The Health Curve

Cardiac Rehab: The Blockbuster Heart Disease Treatment You’ve Never Heard Of - with Patrick Dunn, PhD at the American Heart Association

• Dr. Jason Arora • Season 1 • Episode 6

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Heart disease is the leading cause of death worldwide, killing nearly 20 million people each year, including over 800,000 in the U.S.. 

But what if there was a treatment that could cut the risk of dying from heart disease by a third? Well, it already exists—it’s called cardiac rehabilitation, and it’s one of the most effective ways to help people recover after a heart attack.

Studies show that cardiac rehab can reduce the risk of death by up to 30%—a level of success that beats many prescription drugs. If it were a pill, it would be one of the best-selling drugs ever. Yet, despite its life-saving potential, less than 20% of eligible patients actually enroll. Why? Many people don’t know about it, and doctors don’t always bring it up.

In this episode, we’re breaking down:

  • What cardiac rehab is—and why it’s so powerful
  • Who it’s for—if you have or a loved one has heart disease, this is for you
  • Why so few people do it—and how to change that
  • How it works—exercise, lifestyle support, and the science behind it

If you or someone close to you has had a heart attack, heart surgery, or struggles with heart disease, this episode is a must-listen. 

SPEAKER_00:

Hello and welcome to The Health Curve. I'm your host, Jason Aurora. This week, we're talking about something that could save your life or the life of someone you love. Cardiac rehabilitation. Heart disease is the leading cause of death and disability worldwide, responsible for around 20 million deaths every year. In the US alone, one person dies from heart disease every 30 seconds. But here's the good news. For many people who have had a heart attack, heart failure, or undergone heart surgery, there's a proven way to improve recovery, reduce future risk, and extend life. And it's called cardiac rehabilitation or cardiac rehab. So what exactly is it? Cardiac rehab is a medically supervised program that includes exercise training, education about heart-healthy living and nutrition, and counseling to reduce stress and improve mental well-being. And the numbers speak for themselves. Studies show that participating in cardiac rehab can lower the risk of dying from heart disease by up to a third. And we also know that it significantly reduces the chance of you going back into hospital for heart disease. But here's the problem. Less than 20% of eligible patients actually enroll in cardiac rehab, and that number drops even further for women, older adults, and people from underserved communities. Why is something that is so effective and life-saving so underutilized? We're going to explore that and much more today. We're very grateful to be joined by Patrick Dunn, PhD, who is an expert in cardiac rehabilitation and digital health at the American Heart Association. He has spent decades working to improve access to cardiac rehab and to help more people benefit from this life-saving intervention. Thank you so much for joining us, Pat. Thank you. I want to start with what is cardiac rehab and why is it important?

SPEAKER_01:

Cardiac rehab is a program designed for people after they've had a cardiovascular event. So a heart attack, bypass surgery, a stent. They may have been diagnosed with conditions such as heart failure. So the origins of cardiac rehab, it's really to help that person regain the function that they had prior to their heart attack or their procedure. So it's historically been very focused on exercise. Your heart's a muscle. So just like any muscle, if you exercise it, it'll get stronger. You can do more work with less effort. If you were to have another heart attack, you're much more likely to survive. But clearly heart disease is more than just exercise. So it's also a good format for educating people on things like nutrition, their conditions themselves, their risk factors, such as their blood pressure, cholesterol, and also to learn techniques to help them manage stress, quitting smoking, all of the things really designed to not only return to a functional state, whether it's returning to work or just being a productive member of the family and the community, but also preventing the risk of having it happen again, having another heart attack or the need for another procedure.

SPEAKER_00:

Let's talk about the science of how this works. So how does cardiac rehabilitation improve heart health? Like why is it so impactful?

