Optimal Rehabilitation of the Cardiac Patient with Diabetes

Purpose:
The purpose of the study was to determine a safe blood glucose range for exercising the cardiac rehabilitation patient with diabetes who takes insulin and for discharging the patient post exercise. The staff conducted a study of diabetic patients' pre and post exercise blood glucose results.

Background/Significance:
Diabetes Mellitus (DM) is a highly prevalent condition in the cardiac rehabilitation (CR) setting. Two CR patients experienced significant hypoglycemia post exercise requiring rapid response. There was an absence of local, state or national guidelines to treat hypoglycemia in outpatient CR. Following literature review, CR staff educated themselves about evidence-based recommendations regarding diet, diabetes medications, impact of exercise on blood glucose, and potential for hypoglycemia.

Methods:
CR staff conducted a study of 131 CR patients with diabetes using a purposive, non-random sampling method. Data logs were recorded per visit for 24 months from July 2007-June 2009 for patients with diabetes taking insulin. CR staff recorded patient blood glucoses prior to exercise and immediately after or within 15 minutes post exercise. Acceptable target range for exercising was 100-300 mg/dl. The number of times blood glucose was in this range was manually tabulated. When patient BG was less than 100, CR staff intervened with appropriate treatment and instructed the patient on self-management. When BG was greater than 300, CR staff consulted patient physician.

Results:
Blood glucose in the target range increased by 10% over the study period. Following the study, CR staff developed exercise guidelines and stratified risk for hypoglycemia based upon type of oral agent or insulin therapy. CR staff adopted a hypoglycemia treatment protocol which standardized patient care. CR staff and the Outcomes Committee of the Illinois Society of Cardiopulmonary Health & Rehabilitation (ISCHR) began to study the need for more specific guidelines for diabetic patients in the CR setting. ISCHR and an interdisciplinary team from the American Association of Cardiovascular & Pulmonary Rehabilitation (AACVPR) are now developing national guidelines.

Conclusions and Implications for Practice:
Publication of national guidelines will help standardize care of the CR patient with diabetes. The CR setting provides an excellent opportunity for CR staff to educate, monitor and manage patients with diabetes because of our frequent contact and close relationship.