Attack plan

Cardiac rehabilitation does wonders for patients after heart attacks and surgery. So why do only a small fraction actually receive it?

Arthur Manjourides works on an order of eggs, home fries, and sausage - fare that he no longer eats after his heart attack. (Pat Greenhouse/Globe Staff)

By his own admission, Arthur Manjourides lived for butter. The more butter, the better, which was perhaps not surprising for someone who had spent more than half a century slinging heaping portions of hash and humor at Charlie's Sandwich Shoppe, the South End landmark where pols and paupers alike balance atop the red swivel stools.

That was before last February, when a jolt of pain wrenched him from sleep - heart attack.

Ninety minutes later, he was flat on his back at Massachusetts General Hospital, with doctors wielding their tiny plumbers' tools to clear a potentially lethal clog in one of his arteries.

After they fixed his heart, the cardiologists told him: Now, it's time to change your life.

So they wrote prescriptions for cardiac rehabilitation and a fistful of pills - and Manjourides faithfully attended twice-a-week sessions, where he pedaled an exercise bicycle and received advice about improving his diet and reducing stress.

Now, he's 55 pounds lighter, his cholesterol is lower, he works fewer hours - and when he looks at a croissant, he sees the stern countenance of his trainer.

"We tend to listen when we're scared," said Dr. Aaron Baggish, Manjourides's cardiologist.

Only a small fraction of patients who endure heart attacks and bypass surgery ever do what Manjourides did - despite ample evidence that such cardiac rehabilitation yields significantly longer lives.

A study released this fall found that among patients 65 and older, just 14 percent of heart attack survivors and 31 percent of heart surgery patients entered rehab. And rates were even lower for women, blacks, and Hispanics.

Sometimes, it's because doctors aren't trained to suggest rehab to patients. Sometimes, it's because patients are too busy taking care of other people to take care of themselves. And, sometimes, it's a reflection of a medical system so smitten with the latest technological innovation that it neglects less-invasive approaches that can produce more durable benefits.

"If only 13 or 14 percent of the elderly patients post [heart attack] are getting cardiac rehab, we're doing a terrible job," said Dr. Jerome Fleg, a cardiologist at the National Heart, Lung, and Blood Institute. "It's obviously a golden opportunity to tune the entire patient up."

It wasn't that long ago that patients who lived through a heart attack were told, essentially: Congratulations. You survived. Now spend the rest of your life in sedentary pursuits.

"But then we found, gosh, if you got somebody up by the side of the bed or they stood up, they were doing better . . . than the patient who was on total bed rest," said Gordon Blackburn, cardiac rehabilitation director at the Cleveland Clinic. "Then everybody got a little braver."

At first, that meant sending heart patients for supervised sessions on treadmills or exercise bikes. Later, it was expanded to include extensive counseling on lifestyle changes - stopping tobacco use, improving diet, eliminating sources of stress. Cardiac rehab, closely supervised by nurses, dietitians, and other specialists, typically lasts 12 to 18 weeks and consists of 36 counseling and exercise sessions.

Dr. William B. Stason of Brandeis University, an author of the study that appeared in the journal Circulation in October, said previous research repeatedly demonstrated the value of rehab. Bypass surgery and artery-clearing procedures don't actually cure patients - they only address the most pressing symptoms of heart disease. It takes lifestyle changes and medication to fix the underlying problem.

The Circulation study, which also involved researchers from Harvard and the University of Vermont, examined the billing claims of more than 267,000 patients whose care was covered by Medicare, the federal government's health plan for seniors, in 1997. Cardiology specialists not involved in the study said their experience suggests that enrollment rates have not changed much since.

Doctors are especially concerned by the significantly lower rehab rates among certain groups of patients. For blacks and Hispanics, it may be evidence of broader disparities in healthcare.

In the case of women, that reflects both long-standing social bias and the realities of their lives. Family members, doctors, and even some older women may view exercise as the domain of men. "There may be a logistic factor also," said Donald Shepard of Brandeis, another author of the recent study. "A woman with heart disease may well be older and less likely to have a living husband to help with the transportation and the encouragement."

Another potential factor: Hospitals don't get paid that much for rehab and therefore may not be inclined to promote it, said Dr. Jose A. Suaya of Brandeis, another author of the Circulation study. The federal Centers for Medicare & Medicaid Services pays hospitals $35.33 for each hour-long session of outpatient cardiac rehab for patients who have had heart attacks, bypass surgery, valve replacement or artery-clearing procedures. A top official said that when the agency recently sought feedback about its payment rates, nobody complained.

For Manjourides, 66 ("old as dirt," he said), the route to Mass. General was paved with a lifetime of rich food, a succession of diets, and infrequent appearances at the gym.

In the immediate aftermath of his heart attack, Manjourides, who with his gold earring, beard, and rakish eyes could pass for a jolly pirate, did not fully grasp the magnitude of what had befallen him. It would take the regular drill of cardiac rehab to do that, which Baggish began recommending not long after the heart attack.

"I wanted to get better. I wanted to get healthy," Manjourides said. "I would rather not be alive than have to be crippled by not doing things."

Since finishing cardiac rehab at the hospital, he's signed on at a gym - and he's actually going this time.

A trainer at Equinox Fitness Club is helping him improve his body's response to exercise and relax muscles turned tight from decades spent hunched over a grill.

"He's a work in progress," said his trainer, Pete Bognanno.

So is the menu at Charlie's, the air fragranced by baking omelettes and sizzling potatoes. Manjourides, who runs the restaurant with his siblings, has added marinated chicken breast, vegetarian stuffed peppers, and more fish - for his own sake as well as others'.

Stephen Smith can be reached at stsmith@globe.com.