and increased fitness may decrease the risk of developing coronary heart disease include the favourable effect that exercise has on most risk factors including:
- decreased total cholesterol; increased ‘protective’ high-density lipoprotein cholesterol; decreased triglycerides
- improved glucose/insulin dynamics with better sensitivity to insulin
- reduced total body fat, reduced intra-abdominal fat
- reduced systolic and diastolic blood pressures
In addition, exercise training is known to reduce known triggers for cardiac events by:
- preventing thrombus formation
- improving endothelial function
- reducing potential for serious arrhythmias
Currently 39% of adults in the UK do not achieve the national recommended levels of moderate intensity aerobic activity for at least 150 min per week in bouts of ≥ 10 mins or 75 min per week of vigorous physical activity. Therefore all interventions, strategies and opportunities which increase an individual’s physical activity level are important and beneficial.
Cardiovascular rehabilitation (CR) is delivered by a multi-disciplinary team and aims to improve outcomes for people with CVD, with strong evidence of clinical and cost-effectiveness. The coordinated sum of interventions required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, psychological and social conditions so that the patients may by their own efforts, preserve or resume optimal functioning in their community and through health behaviour, slow or reverse progression of disease.
In the UK, CR has been traditionally described in terms of phases of recovery:
- Phase I is the inpatient stage
- Phase II the early discharge period
- Phase III ( early) is a clinically supervised outpatient programme
- Phase IV ( long-term) is the long-term maintenance of physical activity and lifestyle change
The multi-disciplinary team who delivers the early phase of rehabilitation includes cardiac nurses, doctors, physiotherapists, dieticians, psychologists, exercise professionals and occupational therapists.
The BACPR model has health behaviour change and education as the central factor with equal emphasis on lifestyle risk factor management, psychosocial health and medical risk management. A multidisciplinary team who have the necessary knowledge, skills and competences is needed in order for cardiovascular prevention and rehabilitation programmes to deliver the core components in this BACPR CR model. For further information on the CR model see BACPR 2017 Core Components and Standards.
The usual pathway of care following an early (Phase III) CR programme is for the individual to attend long term exercise (Phase IV) sessions that are held in the community. The role of the exercise professional is crucial in the long-term management of patients with CHD. Their role includes delivering regular supervised exercise classes, designing and monitoring home exercise programmes and encouraging healthy lifestyle behaviours. In addition, the role also includes taking various measurements for audit purposes (functional capacity tests, BMI, blood pressure) and to identify patients who may have developed contra-indications to exercise, which may require further medical management. These community sessions are supervised by an exercise professional who has gained the specialist REPs Level 4 Cardiac Exercise Instructor training.
There is overwhelming evidence for the physical activity and exercise component.It must however be delivered at effective evidence-base doses in order to realise these benefits. Before designing an exercise programme for individuals with cardiovascular disease careful initial screening and risk stratification is necessary in order to identify those who have absolute contraindications to exercise and therefore cannot exercise; and those who are at high risk of having a cardiac event during exercise and therefore will require close supervision and those who have co-morbidities which will require adaptations to the exercise programme. At every exercise session there should be ongoing assessment of symptoms and risk. The exercise prescription should then follow key programming principles eg.including an essential preparatory warm up and post exercise cool down, ensuring progressive cardiovascular exercise and setting an intensity which is associated with increase in fitness at the lowest risk.
The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) is a registered charity which represents and serves the interests of professionals engaged in cardiovascular rehabilitation across the UK. Its membership consists of a range of professionals involved in cardiovascular health, including: nurses, physiotherapists, cardiologists, GPs, dieticians, psychologists, occupational therapists, exercise physiologists and exercise instructors.
The BACPR fulfils a number of roles: Advising and directing national strategy; producing national standards of practice (e.g. BACPR Standards and Core Components of Cardiovascular Disease Prevention and Rehabilitation, 2017); Endorsing guidelines and liaising with allied professional groups (e.g. Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) ‘Standards for Physical Activity and Exercise in the Cardiovascular Population (2015)’ Joint working with key organisations; such as the British Heart Foundation (BHF) and Resuscitation Council UK.
There are now over 4000 instructors with the BACPR Specialist Level 4 Exercise Instructor qualification. Once qualified as a BACPR Level 4 Exercise Instructor there is an opportunity to join the BACPR Exercise Instructor Network (EIN). The main aims of the EIN are to support new and existing BACPR Exercise Instructors, act as a resource for information, support networking and develop ongoing professional development opportunities.
The BACPR–Exercise Professionals Group (BACPR-EPG) is the representative body of health and exercise professionals working within cardiovascular disease prevention and exercise rehabilitation. The BACPR-EPG is collaboration between the BACPR Qualified Exercise Instructor Network (BACPR EIN) , the Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) and the British Association of Sport and Exercise Sciences (BASES). This collaborative body of exercise professionals share the common goal of ensuring that all client and patient groups, either with cardiovascular disease (CVD) or those at high risk of developing the disease, receive quality assured evidence-based services relating to physical activity and exercise.