SPEAKER_01:

So again, the origins of cardiac rehab are around literally physical training. Remember, your heart is a muscle. Also remember, your heart is a very specific type of muscle. It's an aerobic muscle. So it loves rhythmic, continuous movement. activity like walking or light jogging, riding a bicycle, using a rowing machine. Frankly, walking itself is just an amazing low risk, high benefit type of physical activity. There is a role for resistance training. weight training. And increasingly, that role is becoming much more well established. There's also different methods, you know, whether it's doing high intensity interval training, for example, but the reality is still that continuous rhythmic type of activity is really the ideal form of physical activity. It builds the strength in your heart, literally building the muscle. And by doing that, your heart is stronger. It can withstand injury. It can actually help improve the circulation in your heart. It can even improve the circulation throughout your vascular system. So that's from an exercise standpoint, you know, and even back to the days of you can do more work before you get tired, before you would have something like chest pain. But that's from a physical fitness and exercise physiology point of view. Those other factors are also important. Equally important, so learning to eat right, which helps you manage your weight. But it also helps you manage your blood pressure, your cholesterol, your glucose. All of those things are super important. Like you said, managing mental health, getting into good sleep patterns. We're increasingly learning the importance of sleep as far as your overall health. Again, related to the mental health is learning how to eliminate bad habits. And one of the worst habits is smoking cigarettes. You may have other bad habits like overeating or becoming very stressed out. But smoking One of the key things there. So always think of exercise as a key factor, but also don't forget about the other factors. And if you do both of them, your risk profile for leading a longer, healthier life dramatically improves.

SPEAKER_00:

Yeah, and of course, things like smoking and eating unhealthy food causes this inflammation in your heart and vascular system, right, which basically causes blockages over time, makes your blood vessels less elastic, so you can't exercise as well because your heart and cardiovascular system cannot adapt to, you know, those increased needs. And so this is a, it's what we will call the silent killer. Cardiac rehab just sounds a lot like what we would term primary disease prevention. And we even talked about these different aspects a lot in our longevity episode, where it's how do you improve your longevity? And there seems to be a lot of overlap. So can you tell us a bit about primary and secondary prevention and where cardiac rehab fits into that?

SPEAKER_01:

So if you think about it in terms of primordial prevention, so really even preventing the risk factors of heart disease, you know, with things like diet and exercise, and then you get into primary prevention. So again, just preventing the condition, but managing the risk factors. Once you've had the condition, you're in the secondary prevention. So in many ways, with cardiac rehab, you're really at the end stage, it's secondary, or even sometimes it's called tertiary. which means you already have the disease. So you're really just trying to manage the disease. But the reality is the principles of cardiac rehab apply before you ever have that heart attack. So it's actually much more effective to prevent the heart attack to try to recover from it and you do really the same things you exercise you eat better you manage your risk factors and you manage your stress

SPEAKER_00:

so this is really about whether you're preventing the first heart attack or the second or even the third the principles are essentially the same and cardiac rehab just to clarify for our listeners is a specific program that includes all this stuff and is generally tailored to some degree to an individual.

SPEAKER_01:

That's correct. You know, again, historically, it's been offered in a healthcare setting. After you've been discharged from the hospital, even just take a step back, there's different phases of rehab. So the first phase is actually done in the hospital. So if you've ever been in the hospital with a heart attack, The people that are walking you in the hallway, maybe even walking you up and down flights of stairs, that's the first stage. It's called phase one. Phase two is after you're discharged, you come back to the hospital or the healthcare setting, and you go through a 12-week program of monitored exercise training. So it's typically three times a week for 12 weeks, so a total of 36 sessions. That's called phase two. There's also phases three and four. Phase three is kind of a transition period. In phase two, you're both supervised by healthcare professionals and you're monitored with EKG monitoring, blood pressure, heart rate. When you get into phase three, you're still supervised by, it might be a nurse or an exercise physiologist, but you're not monitored. So it's more self-monitoring. And then you move into phase four, which is both unsupervised and unmonitored. And that can be done in a gym, can be done at home, or it could also be done in the healthcare setting.

SPEAKER_00:

When are people generally going to come across cardiac rehab as a concept? Like most people may not have even heard of it.

