Introduction Adv. Cardiol., vol. 24, pp. 1-5 (Karger, Basel 1978)
Rehabilitation of the Coronary Patient H.DENOLIN
In its recent publication on the statistics of myocardial infarction [1], the World Health Organization reminds us that cardiovascular diseases represent the major cause of death in the world. In 1967, these affections were responsible for 37 % of all deaths, more than cancer, accidents, or infectious diseases. This high mortality is not simply due to the aging of the population: data obtained from 29 countries show that 39 % of the deaths in men between the ages of 25 and 64 years are due to cardiovascular diseases, particularly ischemic forms. Mortality has risen faster in the young than in the aged. The same can be said with regard to invalidity, and here again ischemic diseases represent the major cause in the middle-aged man. Therefore, it is necessary to utilize all'means available in decreasing the frequency of myocardial ischemic diseases and subsequent mortality. We have thus seen considerable development in epidemiological studies related to the determination of disease incidence and isolation of probable major risk factors. A great many preventive efforts, by early detection and correction of these risk factors, have been attempted; but the results are not yet evident. On the other hand, the battle against acute complications has greatly developed in numerous countries, and coronary units with up-to-date therapeutics have certainly somewhat reduced the high mortality of the first days. Nevertheless, the early mortality remains high: from WHO figures, 34% of deaths in the first year occur within the first half hour following the onset of symptoms, rendering any idea of intervention uncertain. Deaths from myocardial infarction finally reach 40 % of cases by the end of the first year. Despite the poor prognosis for myocardial infarction, an important number of patients survive the acute phase, and it is therefore essential to maximally reduce the physiological, psychological, and social consequences of the
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
President of the Council of Rehabilitation of the International Society of Cardiology, Brussels
2
disease, and if possible lessen the risk of recurrences and increase the life span. This is the objective of cardiac rehabilitation. Up until about 15 years ago, it was classic and even obligatory to maintain patients with myocardial infarction in bed for 6 weeks, even when the clinical evolution was favorable; and often these patients were forbidden any ulterior physical or professional activity. How well I know that period! Subsequently, as the number of myocardial infarctions increased, these rigid principles were questioned. The benefits of early mobilization without increased risk became rapidly apparent. The first step of readaptation was born: earlier mobilization, evaluation of functional capacity, orientation towards physical activities adapted to the residual capacity. Concomitantly, the interest in ergometry developed: perfection of ergometers, physical tests, interpretation of their results. Though too often the notion of readaptation following infarction still remains concerned with physiological aspects, it has become apparent that the patient develops psychological and social problems which can weigh as much as, or more than, the physical condition of his future, quality of life, and possibilities of social reinsertion. The concept of readaptation has thus been extended to encompass the entire patient, implying not only an improvement of the physical capacity, but a solution to the psychological and social problems as well. In 1967, WHO's Regional Bureau of Europe established the following and still valid definition for readaptation [2]: 'One can define the rehabilitation of cardiac patients, as all the necessary activities ensuring an optimal physical, mental, and social condition, allowing these patients to occupy, by their own means, a position in society as normal as possible.' At the same time, the general principles of rehabilitation [2] - also still valid - were developed: rehabilitation should be early and continuous; it should preoccupy the physician from the first consultation through all stages of treatment or observation. In addition to physiological aspects, rehabilitation should deal with clinical, psychological, and social problems. Finally, it should not be considered an isolated therapeutic activity, but instead as one of the facets of the entire treatment. Since then, the WHO and the Council of Rehabilitation of the International Society of Cardiology have been working together in the development of these concepts: on the one hand, by diffusing as good as possible the notion of earlier and comprehensive rehabilitation and, on the other, by developing methods of approaching the patient and his relations. Though it is still difficult to assess in detail the results or appreciate the quality of proposed programs, one can note, however, that a radical modi-
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
DENOLIN
3
