Philip Ades and Teams Cardiac Rehab Approach Saves Lives and Lifestyles
Philip Ades walks out into the narrow gym, glances quickly at the chattering
bicycles and whirring treadmills jammed against the gray cinderblock walls,
There is no spandex here, no loud music. An old woman, hair gray and sparse,
chugs away determinedly on a treadmill, as a nurse in bright scrubs urges
her on. Two paunchy men in their seventies trade stories and alternate
sets on a leg-press machine.
This gym, tucked away in a remote corner of Patrick Gym, is the breathing,
sweating center of the University of Vermonts nationally renowned
cardiac rehabilitation program. The small space is Adess laboratory,
his classroom, his patients lifeline. This is the place where damaged
hearts become strong, a place where patients rebuild their lives, one
hesitant step at a time. It is also the proving ground for millions of
dollars in research attempting to find the fastest and most effective
ways to bring people back from serious heart problems and make
sure they never succumb again.
For most people, heart disease is their first brush with death.
It is the ultimate teachable moment, Ades says. If youre
ever going to change, its the ideal time.
FROM PHYSIOLOGIST TO SOCIOLOGIST
Heart disease has a way of grabbing your attention. So does Phil Ades.
You live life long and well perhaps, in retrospect, a bit too well
and then the fire starts. Time and genetics and hamburgers conspire.
The arteries narrow. You feel weaker, or perhaps you dont; you fail
a stress test, possibly, or you might have a heart attack, a white-hot
assault on the bodys most precious muscle. Then its a bypass,
a stent, a balloon. Sometimes there isnt a medical emergency, just
a bad cholesterol test and a blunt take-down from Ades, his eyes slowly
moving up from figures on a chart to lock in on your eyes: Do you
want to stop smoking before or after your heart attack?
The doctors professional life is centered on convincing patients
that a long life tastes better than steak, and then channeling that realization
into a diet and exercise program for the rest of their lives. The tools
are simple, treadmills and weights and the food pyramid, but the results
are profound. Cardiac rehabilitation was found to reduce the risk of death
in heart patients by 25 percent after three years in one large comparison
of older studies. Thats a dramatic drop, especially when you consider
that coronary heart disease is the leading cause of death in the United
States. And a good rehabilitation improves the quality of life, not just
its length. Participants enjoy less depression, less obesity, less incidence
of disease, and a better quality of life on dozens of measures objective
Ades and his UVM team try to help their patients do even better by driving
clinical care with a burgeoning research program. The group recently received
$1.5 million from the National Institutes of Health to conduct a long-term
study testing Adess hunch that long, frequent walks might help heart
patients lose weight more effectively than less frequent, shorter workouts.
A smaller version of the trial was extremely encouraging, and Ades thinks
the work may prove to be the groups most important yet, providing
clinicians with a simple but effective tool for combating Americas
epidemic of obesity. Research like this, he says, is one of the most exciting
aspects of the job.
What really makes this interesting for me, the part of the job that
I just truly love, is asking questions that could improve care and then
going out and testing different ways of treating patients to help them
do better, Ades says.
In the mid-1980s, when Ades arrived to direct the program, his research
focus was wonky. He was a measurement freak, conducting muscle biopsies
and monitoring enzymes, and charting progress on dozens of obscure measures.
His goal was to see which regimens most efficiently improved the capacity
for exercise. But as he met more patients and talked with them about their
lives and jobs and fears, his emphasis slowly shifted. The scientist became
a sociologist, and he saw that the results under the microscope didnt
always translate into success at home. He began asking another question,
powerful and simple: How can we help this person do better in the real
world? How can we help them do better at home? Instead of just measuring
the things that he found important, the enzymes and lipid indicators,
he asked his patients to gauge their progress on measures they found important
in their daily lives. The results were dramatic.
In a 1999 study, Ades put patients on a thrice-weekly exercise program
and asked them to assess their daily functioning before and after the
trial. They reported a 20 percent increase in their ability to get things
done, a figure correlated with their improvement on physiological tests.
The study also showed that the exercise program reduced depression significantly.
The results were an encouraging validation that gains in rehab translated
to gains in real life, but subsequent work has shown that the translation
is not a given. Ades says that his teams research shows that getting
stronger in the gym doesnt necessarily mean that patients do more.
Capacity, in other words, does not automatically translate into activity.
Thats a bad thing, since doing more daily activity is crucial to
leveraging the health gains earned in the gym. So Ades is working on a
new study that will measure the effectiveness of combining rehabilitation
with counseling. The aim is to get patients to the point where they can
do more, then encourage them to actually do more, fighting the devastating
spiral of inactivity that feeds upon itself and can leave
older heart patients depressed, helpless, and in fragile health.
Adess goal is to save lives, of course, but he also wants to save
lifestyles. This is not the hottest area of cardiology, but it suits him
Lets face it: It is far, far more exciting to place a $3,000
stent coated with drugs inside someones heart than prescribe and
carry out strength training for an 80-year-old woman, he says. But
that strength training is going to allow her to stay active at home rather
than go to an assisted living facility. I dont know, I find that
THE ART OF THE COMEBACK
Maeck 34, a heart attack survivor and participant in the cardiac
rehabilitation program, rubs her eyes after a lively half-hour of chat
in her Shelburne home and begins telling a story that is typical of the
programs most successful participants. Shes been laughing
and telling tales of trips all over the world and her unlikely discovery
of pumping iron at age 88. The conversation turns to her heart attack
now, and her voice gets quiet. Needing a wheelchair, being chained
to an oxygen tank, thats death for me, she says, a tremor
creeping into her normally strong voice. I couldnt bear it.
