February 3, 2015
by James Beckerman, MD, FACC
Before DAPT, TPA, or even DES, there was … a chair.
I first became aware of this “revolutionary” post-MI intervention as an intern — I was shadowing Bernard Lown, MD, the Nobel Prize winner, inventor of the defibrillator and introducer of lidocaine into medical practice. No stranger to technology, Lown ironically seemed proudest of his early work in the 1950s when the care of cardiac patients was limited to little more than observation.
Until that point, patients with heart attacks were confined to strict bed rest for 4 to 6 weeks. Even sitting in a chair was not permitted. Patients were fed by nurses and forced to use bedpans — they even required assistance to shift their position in bed. But Lown and his mentor, Samuel Levine, MD, theorized that patients would recover more quickly if they spent more time in a sitting position rather than lying in bed. During a 5-month period, Lown recruited 81 patients to participate in this “intervention” — a strangely progressive treatment for its time — in which patients were placed in a chair for 30 to 60 minutes a day for 1 week, and then remained in a chair for the majority of their waking hours during the rest of their hospitalization.
And their patients did well. Levine, more of a traditionalist, believed that the benefit was due to simple physics. Levine opined that gravity caused blood to pool in the legs of a seated person rather than settle into the bases of the lungs of the bedbound, thus helping seated patients breathe more comfortably. Also, more blood in the legs might hypothetically mean less blood moving through the heart, so the recently damaged heart would get some rest. But Lown felt differently as he recognized the lasting impact of just 60 minutes in a chair. How could sitting just an hour a day result in a benefit that would last the other 23?
Lown writes in his memoir, The Lost Art of Healing:
“The ominous implication was reinforced by the physician’s insistence on complete bed rest, proscribing all activity, even to prohibiting movement in bed. The patient was left to the mercy of forces over which he or she had no control. By contrast, patients managed in a chair did not consider themselves hopelessly ill. After all, in our culture the act of dying takes place in bed, so there was some sense of safety in being out of it.”
Lown and Levine presented their research findings to a group of physicians in Atlantic City in early 1951 and never could have known back then that their study would revolutionize the care of patients with heart disease. Their research was a precursor to the modern concept of cardiac rehabilitation, in which we encourage our patients to move more than they believe they can, to try harder than they think they should, and to recover with the confidence and self-esteem that we know they deserve.
But for unclear reasons, we are selling our patients short. Only about 20% to 30% of eligible heart patients are even referred to cardiac rehabilitation, and of those, only about 40% ultimately participate. Whether it is for lack of awareness or lack of availability, it is bad medicine to withhold a life-saving treatment. Cardiac rehabilitation is associated with a 17% lower risk of heart attack at 1 year, and a 20% lower risk of death — with a 25% decreased risk of death related to heart disease. This should put our current spending on new-age stents and lipid-lowering agents into perspective as we focus exclusively on door-to-balloon times and statin prescription rates at discharge. We need to renew our focus on exercise.
Prescribing exercise has never been easier, and patients are looking to us to create an evidence-based, motivating message that moves beyond the one-size-fits-all recommendations from the American Heart Association. While phase II hospital-based programs may not be available or convenient for all of our patients, home-based phase III and phase IV programs are our responsibility to deliver. And data suggests that home-based rehabilitation is as effective as hospital-based programs in improving exercise capacity and cardiac risk factors, not to mention heart attacks and death. Participation rates are surprisingly high — 72% at 6 months and 41% at 4 years. People double their level of physical activity in home-based programs and also experience success in quitting smoking, improving blood pressure and lipids, and reducing depression and anxiety.
Help your patients find their starting line with fitness self-assessments that they can do at home or with friends and family, like the Sitting-Rising Test or Six-Minute Walk Test. Then introduce the idea of fitness as a measurement — like blood pressure or cholesterol — that they can improve over time. Check out www.worldfitnesslevel.org for a fun estimation of VO2max that you and your patients can use to create an exercise program that is tailored to them. From there, create a time-based approach with some accountability. Raise the bar during your clinic visits and include exercise and activity as part of your regular intake — check compliance, make comparisons to prior visits, and acknowledge the benefits of their ongoing treatment. In just minutes, you can reduce costs, improve outcomes, and fill a gap in patient care.
Sixty years ago, Lown changed the practice of cardiovascular medicine by getting patients out of bed and into a chair. Now it is our time to help our patients take a stand.
James Beckerman, MD, FACC, is a cardiologist and Medical Director of Cardiac Rehabilitation and the Center for Prevention and Wellness at St. Vincent Medical Center in Portland, Ore. He is the author of Heart to Start: The Eight-Week Exercise Prescription to Live Longer, Beat Heart Disease, and Run Your Best Race.