SPEAKER_01:

So you either come across it from a loved one, maybe a father or an uncle or a grandfather who had a heart attack. The worst way to find out about cardiac rehab is through your own experience. You wake up in the hospital, you've just had a bypass operation and now they're ready to start cardiac rehab. So again, it's good to be introduced to the concept before it really becomes a critical thing. But frankly, that's how most people learn about cardiac rehab is when they're in a hospital bed, after they've survived that event. The reality is some people don't even survive the event or they have so much damage that it may not even be effective to do cardiac rehab. So again, that's where a cardiac prehab model know really doing all of these preventive measures before the event happens is always the better way to go

SPEAKER_00:

and so i guess as with many of the themes we explore in this podcast you know a lot of people are going to rely on their health care their doctor maybe their nurse to come to them with these things and the reality is most people won't sadly come across it until it impacts them or a loved one but These are all familiar concepts, of course. We talk about exercise, we talk about diet and nutrition, we talk about stress management, mental health support, and risk factor management, you know, smoking, weight management, etc. How important are these different aspects? And can you just do some of them? Or should you do all of them? How should people think about it, particularly for the prehab, the people who may not have been given a cardiac rehab program to do by their doctor? And they're just like, okay, what should I do with the time I have?

SPEAKER_01:

So there's guidelines and recommendations on all of these different domains, whether it's physical activity and exercise, nutrition, managing your weight, blood pressure. You know, specifically with physical activity, it's a good general recommendation to get at least 150 minutes of moderate to vigorous physical activity per week. That applies to everybody. So whether it's getting out, you know, in the park and walking or going to the gym and doing your workouts, Where it gets a little bit more specific in cardiac rehab is, especially if you've never exercised before, it's really important that you get that dose of exercise right. So the frequency, the intensity, and the duration. What a lot of the actual function or operation in cardiac rehab is getting your physical activity to what's called a target heart rate. That target heart rate is typically estimated based on a stress test. It can be estimated based on your age, but the reality is most people who've had a cardiovascular event or on medication that are going to make that heart rate response a little bit abnormal. So it's always better to have a stress test. But the reality is you're giving up a target heart rate. So what you're trying to do then is exercise kind of within that heart rate zone. If you go too high, it places you a little bit higher risk. Again, your heart is a muscle. And if you're working it too hard, that might not be a great outcome. But you want to be working hard enough that it's going to get the benefits. So there is a specific range that your heart likes to be working in.

SPEAKER_00:

Right. And just to note for our listeners that this is based on scientifically backed research. We know what specific things people need to do and how much they need to do it based on the condition of their heart in this case. And for a lot of these things, especially if you have heart disease already, you have to ask your doctor or your healthcare team essentially about it. Because one of the issues which we'll get into is that a lot of doctors or healthcare teams may not bring this up with a patient when they're discharged they may not refer them for cardiac rehab and so a theme that has come up in this podcast is patients need to start advocating for themselves a little bit more and that's one of the goals of this podcast is to educate people so they can do that so if people are going to their doctor and saying you know i'm interested in cardiac rehab what advice would you give those patients like how should they bring that up to their doctor what should they ask for specifically

SPEAKER_01:

Yeah, that's a great question. Because as you say, you know, despite the evidence, and the evidence is very strong, that patients will benefit from cardiac rehab. In fact, if this was a drug that you could put into a bottle, it would be a blockbuster drug, okay? Despite all that amazing evidence, very few patients ever go to cardiac rehab in the range of 20 to 30%. So people do need to be advocates for themselves and for their loved ones. And certainly, if you've had one of those conditions I mentioned, a heart attack, any form of open heart or bypass surgery, an interventional procedure such as an angioplasty or a stent, or if you've been diagnosed with heart failure, you should specifically ask your doctor, what about cardiac rehab? Typically, your doctor is going to know about cardiac rehab, so it might just simply jog their memory. If you're not really sure if you fall into those categories, it's also just a good idea to ask your doctor, what are some things I can be doing to reduce my risk of a heart attack? That might also jog the memory that, oh, you maybe you should think about cardiac rehab. Remember that I mentioned there's different phases. So it's not always a matter of can I go or not? It's really getting you plugged into the right phase. You might actually start out in a phase four program and you're still in a medically supervised environment, but it's not unlike going to a gym. It's just a much safer and frankly more effective way to do your physical activity.

