Introduction
Cardiac rehabilitation (CR) has been defined as the sum of interventions required to ensure the best possible physical, psychological, and social conditions so that patients with subacute or chronic disease may, by their own efforts, preserve or resume as normal a place as possible in the life of the community.1–5
This definition implies a clear need for a multi- disciplinary approach over a long time period.
Cardiac rehabilitation was therefore divided by the World Health Organization into three phases:
(I) the acute phase, (II) the reconditioning phase, and (III) the maintenance phase.4,6
Nowadays, acute rehabilitation starts in the hospital from the first days after an acute heart attack. Phase II CR exists in a multidisciplinary program requiring a range of knowledge and skills to bring together medical treatment, educa- tion, exercise training, and counseling for all people with coronary heart disease (CHD).7
Comparison of phase II and III programs in Europe, more specifically in 15 member states of the European Union, was first performed in the Carinex Survey (1999).6 Phase II is the recondi- tioning phase that starts after the acute coronary event and has a multidisciplinary base including exercise training, risk factor modification, educa- tional programs, and psychosocial counseling.
Phase III is the maintenance phase conducted in sports clubs and cardiac groups focused on adapt- ing physical activity and the modification of risk factors, such as smoking, sedentary lifestyle, hypertension, and hyperlipidemia.
Following the enlargement of the European Union, new member states have given us a new motive for further European research on the occurrence of cardiac disease, the existing reha- bilitative services, and the advancements that have been occurring in recent years. Central and eastern European countries are characterized by heterogeneity due to their national conditions, resources, priorities, economic level, and political trends. Since health follows a social gradient, many inequalities are also noticed in the medical system.8
At European level, there is the same problem as in the entire world – the increasing burden of cardiovascular disease. Recent studies show that central and eastern Europe has higher cardiovas- cular disease mortality compared with the rest of Europe. The cardiovascular mortality rate varies from 5 per 1000 inhabitants in Poland to 9 per 1000 inhabitants in Bulgaria and Ukraine; this is two to three times more than in the West, where the advanced treatments for coronary heart disease have increased the survival rates by 50%.9
Multidisciplinary Rehabilitation
Cardiac rehabilitation is an important aspect of cardiac care strategies. From the Carinex Survey it is obvious that cardiac rehabilitation programs vary between countries in western Europe, but most programs are well organized. In this survey,6 information on staff involvement, duration and content of programming, costs and other organi- zational activities were reported. Wide variations
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Cardiac Rehabilitation: Europe
L. Vanhees, M. Martens, S. Beloka, A. Stevens, A. Avram, and Dan Gaita
30
5. Cardiac Rehabilitation: Europe 31
recorded, although all these countries had more than 20 years’ experience in this field and all rec- ognized the crucial role of comprehensive man- agement of cardiac patients. In eastern Europe most often an in-hospital rehabilitation program is used. It comprises cardiological management and psychosocial interventions during a residen- tial stay in a specific rehabilitation clinic. It is based on the individual’s requirements aiming at the improvement of exercise capacity and quality of life, and medical, educational, and psychologi- cal interventions. It may enhance compliance, resulting in a better long-term implementation of secondary prevention. Nevertheless, there are few specific clinics for phase II and III cardiac rehabilitation.11,12
Frequently, home-based programs follow on from hospital rehabilitation or are used in the period between hospital discharge and ambula- tory cardiac rehabilitation, or sometimes even after an outpatient programme.13,14These home- based programs aim to maintain the patient’s motivation for lifestyle change at a time when there is limited contact with healthcare profes- sionals. Home-based rehabilitation programs usually include education, exercise schedules, written booklets, and psychosocial interventions.
A disadvantage of home-based rehabilitation is that the main part of the program consists of exer- cise with taped counseling of education and psy- chosocial interventions and telephone contact or visits every 2 months.15Specialized sports clubs or specifically designed heart groups may be better at facilitating the long-term secondary preventive lifestyle.10
Special Groups
Participation in CR is less evident in women, the elderly, and socially deprived and ethnic minorities.15People who do not participate in a program often have greater degrees of functional impairment and are the ones most in need of and most likely to benefit from rehabilitation.
The problem of low patient adherence in these groups includes lack of information from pro- fessionals, reduced motivation, and increased anxiety feelings. Further socio-demographic reasons such as education level, deprivation, between countries were reported, but variation
within each country was as great as or even greater than that reported between countries.