When she woke up in a San Antonio hotel feeling queasy with a dull ache
in her chest, Maeck instantly knew what was wrong: her dinnertime martini.
Her diagnostic skills, sadly, do not equal her abilities as a raconteur.
The ache was a heart attack. In the blur of visits and consultations and
decisions that followed, Maeck faced the stark choices of an elderly person
confronted with a jam in the hearts complex choreography. There
was either surgery, difficult and invasive, or a life diminished. A life,
perhaps, without travel, work, snowshoes.
For Maeck, that wasnt a choice. I asked them to give me the
bypass yesterday, she says.
Part of Adess job is helping his patients make changes, showing
them how and why they should adopt better diet and exercise habits. Another
part of the job, connected inextricably with the first, is helping people
like Doris Maeck keep things exactly the same as they were before heart
disease. His work keeps the elderly widower at home with his garden, rather
than shunting him off to assisted living. It keeps the machinist on the
job to protect his benefits, or lets the retired bon vivant with
a bad heart valve keep racking up those frequent flier miles.
His most powerful tool to maintain lifestyle is lifestyle. Walks on a
treadmill or better yet, on the green grass of a Vermont June
build stamina and force the heart and lungs to get stronger. Lifting weights,
so odd and unnatural for many older people, is key to carrying your own
groceries up the stairs, or hefting a laundry basket. Or, in the case
of 84-year-old Littleton Tiny Long, who spent 36 years as
a University of Vermont English professor, to nimbly mounting the trusty
Farmall tractor he uses to mow his South Burlington orchard
Driving the tractor, thats the easy part, Long says.
The hard part was getting out of bed after entering the hospital with
chest pains and leaving twenty-one days later with a quadruple bypass.
Long couldnt even get up to walk for the first ten days; even after
returning home, he spent a month sleeping in his living room to keep movement
to a minimum. But as he healed and got stronger, he began visiting Patrick
Gym for rehabilitation sessions, starting with a few minutes on the treadmill.
The nurses stayed close at first, watching his pulse and blood pressure.
As he got stronger, they edged away. Now Long visits the rehab gym three
times a week to exercise, check in with medical staff and visit with his
fellow patients. He says hes surprised that he looks forward to
the appointments. And hes delighted that he can once again tend
his trees, dragging 150 feet of rubber hose through the orchard so he
can spray antique trees laden with spitzenberg and northern spy apples.
I am grateful that I can still fulfill my duty to the land. We bought
the land, we have taken care of the land for fifty years, and there is
pleasure in watching the trees flourish, Long says.
HABITS OF THE HEART
Ades finds similar enjoyment in watching his patients progress. His role
as a clinician and researcher is to be a coach, catalyst, authority, and
a safeguard. But the strength to change long-held habits, replacing harmful
routines with healthier ones, comes from within. The patients do the work;
Ades offers expertise, and a very personal example.
If I didnt run five days a week, Id be overweight,
he says. I live the way my patients should.
If Ades leaves his running shoes in the closet for more than two consecutive
days, he feels an itch that becomes unbearable. Doing the right thing
for his heart, his body, is easier in many senses than sitting around,
he says, a rare thing in a contemporary culture characterized more by
effort-sparing innovations like the Segway scooter than sweat. Habits
are powerful and work for good as well as ill. So Ades might ask a patient
to take walks four times a week at noon, trying to create a pattern, an
Cardiac rehab participants say that their regular visits to the facility
also help establish exercise as a habit. The fellowship of exercising
week after week at the same time with the same small group of people has
rewards, says Bill Daniels, a retired UVM history professor, that go beyond
We used to joke that you never left this program alive, says
Daniels, who has been in the program since his triple-bypass in 1995.
Thats a much better thing than it sounds like after youve
had a gummed-up heart and should be dead.
Most participants dont, and cant, spend as much time in Patrick
Gym as Daniels. But most agree that the support they receive from other
patients is as valuable as the counseling they receive from medical staff.
The center, like the town, is a small and convivial space; the gray cinderblock
walls only look drab. The room is alive with the sounds of movement, and
conversation. Its exercise, and also social occasion. Its
a support group, Daniels says.
Maeck agrees. It was such a scary time after the surgery, and it
was important to know I was not alone, she says.
She takes that sense of fellowship home with her when she leaves the gym.
Sitting on her sofa, just back from playing bridge with friends, Maeck
muses on how lifting weights and walking on a treadmill, so unfamiliar
before, are now a crucial part of letting her live life where she wants,
in the way she wants, with travel, walks, and volunteer work.
Every morning when I get up, I think, I made it, she
says. I look out the window, and I can see the mountains. But even
if it is cloudy, its still a fine day. Im up, Im moving.
Life is good.
The alarm on the dryer blares, interrupting her. The 88-year-old jumps
up to check the load. She smoothly hefts the pile into a basket, completing
another chore, getting another thing done for herself on a cold, gray,
exquisitely beautiful day.