fication of old concepts has occurred: the length of immobilization and hospitalization has been reduced, the return to work is more frequent, the quality of life for convalescent patients has improved. The difficulty in evaluating the benefits results from the constant development of new attitudes and the growing impossibility in forming 'control' groups; however, you can believe the cardiologists with long experience: the therapeutic attitude vis-a-vis myocardial infarction has greatly evolved over the years. The results of rehabilitation, as we conceive it today, in morbidity and mortality, are particularly difficult to analyze due to the global change in therapeutic attitudes mentioned. But we have recently become conscious of having overly neglected one of the aspects of rehabilitation: the correction of residual risk factors and development of greater secondary prevention. The indisputable benefits obtained by the complete rehabilitation of patients with myocardial infarction should not prevent us from constant critical evaluation of our methods and principles, and admitting the empirical nature of certain present prescriptions. In effect, the questions regarding the validity of our physical training programs (onset, intensity, duration), psychological methods of approach, methods of secondary prevention, economic and social results, prescription of sports and professional activities, organization of treatment centers, etc. remain quite numerous. This was particularly demonstrated during the excellent symposium organized in Tel Aviv by Dr. KELLERMAN, in December 1975, and whose conclusions have just been published [3]. The place offunctional evaluation in readaptation programs, the role purely psychological of tests of physical capacity, the benefits of physical training programs, the organization of institutions, the cost versus benefit of programs are just some of the problems constantly raised. The indispensable critical evaluation regarding all these problems requires a free flow of information and discussion. It is from this point of view that the Council of Rehabilitation of the International Society of Cardiology, created in 1966, decided, for the celebration of its 10th anniversary, this first congress on the rehabilitation of coronary patients. A number of speakers will present the actual state of dominant problems, and we hope that during the open discussions numerous points of view will clarify the problems, underline the questions stimulating new research, and lead to original thoughts. For the present, let us thank Professor KURT KONIG for having had the perseverance in organizing this congress, in spite of actual difficulties. He is
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
Rehabilitation of the Coronary Patient
DENOLIN
4
one of the pioneers of ergometry and rehabilitation, and the best animator of our Council who deserves our gratitude. I would also like to thank the international organizations that have joined us in our work: the WHO, without whose aid our efforts in rehabilitation would often have been in vain, International Rehabilitation, the Council of Europe, the National Excercise and Heart Disease Programs of the United States, the World Rehabilitation Fund, all with whom the Council wishes to maximize contact and collaboration. It is also with the aim of improving the ties between all those interested in rehabilitation and its many problems that the International Council has decided to create a 'Study Group on the Rehabilitation of Cardiac Patients' in which all can join through a minimal fee; the principle objectives being to promote a rapid exchange of ideas and information, stimulate new research, induce contacts through the regular publication of a bulletin. We hope to have many subscribers and especially contributions in the form of articles, questions, announcements of meetings, etc. Moreover, the works of greater impact will be entered in a special section of the review Cardiology directed by our friend J. KELLERMAN. One of the merits of this congress will also be, I hope, to attract further interest from the medical corps, the public authorities and eventually the patients themselves, on the fundamental aspect of rehabilitation as an integral part in the daily treatment of ischemic disease. It may seem paradoxical, opening this first congress devoted to the rehabilitation of myocardial patients, but we look forward to the time when the term rehabilitation will disappear, that it cease to be a particular discipline, and instead become integrated into the complete and classic treatment of our patients. I hope that the exchange of views to follow will contribute to this goal, though all the problems may not be resolved here. In future meetings we will breech other topics such as angina pectoris, patients with coronary bypass, arterial hypertension, congenital and valvular diseases, all the subjects that might be touched upon or forgotten during the present congress, notably because of a lack of sufficient information. I look forward to the debates and thank you for your participation.
4
Organisation mondiale de la Sante: La sante publique en Europe, vol. 5: Registres de l'infarctus du myocarde (Bureau regional de l'Europe, Copenhague 1977).
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
References
Rehabilitation of the Coronary Patient
3
Organisation mondiale de la Sante: La readaptation des malades cardio-vasculaires, No. EURO 0381 (Organisation mondiale de la Sante, Geneve 1967). KELLERMAN, J. K. and DENOLIN, H. (eds): Critical evaluation of cardiac rehabilitation (Karger, Basel 1977).