SPEAKER_00:

Right. And how important is the mental health component of cardiac rehab? It's critical.

SPEAKER_01:

First of all, it's almost a normal response after you've had a heart attack or a significant cardiovascular event to be depressed or anxious. Frankly, if you're not depressed and anxious, we probably need to, you know, think more about just how in touch you are with yourself and your body. So it's a very normal process. It doesn't always mean that you're going to need to be treated with medications or therapy, but it's a very normal process. very normal process. But even beyond those emotions, so the compliance, the adherence, the motivation, those are long term pursuit, and you really need to build your mental health muscles. to stay on it, to stay compliant and motivated. You need to do it for the rest of your life. You don't need to be running marathons, but you need to be physically active. You need to keep your body and your mind strong and active for as long as you possibly can.

SPEAKER_00:

We'll get back to this conversation in just a moment. But if you're finding this episode helpful... Here's a quick ask. Take a second to follow or subscribe to the Health Curve podcast wherever you're listening. And if someone in your life would benefit from this episode or any of the others you've heard, please send it their way. All right, let's get back to it. And this is hard work that even people who are very motivated, it can get them down as well because it's so all encompassing. So It would be good to get into what are some of the common misconceptions about cardiac rehab and why are participation rates so low? We know that only about one in five eligible patients enroll in cardiac rehab. What are some of the reasons for that and what can people do about it?

SPEAKER_01:

As we talked about, you know, one of the reasons is just lack of awareness, both by the patient and their family, but also maybe the healthcare professionals involved. And not only awareness that the program exists, but also just awareness that the person might benefit. You can be relatively fit and still have a heart attack. So a misconception would be, well, I'm already pretty active. I really don't need to do this. That is a myth because, again, you get the other benefits of that exercise training. That's one. Another is, frankly, reimbursement. In many cases... The insurance company, they pay for the hospitalization, the bypass surgery, critical care, and then many times don't pay for the cardiac rehab, which to me, it just seems like that's kind of a misguided strategy. There could be some financial constraints. There may also be just some logistic constraints. Many people live too far from the healthcare setting. They might have been medevaced in from a rural area into an urban center for their procedure. Now they're back home and they live 20, 30, 50 miles from the center. And it's just not logistically possible for them to drive into that three times a week. Many people have the goal of returning to work. So again, if you're wanting to return to work and the rehab sessions are during working hours, you might not be able to for those reasons. So there's a lot of reasons and they really all add up to pretty low participation rates.

SPEAKER_00:

And so I think the first point you mentioned in particular in that if you engage in cardiac rehab regularly, A lot of people say, oh, I already go for a walk every night. I'm already pretty active, pretty fit. But I think that's a really critical one in that this can train you to be even better at managing your heart health and your overall health. It's essentially a training program for how to manage that even better. So whilst you may go for a walk for an hour every night, this is going to teach you a whole load of tricks that will give you a toolbox for doing this in lots of different ways and will improve your life overall because you can be adaptable then, right?

SPEAKER_01:

I mean, the reality is, you know, over the 40 years of doing Many people, after they've had their heart attack and after they've gone through the rehab experience, actually come out on the other end, frankly, in a healthier and happier space than they were before their heart attack. So yes, even if you get out on the weekends and do a round of golf, that doesn't mean that you're really in ideal cardiovascular health. it's always a good idea to go back, reset, figure out what that physical activity, fitness plan, as well as those other factors. And like I say, many people, they lead more fulfilling lives after the fact because they just developed better life skills.

SPEAKER_00:

Why else do people fail to complete cardiac rehab?

SPEAKER_01:

Are there any other reasons that people might relate? The unfortunate thing is if you stop the rehab, then you will start losing some of those benefits that you worked so hard to achieve. So a critical thing is figuring out within your lifestyle what how to maintain this new lifestyle that you've achieved. How do you fit exercise into your lifestyle? It's very challenging for people to leave busy lives. So a lot of it is around prioritizing, making that an important part of your day and your week.

