Your consultant has asked you to set up an audit of secondary prevention measures taken in your patients who have had an acute MI.
Which one of the following would be the correct standards/targets to assess?
The National Service Framework for Coronary Heart Disease (NSF CHD) has set the target that 85% of people discharged from hospital with a primary diagnosis of acute MI or after coronary revascularization should be offered cardiac rehabilitation, and that 1 year after discharge at least 80% of people should be non-smokers, exercise regularly, and have a BMI <30 kg/m2 . NICE and ESC guidelines recommend that post-MI patients should aim for a target BP of <140/90 mmHg and a target cholesterol of <4 mmol/L (and LDL of <2 mmol/L (<1.8 mmol/L ESC)). All patients should be offered treatment with aspirin, a statin, an ACE inhibitor/ARB, and a beta-blocker. Patients should receive dual antiplatelets12 months following an ACS irrespective of angioplasty or the type of stent. Patients with signs or symptoms of heart failure and EF <40% (EPHESUS trial) should be offered treatment with an aldosterone antagonist.
Cardiac rehabilitation programmes aim to consider the psychological and social implications of CHD as well as the practical lifestyle and medication measures involved in secondary prevention.
Which one of the following steps would not be an appropriate part of a cardiac rehabilitation programme?
The Borg Scale is used to assess the rate of perceived exertion, not quality of life. There are two Borg Scale systems—the original scale rates exertion from 6 to 20 compared with range 0–10 for the Borg CR10 Scale. The odd range of 6–20 is to follow the general heart rate of a healthy adult by multiplying by 10. The other measures listed in the question should be included in a CR programme, along with practical advice on return to work, driving, travel (including air travel), and return to sexual intercourse.
A newly qualified physiotherapist has started working on the cardiology ward and is interested in the exercise component of cardiac rehabilitation.
Which one of the following statements would give correct information about the structured exercise component of the CR programme?
Exercise sessions should involve moderate-intensity aerobic activity at least twice a week for a minimum of 8 weeks. Resistance training is an integral part of rehabilitation exercise. Exercise sessions usually last for 1 hour including a 10–15-minute warm up, an aerobic phase for 20–30 minutes, and a 10-minute cool-down. Patients should be prescribed an individualized exercise regime. Exercise intensity can be monitored using a pulse monitor or by manual pulse-taking, and looking at a percentage of the acquired maximal heart rate or estimated maximal age-predicated heart rate. Rating of perceived level of exertion is encouraged using the Borg Scale (either the 6–20 scale or the CR10 scale). When using the Borg Scale, low to moderate exertion corresponds to a score of 11–13 (4–6); a score of 15 (7) or more would indicate a high level of exertion.
The National Audit of Cardiac Rehabilitation has highlighted the problem of poor uptake of CR, with a mean of 4% of the target population taking part in 2008–2009.
Which one of the following statements is correct with regard to efforts to improve access to CR services?
The statements are all correct. Improving accessibility to rehabilitation services is vital. Greater referral (i.e. opt-out approach) is essential. Flexibility in provision is important, and patients should be offered the choice of hospital-, community-, or home-based programmes. Services should be culturally sensitive, with bilingual team members if required, and resources should be available for the visually and hearing impaired.
You are asked to help develop CR services in your area with the resources available.
Which one of the following patient groups should be prioritized to receive support from the CR programme?
As a matter of priority CR should be offered to all patients who have had an acute coronary syndrome (including STEMI, NSTEMI, and unstable angina), those patients undergoing reperfusion via either CABG or PCI, and patients newly diagnosed with chronic heart failure or with a step change in the clinical presentation of their condition. Increasingly there is also evidence to support the benefit for other patient groups, including patients with stable angina, with congenital heart disease, following cardiac transplantation, and with implantable cardiac defibrillators or ventricular assist devices.
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