LAUSR

Heart failure and coronary heart disease are the most common cardiac diseases. Drug treatments, recanalisation procedures, pacemakers and defibrillators have greatly improved the prognosis of patients with these diseases. However, these are chronic conditions and the relatively short duration of hospital care (mean hospital stay <5 days for acute coronary syndromes, <10 days for heart failure) cannot claim to solve all the problems of a chronic condition. Health and dietary measures, regular physical activity – or at least a decrease in sedentary lifestyle – have a role as important as drug treatment. The role of therapeutic education has been recognised in recent years in these two pathologies. After a myocardial infarction or a heart failure decompensation episode, the value of cardiac rehabilitation, whether hospital or outpatient based, has been widely demonstrated. For most scientific societies, rehabilitation benefits from a level IA recommendation, the highest level. In addition to improving symptoms, quality of life and return to work, rehabilitation improves the prognosis of patients, even with the current use of stents, statins, angiotensinconverting enzyme inhibitors, resynchronisation, transcatheter aortic valve implantation and defibrillators. The recent French Health High Authority recommendations indicate cardiac rehabilitation after myocardial infarction as one of the quality criteria for a cardiology department. In patients with chronic heart failure, the benefit of physical activity on symptoms and quality of life, and probably also on prognosis, is incomparable, regardless of their left ventricular ejection fraction. However, in France, as in many countries, rehabilitation is offered to only a small number of patients: <30% post-myocardial infarction and <10% after heart failure. The reasons are well known: a lack of structure, a lack of funding, little reward for a hospital from a financial viewpoint, long waiting times for acceptance, transportation problems, early return to work and also a lack of knowledge of the beneficial effects of rehabilitation by both patients and doctors. Low attractiveness for practitioners in structures disconnected from cardiology departments has also been reported as a barrier to the implementation of rehabilitation. Rehabilitation is increasingly being performed in the outpatient mode rather than the residential mode, the latter being mainly proposed for elderly patients or patients with significant co-morbidities. However, if rehabilitation structures are located far outside the city centre, as is often the case in France, it is easy to understand that if patients have to travel several kilometres, several times a week, to attend the rehabilitation centre, irrespective of whether public transport costs are covered by health insurance, it is difficult to envisage extending residential rehabilitation to the outpatient department. It is also often claimed that therapeutic education can simply be carried out during the acute hospitalisation phase. However, under pressure from administration and financial constraints, hospital stays are becoming increasingly short, preventing the realisation of a real therapeutic education. At best, we can only provide therapeutic information. Admittedly, this therapeutic education can also be carried out in the community by practitioners, but the time constraints of our colleagues, general practitioners or cardiologists, generally limit the time that can be devoted to therapeutic education. Therapeutic education requires real expertise, specific training and doctors are not necessarily good teachers. At a distance from the post-acute phase, new modalities of education by doctors or nurses in the community, or by telemedicine, are now being developed. It is therefore generally agreed that it would be interesting to increase the number of cardiac rehabilitation structures – residential and outpatient – especially as