Change of heart; Cardiac rehab is hard, but payoff is health.

Byline: Elizabeth Cooney

WORCESTER - It's a long walk to the fitness center.

Down two corridors stretching 10 minutes away from the last elevator in the basement of UMass Memorial Medical Center -University Campus, employees and outpatients participating in rehabilitation programs share a space filled with elliptical trainers, treadmills, mirrored walls and hope.

Cardiac patients come here to learn from nurses who specialize in exercise, dietitians who teach nutrition and a psychologist who illuminates the psychosocial components of recovering from a serious condition. Heart attacks, blocked arteries opened by stents, chest pain caused by angina or heart valve repairs brought them to this place. Motivation to get better keeps them coming three times a week for six weeks and sometimes beyond.

Andy Cesnickas of Shrewsbury pushes himself, sometimes too hard for the nurses who monitor patients as they exercise. He had open-heart surgery in October after a faulty heart valve left him breathless, unable to walk up the stairs to his job as a correction officer. He's 58 and determined to regain his strength.

"I am all about getting healthy," he said after working up a sweat on the treadmill. "I'm thrilled. I got extra life."

Anastasia Nichols of Leicester was apprehensive about coming. She's 33 and a lot younger than the other participants, but her cardiologist at Massachusetts General Hospital recommended a program to help with high blood pressure, angina and asthma that made it hard for her to walk even one block.

"I feel so much better about myself," said Ms. Nichols, a dispatcher at Yellow Cab, whose cheeks were flushed from exertion on the elliptical. "I feel 100 percent better than when I walked in."

The UMass Memorial program is one of seven in Central Massachusetts designed to help heart patients achieve a healthy lifestyle and avoid further heart problems. But like programs around the country, they reach only one-third of patients who should take advantage of them, according to a report from the Centers for Disease Control and Prevention, even though studies dating back to the 1970s have shown that participants live longer and feel better.

The missing two-thirds of patients are deterred by a variety of barriers, health experts say.

They typically have to be referred to rehab programs by their doctors, although some programs accept patients who come on their own. Cardiologist Dr. Naomi Botkin said it's regrettable that the topic of cardiac rehab might be crowded out of a post-heart attack office visit, while the doctor discusses medication doses and when the patient can go back to work.

They have to be able to afford the cost. Insurance policies usually cover the program but may require a co-payment. Meeting three times a week can be expensive at co-pays of $25 per session, for example.

People who are just returning to work after an absence may not be able to find the time to come, or be afraid to ask their employers for it.

Some people may think medications to lower their cholesterol or blood-pressure are enough to keep them healthy.

"It is sometimes hard to convince patients with perfect cholesterol panels they should get on the treadmill and make some changes," said Dr. Botkin, who is the medical director of the UMass Memorial program.

Some people suffering from depression - a common condition that comes with heart disease - may be unable to get there.

"Depression can be a huge barrier for patients," Dr. Botkin said. "They've just been hit with a huge new diagnosis, and it takes a certain type of personality to pick up and get back on the horse again, and say `I'm ready to get on with my life and make changes so I don't end up back in the hospital.'"

For a variety of other reasons, patients just don't want to go, Dr. Botkin said.

"Not every patient is motivated to do the difficult work that is involved in lifestyle change," she said about lifelong patterns of eating or sedentary ways. "Going to cardiac rehab takes a sense of commitment to start making those changes and spending an hour and a half three days a week for several weeks doing this."

Rehab nurse Susan Carrigan knows it's hard for patients to contemplate changing their eating habits and activity levels, especially when they are dealing with a serious diagnosis like heart disease. She and her colleagues visit heart patients while they are hospitalized at UMass Memorial to discuss what changes they can make to improve their recovery.

"We tell them it's a whole new beginning, not the end," she said. "It can be depressing. It can be scary."

She also tells them it's not a good idea to try to change everything all at once. But she does suggest where they can start.

If they smoke, quitting is the first piece of advice.

If diet is the problem, she tells them to pick one thing to do about it. If they are also quitting smoking, they shouldn't worry about gaining weight.

"I tell them you'd have to have a 100-pound weight gain to have the same impact as a pack of cigarettes," she said.

If exercise is the target, she tells them they don't have to do their 30 minutes per day all at once. Split that into 10, 10 and 10 to get the same benefit.

She also thinks of ways exercise can fit into a workday, telling truck drivers they can work in some activity while at a truck stop.

"I tell them that 46 times around an 18-wheeler equals one mile," she said. "Their eyes light up."

The program offers trips to the supermarket with a dietitian to learn how to make the healthiest purchases, and separate hands-on cooking classes are also available.

Ms. Carrigan, like all her colleagues, wishes more people would take part. Programs have been closed around the state, including one at Athol Memorial Hospital.

"When you really look at the overall benefits, you really get a lot of bang for the buck. It doesn't cost a lot, patients feel better and they don't feel so anxious," she said. "Plus, the spinoff affects what they do at home. Families eat better and exercise together."

Some patients have formed walking groups through the rehab classes and a heart-healthy dinner group began after cooking classes ended.

"It's not just exercise," Ms. Carrigan said, surveying the fitness center. "It's changing what you're doing with your life."

She'd like to see more patients making those changes.

"We still have a long way to go."

Programs

Cardiac rehabilitation programs in Massachusetts must meet standards set by the state Department of Public Health following a 1985 law requiring insurance companies to cover the cost. These are some programs in the region:

Baystate Medical Center, Springfield [phone]

Day Kimball Hospital, Putnam, Conn. [phone]

Harrington Hospital, Southbridge [phone], ext. 2695

HealthAlliance, Leominster [phone]

Heywood Hospital, Gardner [phone]

Marlboro Hospital, Marlboro [phone]

Milford Regional Medical Center [phone], ext. 2464

St. Vincent Hospital, Worcester [phone]

UMass Memorial Medical Center, Worcester [phone]

ART: PHOTOS

CUTLINE: (1) Andy Cesnickas, who had open-heart surgery in October, uses the treadmill at the cardiac rehab center at UMass Memorial Medical Center -University Campus. (2) Anastasia Nichols' cardiologist at Massachusetts General Hospital recommended a program to help with high blood pressure, angina and asthma

PHOTOG: T&G Staff Photos/CHRISTINE PETERSON