Prof. H. DENOLIN, International Society of Cardiology, 178, avenue W. Churchill, B-1180 Brussels (Belgium)
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
2
5
Rehabilitation of the Coronary Patient H.DENOLIN
In its recent publication on the statistics of myocardial infarction [1], the World Health Organization reminds us that cardiovascular diseases represent the major cause of death in the world. In 1967, these affections were responsible for 37 % of all deaths, more than cancer, accidents, or infectious diseases. This high mortality is not simply due to the aging of the population: data obtained from 29 countries show that 39 % of the deaths in men between the ages of 25 and 64 years are due to cardiovascular diseases, particularly ischemic forms. Mortality has risen faster in the young than in the aged. The same can be said with regard to invalidity, and here again ischemic diseases represent the major cause in the middle-aged man. Therefore, it is necessary to utilize all'means available in decreasing the frequency of myocardial ischemic diseases and subsequent mortality. We have thus seen considerable development in epidemiological studies related to the determination of disease incidence and isolation of probable major risk factors. A great many preventive efforts, by early detection and correction of these risk factors, have been attempted; but the results are not yet evident. On the other hand, the battle against acute complications has greatly developed in numerous countries, and coronary units with up-to-date therapeutics have certainly somewhat reduced the high mortality of the first days. Nevertheless, the early mortality remains high: from WHO figures, 34% of deaths in the first year occur within the first half hour following the onset of symptoms, rendering any idea of intervention uncertain. Deaths from myocardial infarction finally reach 40 % of cases by the end of the first year. Despite the poor prognosis for myocardial infarction, an important number of patients survive the acute phase, and it is therefore essential to maximally reduce the physiological, psychological, and social consequences of the
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
President of the Council of Rehabilitation of the International Society of Cardiology, Brussels
2
disease, and if possible lessen the risk of recurrences and increase the life span. This is the objective of cardiac rehabilitation. Up until about 15 years ago, it was classic and even obligatory to maintain patients with myocardial infarction in bed for 6 weeks, even when the clinical evolution was favorable; and often these patients were forbidden any ulterior physical or professional activity. How well I know that period! Subsequently, as the number of myocardial infarctions increased, these rigid principles were questioned. The benefits of early mobilization without increased risk became rapidly apparent. The first step of readaptation was born: earlier mobilization, evaluation of functional capacity, orientation towards physical activities adapted to the residual capacity. Concomitantly, the interest in ergometry developed: perfection of ergometers, physical tests, interpretation of their results. Though too often the notion of readaptation following infarction still remains concerned with physiological aspects, it has become apparent that the patient develops psychological and social problems which can weigh as much as, or more than, the physical condition of his future, quality of life, and possibilities of social reinsertion. The concept of readaptation has thus been extended to encompass the entire patient, implying not only an improvement of the physical capacity, but a solution to the psychological and social problems as well. In 1967, WHO's Regional Bureau of Europe established the following and still valid definition for readaptation [2]: 'One can define the rehabilitation of cardiac patients, as all the necessary activities ensuring an optimal physical, mental, and social condition, allowing these patients to occupy, by their own means, a position in society as normal as possible.' At the same time, the general principles of rehabilitation [2] - also still valid - were developed: rehabilitation should be early and continuous; it should preoccupy the physician from the first consultation through all stages of treatment or observation. In addition to physiological aspects, rehabilitation should deal with clinical, psychological, and social problems. Finally, it should not be considered an isolated therapeutic activity, but instead as one of the facets of the entire treatment. Since then, the WHO and the Council of Rehabilitation of the International Society of Cardiology have been working together in the development of these concepts: on the one hand, by diffusing as good as possible the notion of earlier and comprehensive rehabilitation and, on the other, by developing methods of approaching the patient and his relations. Though it is still difficult to assess in detail the results or appreciate the quality of proposed programs, one can note, however, that a radical modi-
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
DENOLIN
3