SPEAKER_00:

People are definitely gonna keep thinking that we're just nagging them to sleep more, eat better, exercise more. But the reality is, look, healthcare is doing its best, but it's not able to keep up with what human beings need at the moment in its current form. And so folks have to advocate for themselves and take control of that health journey a bit.

SPEAKER_01:

We've also learned that it's much better when you're the one nagging yourself. When you're the one making the decision that, yes, I need to be more active. I need to lose a few pounds. I need to maybe stop smoking cigarettes. It's always more effective when you're the one making that call versus hearing it from your doctor or your spouse, coworkers, or your family members. When you're hearing it from other people, You tend to try to get on the other side of the argument. I don't need to do that. You're telling me to do that, but I don't need to do that. And that's just an argument you're never going to win. When you get to the point where you're the one advocating for yourself and making those decisions, you're always going to be in a better place.

SPEAKER_00:

What we see a lot of is women and underserved groups and minorities have worse outcomes in many things, all aspects of health and disease. But with cardiac rehab, we have lower enrollment rates amongst women, people with less education, less income, different racial minorities, ethnic minorities. Despite You know, again, in women, we've done an episode on this heart disease is the biggest killer in women worldwide. So why is it that certain groups have lower enrollment and completion rates for cardiac rehab than others? And what can we do about it?

SPEAKER_01:

As low as participation rates are in general, anytime you start looking at some groups such as women, such as minority groups, low income, low education, those numbers get even smaller. You know, with respect to women, there used to be much more of a perception that rehab is really more of a man's thing. And women would feel kind of intimidated going into more of like a gymnasium type of a setting and, you know, be working out with the guys. You know, have to say, I think our culture has really changed from the time I started working in rehab. I think women now are much more comfortable in those settings. And frankly, those settings have improved. They don't tend to be the masculine locker room type of settings. They're much more conducive to both men and women. But it's also important for other groups too, again, that they're in safe places with familiar people and just more accommodating. They don't have to travel across town to get to the site. So women, other underserved, under-resourced communities, we can always do a better job, frankly, of meeting their needs. The reality is they all benefit. There's also maybe a perception, well, women don't really have heart disease at the rates of men. They probably don't need it. And that couldn't be further from the truth. And the reality is, and again, this is from my 40 years of experience, not only women, but people of all ethnic backgrounds and racial groups and socioeconomic classes, they do equally as well as the more traditional elderly white male that's in the program. Sometimes they do incredibly well. There's no reason for profiling to say, well, you would benefit, but you wouldn't benefit. Frankly, these are the types of things that everybody benefits from.

SPEAKER_00:

Yeah. And in the case of women in particular, we covered this a bit in our other episode on cardiovascular disease prevention in women. There are these stereotypes around the fact that maybe this doesn't impact women as much, heart disease is a man's disease, but also in these historical sort of cultural things in caregiving roles in the home, women put it off because they feel they don't have time to prioritize their own health over that of their family or their children. And so we really need to debunk this and speak the scientifically backed truth on this?

SPEAKER_01:

Absolutely true. Women need to advocate for themselves. And frankly, in many cases, they are the caregivers in their family. So what better way to advocate for the whole family than to get the whole family involved in a, you know, a rehab, prehab, you know, instead of it just being the mom or the dad doing the rehab, why couldn't she have the whole family participating? That might not be going to the hospital based rehab program, but the that might be getting the family much more involved in physical activity, in gaining better nutritional habits, maybe reducing some of their screen time. So there's a lot of ways that you can also lean into family caregiving. And it's not that it's always the female, there may be males that are also in that caregiving role. And that's the same thing. Instead of I don't have time, it's like, why don't we incorporate the family and make the time so we can be with the family and we can be doing things that benefits everybody in the family.

