Cardiac rehabilitation in patients with CVD and alcohol addiction

Cardiac rehabilitation (CR) is a well proven and established process for patients with an acute or chronic diagnosis/treatment for the many facets of heart disease, but in particular cardiovascular disease. A comprehensive CR programme incorporates several weeks of monitored and guided exercise for the recovery aspect and a series of talks and supports to help the individual manage their condition for the future.

Overview of CR programme

A letter of invitation, a date for a group session with an overview of what will be offered, a brief assessment, an appointment for a treadmill ECG test and a start date for their programme are issued to each patient. Each programme runs twice per week, over eight weeks, with 10 patients per group. Exercise sessions are guided and supervised with a nurse and physiotherapist. A circuit of exercise machines, optional use of a Wii station, warm-up and warm-down sessions, ECG telemetry monitoring, blood pressure checks and laughter all combine to help the person regain or gain core strength and fitness. This process goes a long way to help the person regain confidence following a heart attack, procedure and/or surgery. Education, support and lifestyle management are key components of CR. 

Working with people following a recent health diagnosis or treatment offers a timely and potentially effective partnership, and building trust and credibility is a key part of that process. There is nothing like a recent scare to concentrate the mind.

Our team is made up of nurses, physiotherapist, psychologist, with input from a cardiologist, cardiac technician, pharmacist and dietician, and can include other links within the hospital as indicated.  

Many of the education sessions are in groups, given by different team members. An overview of the heart, how it works, what can go wrong and what needs attention, and the impact of contributing factors usually offers a lively interactive discussion. Talks offered include the importance of understanding and taking prescribed medicines, recognising and managing harmful stress, and sexual activity after heart treatment.

We use a proven and established psychological questionnaire, the Hospital Anxiety and Depression Scale (HADS) at the beginning and end of the programme.  

An important part of the lifestyle management involves awareness-raising and then one-to-one risk factor assessment and guidance on management.

The key targets of the programme include getting lipids, blood glucose, blood pressure, smoking, weight, alcohol, physical fitness levels and stress/psychological factors to desired levels.

Alcohol consumption, and reducing alcohol health harm

At international level 

The World Health Organization (WHO) gathered in 2012 at the first Global Alcohol Policy Conference (GAPC), to follow on from the WHO Global Strategy to Reduce the Harmful Use of Alcohol. The focus was on the main policy framework of principles, priority areas for action at global level, and providing a portfolio of policy options and measures that could be considered for implementation at national and local levels.

Rationale for action

Globally alcohol consumption is the third-leading risk factor for death and disability. In 2004 the harmful use of alcohol accounted for 2.3 million deaths, with more than half of deaths occurring from non-communicable diseases, including cancers, cardiovascular disease, liver cirrhosis and alcohol dependence. 

A significant public health burden is caused by alcohol-related injuries including road traffic accidents, falls, drowning, suicide, poisonings and domestic violence. Increased causes for concern and action include the role of alcohol in HIV and TB. There is also an increased culture of drinking among young people and women of childbearing age that raises concern.   

Evidence-based and cost-effective interventions exist to reduce the harmful use at global, national and local levels. These interventions include measures to raise taxes on alcohol, restrict access to retailed alcohol, and enforce bans and restrictions on alcohol advertising and marketing.

Significant international reviews of hospital emergency departments (EDs) highlighted the scale of the problem of harmful alcohol use. Alcohol misuse places a considerable burden on health services. ED and liaison psychiatry consultants combined resources to establish processes to deal with the problems.

Ireland 

A recent document from the Royal College of Physicians of Ireland (RCPI) – Reducing Alcohol Health Harm (April 2013) – gives a detailed overview of alcohol and Irish society. It outlines the scale of the problem, the cultural setting, the personal, family and social impact. It also makes recommendations to adopt proven solutions from international guidelines/standards into national policy. 

The HRB findings on attitudes and awareness of standard drink measures and low-risk weekly consumption amounts showed that less than one in 10 was clear on the various measures and recommended weekly number of standard drinks for men and women. 

Some facts outlined

The average Irish person spends approximately €2,000 per year on alcohol

• One in four injuries presenting to EDs is related to alcohol 
• Alcohol-related disorders accounted for one in 10 first admissions to Irish psychiatric hospitals in 2011
• Binge and excessive drinking frequently leads to a long list of problems, including unsafe sex, unwanted pregnancies, relationship disharmony and domestic violence 
• Drinking while pregnant can cause a range of birth defects, and intellectual impairments in the unborn child
• Some 16% of child abuse and neglect cases are associated with adult drinking patterns
• From 2003-2005 over half of all drivers fatally injured in road traffic accidents had alcohol in their blood
• Alcohol is a major contributing factor in suicide in Ireland – more than half of people who died from suicide had alcohol in their blood
• Cirrhosis of the liver, and alcoholic liver disease, has doubled in the past 15 years. And alcohol, even at low levels, increases the risk of many types of cancer. 