fication of old concepts has occurred: the length of immobilization and hospitalization has been reduced, the return to work is more frequent, the quality of life for convalescent patients has improved. The difficulty in evaluating the benefits results from the constant development of new attitudes and the growing impossibility in forming 'control' groups; however, you can believe the cardiologists with long experience: the therapeutic attitude vis-a-vis myocardial infarction has greatly evolved over the years. The results of rehabilitation, as we conceive it today, in morbidity and mortality, are particularly difficult to analyze due to the global change in therapeutic attitudes mentioned. But we have recently become conscious of having overly neglected one of the aspects of rehabilitation: the correction of residual risk factors and development of greater secondary prevention. The indisputable benefits obtained by the complete rehabilitation of patients with myocardial infarction should not prevent us from constant critical evaluation of our methods and principles, and admitting the empirical nature of certain present prescriptions. In effect, the questions regarding the validity of our physical training programs (onset, intensity, duration), psychological methods of approach, methods of secondary prevention, economic and social results, prescription of sports and professional activities, organization of treatment centers, etc. remain quite numerous. This was particularly demonstrated during the excellent symposium organized in Tel Aviv by Dr. KELLERMAN, in December 1975, and whose conclusions have just been published [3]. The place offunctional evaluation in readaptation programs, the role purely psychological of tests of physical capacity, the benefits of physical training programs, the organization of institutions, the cost versus benefit of programs are just some of the problems constantly raised. The indispensable critical evaluation regarding all these problems requires a free flow of information and discussion. It is from this point of view that the Council of Rehabilitation of the International Society of Cardiology, created in 1966, decided, for the celebration of its 10th anniversary, this first congress on the rehabilitation of coronary patients. A number of speakers will present the actual state of dominant problems, and we hope that during the open discussions numerous points of view will clarify the problems, underline the questions stimulating new research, and lead to original thoughts. For the present, let us thank Professor KURT KONIG for having had the perseverance in organizing this congress, in spite of actual difficulties. He is
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
Rehabilitation of the Coronary Patient
DENOLIN
4
one of the pioneers of ergometry and rehabilitation, and the best animator of our Council who deserves our gratitude. I would also like to thank the international organizations that have joined us in our work: the WHO, without whose aid our efforts in rehabilitation would often have been in vain, International Rehabilitation, the Council of Europe, the National Excercise and Heart Disease Programs of the United States, the World Rehabilitation Fund, all with whom the Council wishes to maximize contact and collaboration. It is also with the aim of improving the ties between all those interested in rehabilitation and its many problems that the International Council has decided to create a 'Study Group on the Rehabilitation of Cardiac Patients' in which all can join through a minimal fee; the principle objectives being to promote a rapid exchange of ideas and information, stimulate new research, induce contacts through the regular publication of a bulletin. We hope to have many subscribers and especially contributions in the form of articles, questions, announcements of meetings, etc. Moreover, the works of greater impact will be entered in a special section of the review Cardiology directed by our friend J. KELLERMAN. One of the merits of this congress will also be, I hope, to attract further interest from the medical corps, the public authorities and eventually the patients themselves, on the fundamental aspect of rehabilitation as an integral part in the daily treatment of ischemic disease. It may seem paradoxical, opening this first congress devoted to the rehabilitation of myocardial patients, but we look forward to the time when the term rehabilitation will disappear, that it cease to be a particular discipline, and instead become integrated into the complete and classic treatment of our patients. I hope that the exchange of views to follow will contribute to this goal, though all the problems may not be resolved here. In future meetings we will breech other topics such as angina pectoris, patients with coronary bypass, arterial hypertension, congenital and valvular diseases, all the subjects that might be touched upon or forgotten during the present congress, notably because of a lack of sufficient information. I look forward to the debates and thank you for your participation.
4
Organisation mondiale de la Sante: La sante publique en Europe, vol. 5: Registres de l'infarctus du myocarde (Bureau regional de l'Europe, Copenhague 1977).
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
References
Rehabilitation of the Coronary Patient
3
Organisation mondiale de la Sante: La readaptation des malades cardio-vasculaires, No. EURO 0381 (Organisation mondiale de la Sante, Geneve 1967). KELLERMAN, J. K. and DENOLIN, H. (eds): Critical evaluation of cardiac rehabilitation (Karger, Basel 1977).
Prof. H. DENOLIN, International Society of Cardiology, 178, avenue W. Churchill, B-1180 Brussels (Belgium)
Downloaded by: University of Cambridge 131.111.164.128 - 1/31/2019 9:10:04 PM
2
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