SPEAKER_00:

Right. Today, we have cardiac rehab in a few different forms. It's delivered in a few forms. Historically, it was in hospital, generally speaking, or in a cardiac rehab center, depending on the severity. Today, we have that we have hybrid programs where some bits of it are in person, some bits of virtual, then we have these virtual only programs. Where is cardiac rehab from a delivery perspective today with regards to technology? And what are some of the innovations in this space that are coming?

SPEAKER_01:

Yeah, so the technology, frankly, has evolved. And the pandemic really helped us prove the point that people will do these things. So just real briefly, during COVID, about 75% of cardiac rehab programs actually shut down. You think about it for all the right reasons for social distancing. So that really left a lot of people without a program. That's where the technology really came into play. And the technology can be a telehealth where you could be doing a virtual session. It could also be an educational format, you know, watching a video on your smartphone, remote patient monitoring where you're tracking your blood pressure, your physical activity, your weight. And frankly, it can also be a social platform for patients to connect with their healthcare team and to other patients. Those really four factors. So doing virtual visits, doing remote monitoring, doing education and having a social platform All of those things really constitute what you can deliver in a cardiac rehab program. Now with even advanced technologies like artificial intelligence and even things like virtual and augmented reality, there's really some amazing opportunities for really taking those things to the next level. And then just briefly, is it better or worse? Well, the reality is you can attract more people in a virtual type of program because you eliminate that distance factor and also the time factor. If you don't have time to get to the rehab program or you can only get there during certain parts of the day, you can eliminate many of those factors. The data shows that these virtual programs are as effective and as safe, which is also important, as traditional center-based programs. For most people, there are still some people that you might need to have direct medical supervision. But for the majority of patients, they do great with these programs.

SPEAKER_00:

So I guess the takeaways for people are, I believe the statistic is 80 to 90% of heart disease is preventable through lifestyle changes. That's sort of the big headline. And that cardiac rehab works, it's scientifically backed, it's available in many different formats, whether in person or virtual. So you know, most people who need it, if not all can engage in it in some way. And so If you've been referred for cardiac rehab or a loved one has been referred, do it. If you haven't been referred, but you have some sort of heart disease again, or it's that of a loved one, ask about it. No matter what age you are, start doing a version yourself. We talked about this in the episode on longevity. There's a lot of overlap here around what you need to do yourself to reduce your risk of heart disease.

SPEAKER_01:

I mean, the reality is don't wait for the heart attack to happen. You know, start early and maybe that heart attack never happens. You know, so don't wait. Not everybody survives that first heart attack. So again, you're just playing the odds if you wait until that. Be proactive with your health and it'll pay off. Bet on yourself. And it'll be a good investment. You mentioned being an advocate for yourself, being a lifelong learner. Don't be discouraged if you go through cycles where you're not as active or maybe you've gained a couple of pounds. The good news is you can always get back to where you need to be. So don't get discouraged. Don't feel like you're a failure. Just get back in the game. Jump back on that horse. Keep your body strong and your mind strong. If you do both of those things, good things will happen.

SPEAKER_00:

And I think a lot of people think you have to be a perfectionist with this. There's this whole 80-20 rule, which is just over time, as long as you keep coming back to it, you will overall be in a much better spot than if you think I have to do this all or nothing once. If it's not all, it's not going to work. That's obviously not true.

SPEAKER_01:

The activity itself does not need to be painful, super strenuous. I mean, even if you think about the level of exertion of a brisk walk, that's almost like the ideal level of intensity. So that's doable for almost all of us. So also think, well, I'm not very athletic, you know, I'm not very coordinated. If you're coordinated enough to walk, then you'll be fine. And if you can't walk, there's also things you can do with your upper body. So there's always ways to be physically active. And the reality is, do things you enjoy, make it fun. You know, if it feels like it's hard work, and not fun, it's much harder to stick with it. If you find things you enjoy, then lean into what you enjoy and just keep enjoying it.

SPEAKER_00:

Pat, thank you so much for joining us. This has been incredibly educational and informative and I hope our listeners get a lot of benefit from this. So thank you so much for joining us.

SPEAKER_01:

Thank you. Thank you.