Most programs contain exercise testing and train- ing, psychosocial interventions, diet and smoking counseling, family and spouse involvement, and some other components. All these programs have the same aims: functional adaptation, an increase in exercise capacity, and improvement of quality of life and psychosocial status. The most striking difference in the phase II programs studied in the Carinex Survey was probably the type of organi- zation: institution-based versus outpatient versus home-based programs. The Carinex Survey demonstrated that there is a moderate range of duration for phase II from 4 weeks to 13 weeks (Table 5-1).6The duration of phase II in countries where an inpatient rehabilitation model was used was limited to 4 weeks. When outpatient rehabili- tation was performed the duration of phase II programs ranged from 7 to 26 weeks.
A short duration of the reconditioning phase requires a well-organized follow-up in phase III.
Most countries try to maintain phase III “as long as possible.” The continuity of the program depends on individual motivation to continue the program and the social security system that reim- burse patients. Physical training during phase III, so far, is limited but it leads to reinforcement of previous condition and lifestyle.10
Regarding cardiac rehabilitation programs in eastern Europe, few international data are
TABLE 5-1. Duration of phase II cardiac rehabilitation across Europe (weeks)
Ireland 8.8 ± 2.17
United Kingdom 9.15 ± 3.32
The Netherlands 7.0 ± 2.07
Belgium 12.71 ± 7.50
Germany 3.87 ± 0.30
Italy 6.97 ± 5.51
France 3.00 ± 0.0
Spain 10.33 ± 3.20
Portugal 13.0 ± 6.86
Greece 8.00 ± 0.00
Austria 3.70 ± 0.67
Finland 7.51 ± 11.85
Sweden 10.0 ± 0.0
Total 8.44 ± 5.31
32 L. Vanhees et al.
and the family environment should be considered.16
The cardio-rehabilitation service should be available for all CHD patients according to their needs and the level of impairment. A cardiac reha- bilitation system should be available on a common European cross-border basis for every country instead of by selection procedures such as medical needs, rehabilitation center, and the duration and implementation of the rehabilitation program.17
In some European countries, CR is still in the early stages of development with low rates of patient participation, limited encouragement and introductions from medical doctors, and social health systems that do not support such innova- tions. It is clear that a lot of changes must be undertaken to advance the socio-political base so that all cardiac patients receive the appropriate information and rehabilitation treatment.18
Organization
In 1964, cardiac rehabilitation was for the first time described and discussed in a WHO report.4 In October 1967, the first meeting of the WHO Regional Office for Europe on Cardiac Rehabilita- tion was held at Noordwyk aan Zee in the Netherlands. The leading organization in Europe concerning cardiology, the European Society of Cardiology, started to restructure itself into working groups. The Working Group on Epidemi- ology and Prevention was founded in 1976 and their first scientific meeting was held in Dublin in 1977. In 1980, the Working Group on Exercise Physiology was founded by Jean Marie Detry from Belgium and Bruno Caru from Italy, followed by the Working Group on Cardiac Rehabilitation in 1984, founded by Peter Mathes from Germany and Risteard Mulcahy from Ireland. In 1994, the latter two working groups amalgamated into the Working Group on Cardiac Rehabilitation and Exercise Physiology.
In the meantime, in the period 1987–1992, experts with different professional backgrounds in cardiac rehabilitation from various European countries discussed in several meetings the long- term approach and the multidisciplinary aspects of cardiac rehabilitation. These meetings have revealed great variation in the development
and structure of cardiac rehabilitation activities within the member states of the European Union (EU). In 1992, the European Association of Car- diovascular Rehabilitation (EACVR) was estab- lished, with the aims to represent and to promote the multidisciplinary organization and the long- term approach in CR throughout Europe. In 1999, the EACVR joined the Working Group on Cardiac Rehabilitation and Exercise Physiology.
The European Association for Cardiovascular Prevention and Rehabilitation was launched in 2004 and was formed through the merger of the ESC Working Groups no. 1 (cardiac rehabilitation and exercise physiology) and no. 13 (epidemiol- ogy and prevention). Its mission statement is
“to promote excellence in research, practice, edu- cation and policy in cardiovascular prevention and rehabilitation in Europe.”
Conclusion
After the end of the acute phase, all patients should be able to follow a multidisciplinary CR program. Thereafter, everyone should be advised to maintain an active lifestyle and adherence to secondary preventive measures. This lifelong sec- ondary preventive lifestyle must be promoted by all healthcare providers and can be facilitated by specialized sports clubs or by specifically designed heart groups.
Professionals who are responsible for rehabili- tation programs need to develop a European action plan for the inclusion of all cardiac patients who are eligible to participate and benefit. Future challenges to cardiac rehabilitation include devel- oping patient-focused services across the bound- aries of primary, secondary and social care, and increasing patient and public involvement in ser- vices.19 The application of socio-political inter- ventions concerning all parts of society – global, European, national, regional, local, familial, and individual – will amplify the benefit of modern medical interventions.20
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