Attendance and completion of cardiac rehabilitation following heart transplantation: a survey service evaluation from the referring transplant centre

Introduction

The benefits of exercise on cardiovascular health are well documented both in the prevention of health deterioration and in the recovery of post-operative patients (1). One of the biggest risks post-discharge following heart transplantation is rejection, which can occur at any time during the patient’s post-operative lifetime. Five years following heart transplant one third of patients are diagnosed with cardiac allograft vasculopathy (CAV) this increases to >50% after 10 years (2). Due to graft denervation CAV does not present with angina pain; instead, first clinical presentation may be heart failure or sudden cardiac death. Treatment of established vasculopathy is poor so focus is currently on early identification and prevention (3).

CAV alone accounts for 10% of deaths in the heart transplant population per year and current evidence suggest exercise plays a big role in both preventing this complication and in its early detection (4). During the transplantation procedure the sympathetic and parasympathetic pathways are severed; this denervation causes a loss of efferent and afferent nerve signalling into and out of the heart. Due to this the transplanted hearts response to exercise is deranged in multiple ways; slower increase in heart rate; to a lower heart rate max; with a longer time to return to a baseline heart rate; that is higher than a normal heart rate at rest (5).

Reinnervation can occur in 40–70% of heart transplant patient late after their surgery however is often unbalanced and can differ between persons. Reinnervation of the sympathetic pathways can occur at 5–6 months post-operatively but is more likely to occur at 18 months post-operatively. The parasympathetic pathway can be reinnervated as early as 3–6 months post-transplant but mostly occurs around two years. Sympathetic reinnervation can occur without parasympathetic reinnervation, but the latter seems to appear only in sympathetically reinnervated recipients. Cardiac reinnervation is highest in the left antero-basal wall of the heart and lowest in the septum and sinoatrial node regions; this is also described as being highest in the left anterior descending territory; followed by the left circumflex territory and lowest in the right coronary artery territory (5). Exercise at a moderate to intense physical training could improve the state of cardiac re-innervation as shown by improving heart rate variability (HRV) (5).

Current clinical referral pathway

At Royal Papworth Hospital (RPH) in Cambridge current practice is to refer heart transplant patients on to their local cardiac rehabilitation (CR) team for ongoing exercise prescription and monitoring post-discharge. Prior to discharge the physiotherapist responsible for the care of the patient will contact the local team and discuss whether the referral will be accepted; unfortunately, some centres still do not accept heart transplant patients. It is not reported in the literature why some centres do not accept this patient group though anecdotally it would appear to be around funding, expertise, and experience. Those patients who do not have access to a CR service due to the speciality of surgery performed, are given an exercise programme on discharge with advice on how to progress, though they are expected to complete this autonomously. Following this, a personalised letter is sent to the CR team with a full handover of the patient’s hospital stay, exercise capacity on discharge and precautions to adhere to whilst exercising. Within the report there is clear guidance on the safe prescription of exercise in this population given the severance of the vagal nerve during the surgical procedure. Once this referral has been accepted and supporting information sent, physiotherapy care is handed over to the cardiac rehabilitation team and no further routine contact is made from RPH physiotherapy department. Input is provided to patients at RPH if required in out-patient clinics or as an inpatient if readmitted; it is presumed that they attend and complete their CR course; currently it is not known by the referring centre whether these patients do as expected or whether they continue to adhere to exercise afterwards.

The aim of this service evaluation was to (1) investigate whether people that have had heart transplants and have been discharged from RPH have attended and completed CR by six months post-discharge and (2) to ascertain the barriers preventing participation and adherence to CR.

Methods

All patients referred to CR in the six-month period from January 2019–July 2019 were reviewed. 25 patients who received heart transplants at Royal Papworth hospital between these dates were referred to 23 different CR centres. These centres were contacted via email and a follow up telephone call if no response was received via email; the centres were identified from the referral forms sent that are kept by the RPH Physiotherapy team in a secure folder.

Each centre was emailed via the contact details found on the British Heart Foundation CR Finder tool (6) and asked the following four questions:

• Did the patient attend?

• Did the patient complete the course?

• Why did the patient not attend?

• Why did the patient not complete the course?

Using the Health Research Authority Decision tool, it was deemed that ethical approval was not required for this service evaluation (7). Research and Development approval was requested and granted by the research and development team at the Royal Papworth Hospital.

Results

Responses for 22/25 patients were received; three centres did not respond when contacted accounting for the three patients for which responses were not received. At six-months post discharge from hospital only 32% (n = 7) of heart transplant patients operated on at RPH between January–July 2019 had attended and completed CR.

Figure 1: Percentage of patients attending and completing cardiac rehabilitation.

Figure 1 shows that 32% (n = 7) of patients had attended and completed CR; one patient still being on the waiting list; and 63% (n = 14) of patients had not completed a CR course at six months post discharge from hospital; this is summised by adding those that did not attend at all; 27% (n = 6); with those that attended but did not complete the course; 36% (n = 8).

Six (27%) patients did not attend CR at all within the first six-months post discharge from RPH. Reasons for non-attendance included: Unable to contact (n = 3), post-operative complications (n = 1) and preference of having a home exercise programme (n = 2).