Alcohol plays a significant role in some of the conditions associated with heart disease. Heavy alcohol use contributes to and exacerbates hypertension, atrial fibrillation and alcoholic cardiomyopathy. When addressing the comorbidities and risk factor management associated with heart disease, guidance on alcohol intake must be an integral part.

The RCPI supports low-risk guidelines of 11 standard drinks per week (112g pure alcohol) for women and 17 standard drinks per week for men (168g) as per the National Substance Misuse Strategy. It also supports DOH guidelines of spreading the drinks out over the week, no more than five standard drinks in any one sitting, and at least three alcohol-free days during the week. When you consider that a pint counts as two standard drinks, this means a big shift in habits for many people. As alcohol use is linked to many factors including habit, mood, dependence and addiction, access to an array of supports is essential.

Screening and brief intervention

Targeted action from the Policy Group on Reducing Alcohol Health Harm (RCPI) proposed that alcohol screening and brief interventions should be embedded in clinical practice.  

Acute hospitals should have an alcohol team, led by a consultant or senior nurse. At the Mater Hospital, following large-scale studies by the ED and the liaison psychiatrist, an alcohol counsellor is in place for inpatients on a half-time basis. One other Dublin hospital also has an alcohol nurse. Both centres have plans to employ a nurse specialist to lead acute inpatient alcohol management but, as yet, no resources are available for outpatient clinic follow-up.

Brief intervention in the form of screening, awareness-raising, appropriate referral and signposting to services are all carried out in response to acute admissions by the alcohol nurse/counsellor in the two hospitals surveyed.

The screening tool used is called AUDIT (Alcohol Use Disorders Identification Test). It was developed and evaluated over a period of two decades, and has been found to provide an accurate measure of risk across gender, age and culture. AUDIT consists of 10 questions about recent alcohol use, alcohol dependence symptoms and alcohol-related problems. It is brief, rapid and flexible. It can be used either as a questionnaire or through interview. This forms the basis of a structured and supportive brief intervention.

The document gives an excellent overview of the scale of the problem, proposes evidence-based solutions, and indicates the need for national debate and co-ordinated action for this significant health risk.

Cardiac rehabilitation

In the cardiac rehabilitation setting, we use a patient-held document called a ‘heart chart’. This chart lists cardiovascular risk factors, including family history, age, smoking, lipids, hypertension, physical activity, weight/BMI, diabetes, alcohol and stress. 

Each of these topics is discussed in a group session during the first few weeks. We use DVDs, diagrams, models such as actual stents, a model food pyramid with actual-size samples, as well as booklets to support each message. Family members are welcome to attend and language interpreters are involved when indicated. 

A one-to-one appointment is given to each person – to identify factors and behaviours that may affect the individual, explaining that certain factors increase the progression of heart disease and  that altering some of those same factors can therefore reduce the process. We also explain that there are other far-reaching benefits to adopting a healthy lifestyle. The session involves discussing each factor, using clinical results in the case of bloods, blood pressure, and weight/BMI/waist measurements. We go into detail regarding smoking history, alcohol use, exercise history, managing weight and other conditions such as diabetes. Appropriate referral and signposting to relevant services is a part of this process, for example smoking cessation services and long-term exercise programmes. A full report is sent to the GP and to the referring consultant.

The cardiac event can often provide a wake-up call for life and lifestyle change. When explaining the results of the HADS psychological questionnaire, it gives an opportunity for the patient to discuss any personal details or difficulties that they would not reveal in a group setting, such as alcohol abuse. Personal, family or relationship traumas can frequently be barriers to making recommended changes. 

We then offer individual appointments to the psychologist and other relevant services. Following targeted health strategies over the past years, there have been real improvements to services treating cancers and CVD. There are pockets of excellent initiatives to deal with the problems associated with alcohol misuse, however a co-ordinated, comprehensive and integrated strategy to address the harmful effects of alcohol is overdue.

Source material

1. WHO, GABC, AUDIT 
2. Psychiatric services to emergency departments. London, 2004
3. Alcohol and Injury in Emergency Departments (WHO multicentre study)
4. Hope A, Gill A, Costello G, Sheehan J, Brazil E, Reid V. Alcohol and Injuries in A/E, a national perspective (Ireland). 2005
5. RCPI Policy Group on Reducing Alcohol Health Harm. April, 2013 (April)
6. DOHC: Series of Health Strategies, with references to harmful alcohol use. Re CVD – Building Healthier Hearts 1999, Slán 2007, National CV Health Policy 2010-2019, ACS, Model of Care 2012