Heart surgery is just the start
Published Sunday, Apr. 19, 2009
Think of the worst traffic jam imaginable, Southern California bad. Imagine congestion choking off movement to all but a trickle, idling automobiles and causing noxious exhaust to build up until only gridlock remains.
That was the shape of Robert Elam's heart back in December 2004. Three arteries were completely blocked and two were 90 percent clogged. Blood was still pumping, all right, but the backup was so pronounced that it seeped rather than flowed through his system.
Quintuple coronary artery bypass surgery saved Elam's life. But had the 60-year-old Sacramento man not made the conscious, postoperative decision to dedicate himself to a cardiac rehabilitation program, it's doubtful he'd be hale and hearty enough to jump on his road bike and join his wife, Sue, next month on the four-day, 330-mile NorCal AIDS Challenge.
"I'm not a model patient," Elam says, smiling. "A model patient wouldn't be a patient (in the first place)."
But Elam is an example of how lifestyle changes can make all the difference in long-term survival for those with serious heart conditions such as bypass, angioplasty, valve repair and myocardial infarction (the fancy name for a heart attack).
Numerous studies have shown that cardiac-rehabilitation programs have helped reduce deaths from heart disease by as much as 30 percent, as well as significantly lower blood pressure and total cholesterol levels.
And yet a 2007 study in the journal Circulation reported that only 18 percent of heart patients participate in a formal rehabilitation program after hospital discharge. The report splits the blame between cardiologists who do not prescribe rehab, patients who eschew exercise and insurance companies for covering only the first three months of such programs.
"Cardiac rehab is a few hundred dollars and, still, some insurance (plans) won't pay for it," says Dr. John Chin, a cardiologist who is the medical director for Sutter Sacramento's cardiac rehabilitation program. "But they will pay 30, 40, 50 thousand dollars for the bypass. That doesn't make sense.
"Now, it's been quantified that patients going through rehab benefit, with a decrease (of heart-attack) reoccurrence of 25 percent."
Cardiologists, too, bear some responsibility, Chin adds.
"We think the best time for cardiac rehab is not immediately post-discharge but six to 12 weeks out," Chin says. "A lot of cardiologists will see (patients) for the four-week follow-up and release them to primary care and never think about (rehab)."
Too few patients buy in
Still, much of the problem stems from the patients' reluctance to participate. The Journal of Cardiopulmonary Rehabilitation reports that only half the patients referred to programs by doctors ever enrolled. Of those, only about one in five patients follow through with therapy.
"We need (the patients) to buy in to our program," says exercise physiologist Ken Rogaski, manager of Mercy General Hospital's heart and vascular rehabilitation center. "Let's be perfectly frank: These changes we are asking them to make aren't easy.
"The attitude of some people is, 'I gotta get back to work. I can't take the time off to do this.' And some people think they don't need it. Once 'normal life' returns for these patients, it becomes more of a challenge."
Rogaski says Mercy, which performs more bypass surgeries than any other Northern California hospital, has a high attendance rate among its recovering heart patients. Those who are dedicated, he says, are really dedicated.
"The nice thing is with this patient population, they are very motivated because they are scared, and fear is a great motivator," he says. "I'm not saying we get everyone to make huge lifestyle changes, but most times it's a positive effect."
Motivation can slip
Even someone seemingly as motivated as Elam, whose wife is a nurse practitioner for Kaiser Permanente in Sacramento, can backslide. After surgery, he lost a lot of weight after the exercise and dietary program Kaiser recommended. He had never had poor eating habits, anyway, and his cholesterol had never reached dangerous levels.
"But as the memory of the surgery faded, so did that commitment," he says.
Two years ago, as a gentle reminder, Sue bought Robert a road bike for Christmas. Unknown to her, in one of those marital mind-meld episodes, he had bought one for her, as well.
The couple set their sights on participating in Kaiser's NorCal AIDS Challenge charity team.
"When we started, just getting down to the (American River) bike trail was a challenge – four miles one way," Elam says. "Then we got to where we could ride all the way to Beal's Point (in Folsom) and back. You pace yourself. That's what I'll have to do. I don't recover from physical activity near as fast as I used to."
But given Elam's condition five years ago, when he could barely walk around the block right after the surgery, doing a 64-mile, out-and-back on the bike trail could be deemed a success.
It's about the long haul
Cardiac rehabilitation specialists, however, aren't looking to turn heart patients into endurance athletes. They simply want them to adopt healthful habits to prolong their lives.
"When these people think of exercise, they get this picture of someone jogging and sweating profusely," Mercy's Rogaski says. "But to get benefits we're talking about, you just need a moderate intensity of exercise.
"You need a daily prescription prescription, just like when the doctor prescribes medication. You wouldn't think of not taking it, so that has to become the thought pattern for exercise, as well."
Bill Mason, an 81-year-old Sacramento man who had quadruple bypass surgery in 2003, admits being slightly taken aback when a Mercy cardiac nurse came to his bedside and explained what was involved in the rehab program.
Yet he readily agreed to take part in the three-month conditioning program covered by his insurance. And, in the past five years, he spends $50 a month out of his own pocket to continue treatment at the center.
"This is so much better than a gym membership," Mason says. "They know everything about me and my situation, whether I'm doing less or more than this time last year. They give you the personal attention."
In the first three months of rehab, patients' hearts are monitored during aerobic exercises that range from treadmill walking to exercise bikes. (Resistance training with weights is limited to 10 pounds in this phase.)
"We err on the side of caution," Rogaski says.
Mason recalls walking on a treadmill while hooked up to a heart monitor and having Rogaski approach him.
"He said, 'Mr. Mason, will you please turn off the treadmill?' " Mason recalls. "He told me to lie on the floor, so I did. What happened was, they spotted some atrial fibrillation and they pounced on it. A nurse wheelchaired me across the plaza to the cardiologist office building. Turned out that everything worked out."
Sessions feel personal
Such peace of mind while working out is what drew Elk Grove painting contractor John Raygurt, 71, to cardiac rehab instead of joining a gym.
"They are so thorough," he says. "The feeling you get is that they really care, not like so many times in doctor's offices where they just say, 'OK, next patient.' "
Another benefit of rehab is bonding with other heart patients.
"I hesitate to use the term 'support group,' because of unfortunate connotations, but that's what it feels like," Mason says. "Maybe somebody found a new low- sodium chicken recipe and shares it. We're all in this together."
It could be that Robert Elam will be the lone quintuple-bypass patient participating in the NorCal AIDS ride, but he won't feel alone. Sue Elam and hundreds of other riders will pedal along and he also will take a vital piece of rehab equipment with him.
"I'll wear a heart monitor," he says. "It's for my peace of mind."
"This is the best thing I ever did!" - John C.
"Cardiac Rehab. keeps me going." - Peggy W.
"You have changed my life." - Stuart G.
"Cardiac Rehab. provides a social outlet, is much more supervised than a health club and keeps me honest." - Al D.
"I love it!" - Nancy C.
"This has been one of the happy times of my life. I am going to miss the positive uplift they all gave me. I will miss the exercise program they had planned for me. In fact, I will miss everything here, from Lyvonne's happy greeting, to Julia's encouragement, to Shirley's 'Buellah", and both Shirley's have been a great support. Thank you everyone."
"I have enjoyed every moment of each class, for this entire staff has been professional, caring and very observant of each person. But, most of all, it guided me to the right direction of my life. I shall continue on; I have a passion to do so. Thanks to all of you for giving me the direction on my quest to a happy lifestyle." - Sonny
"This is a wonderful program. The people were absolutely first rate."