Discussion

It is known that better long-term outcomes post heart transplant are achieved through maintaining a consistent exercise routine as well as keeping a moderate level of fitness (4–5). Government recommendations of 30 minutes of moderate to intense exercise five times a week for a healthy adult are often used as a target (8). From the information collected from this service evaluation it is was found that in a 6-month period only 30% of the patients that had a heart transplant had completed cardiac rehabilitation; due to the means of data collection it was difficult to ascertain a reason as to why adherence had been poor. Although the total number of patients was low; this still accounts for the total caseload of heart transplant patients for this period at the Royal Papworth Hospital. It is important to consider a patients access to CR as this is not consistent across the country; in some cases the cardiac population do not have access to CR and are unable to be offered CR post heart transplant.

Information regarding why follow-up was inconsistent across the different CR centres when contact was lost or lack of attendance from, patients could have been explored and why some patients were not referred when moving out of area should have been collected which does present a limitation of this service evaluation. Future work could explore the patient perspectives of adherence to completing the full course of CR. The impact of attendance during/following the post-transplantation medical optimisation period could also be further analysed; during this time; the medical team work with our patients to optimise immunosuppressant’s, anti-rejection medications and stabilise any complications that may have arisen post operatively. Investigation of other forms of exercise or physical activity whether this is formally prescribed exercise, activities of daily living or otherwise would be beneficial. Further exploration into these areas could provide more options for the patient to be able to adhere fully whilst still being able to adapt their lifestyle around this life changing time. It is hoped that this could highlight the need for further research looking at why patients may not consistently engage in CR post heart transplant leading to poor completion levels at six months post discharge; further service evaluation exploring the benefits and limitations of a telephone follow-up service could also provide further information to guide clinical practice on the best way to support this patient group post-discharge to engage with and furthermore complete CR.

Conclusion

In conclusion 30% will never be an acceptable rate of attendance to CR however, further service improvement could be done to improve the engagement of potential CR users and ensure better attendance rates in the future. As the referring centre it is vital we can improve engagement and understanding of the importance of CR following heart transplantation. It is essential that patients are provided with adequate follow-up to ensure that access to and adherence to a long-term exercise programme is met. In doing this, early identification of rejection, prevention of long-term co-morbidities as well as a healthy lifestyle may be achieved furthermore reducing mortality rates and improving quality of life in this patient group.

As a result of this information, the RPH Physiotherapy team responsible for the care of transplant patients have implemented a telephone follow-up service at six weeks and six months post discharge to review exercise routines and support further with referrals. Further data is being collected to see whether this is sufficient or whether face-to-face or virtual follow up meetings would provide better adherence and outcomes. The physiotherapy team have implemented this as an appropriate service to support the aftercare of the RPH heart transplant patient group and therefore individual CR centres have not been informed of this.

Acknowledgements

Presentation opportunity at Society for Cardio Thoracic Surgery Annual Research conference (November 2020).

Physiotherapy Service Lead Allaina Eden, for support with proof reading, feedback and publishing this work in this form.

Physiotherapy Team Lead Emma Matthews, for supporting with non-clinical time to complete the data collection and support with proof reading and feedback.

References

1 Pinckard K, Baskin KK, Stanford KI. Effects of exercise to improve cardiovascular health. Front Cardiovasc Med. 2019;6:69. https://doi.org/10.3389/fcvm.2019.00069.

2 Lund L, Edwards L, Kucheryavaya A, Benden C, Christie J, Dipchand A, Dobbels F, Goldfarb S, Levvey B, Meiser B, Yusen R, Stehlik J, International Society of Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: 31st official adult heart transplant report – 2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33(10):996–1008. https://doi.org/10.1016/j.healun.2014.08.003.

3 Nikolova AP, Kobashigawa JA. Cardiac allograft vasculopathy: The enduring enemy of cardiac transplantation. Transplantation. 2019;103(7):1338–1348. https://doi.org/10.1097/tp.0000000000002704.

4 Kittleson M, Patel J, Rafiei M, Osborne A, Chang D, Czer L, Kobashigawa J. Role of cardiac rehabilitation after heart transplantation in the reduction of cardiac allograft vasculopathy. Am J Transplant. 2013;(13). https://atcmeetingabstracts.com/abstract/role-of-cardiac-rehabilitation-after-heart-transplantation-in-the-reduction-of-cardiac-allograft-vasculopathy-the/. [Accessed 28th November 2022].

5 Awad M, Czer L, Hou M, Golshani S, Goltche M, Robertis M, Kittleson M, Patel J, Azarbal B, Kransdorf E, Esmailian F, Trento A, Kobashigawa J. Early denervation and later reinnervation of the heart following cardiac transplantation: A review. J Am Heart Assoc. 2016;5(11):e004070. https://doi.org/10.1161/jaha.116.004070.

6 British Heart Foundation. Cardiac rehabilitation programme and certification register. http://www.cardiac-rehabilitation.net/cardiac-rehab.htm [Accessed 28th November 2022].

7 Medical Research Council. Do I need NHS REC review? http://www.hra-decisiontools.org.uk/ethics/ [Accessed 28th November 2022].

8 Public Health England. Health matters: getting every adult active every day. 2016. https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day [Accessed 28th November 2022].