The Clinical Practice Guideline Cardiac Rehabili- tation, prepared for and promulgated by the US Department of Health and Human Services,1char- acterizes cardiac rehabilitation as the provision of comprehensive long-term services involving medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counsel- ing, and behavioral interventions. The goal of this multifactorial process is to limit the adverse phys- iologic and psychologic effects of cardiac illness, to reduce the risk of sudden death or reinfarction, to control cardiac symptoms, to stabilize or reverse progression of the atherosclerotic process, and to enhance the patient’s psychosocial and vocational status. The guideline defines that pro- vision of cardiac rehabilitation services is directed by a physician, but can be implemented by a variety of healthcare professionals.
Although many patients with coronary heart disease are appropriate candidates for cardiac reha- bilitation services, only 11–20% of eligible patients in the US currently participate in supervised, struc- tured cardiac rehabilitation programs. Major barri- ers to cardiac rehabilitation include the low patient referral rate; poor patient motivation; inadequate insurance reimbursement; and geographic limita- tions as to the accessibility of structured program sites. Typical insurance reimbursement covers 36 exercise sessions (three times weekly for 12 weeks) and the associated education and counseling.
Although traditionally most candidates for cardiac rehabilitation were patients following myocardial infarction or coronary artery bypass graft surgery, contemporary use also includes patients after percutaneous coronary interventions;
heart transplantation recipients; patients with stable angina or stable chronic heart failure; those
with peripheral arterial disease with claudication;
and patients following other cardiac surgical proce- dures such as those for valvular heart disease.
Components of Cardiac Rehabilitation
The components of cardiac rehabilitation analyzed in the guideline include exercise training; educa- tion, counseling, and behavioral interventions; and organizational issues, including consideration of alternative approaches to the delivery of cardiac rehabilitative care (to be discussed subsequently).
Highlighted by the guideline is the effectiveness of multifactorial cardiac rehabilitation services, inte- grated in a comprehensive approach.
The physiologic parameters targeted by cardiac rehabilitation interventions include an improve- ment in exercise tolerance and in exercise habits;
optimization of coronary risk factors, including improvement in lipid and lipoprotein profiles, body weight, blood glucose levels and blood pres- sure levels, and cessation of smoking. There should be attention to the emotional responses to living with heart disease, specifically reduction of stress and anxiety and lessening of depression. An essential goal, particularly for elderly patients, is functional independence. Return to appropriate and satisfactory occupation is thought to benefit both patients and society.
Benefits of Cardiac Rehabilitation
The most substantial evidence-based benefits of cardiac rehabilitation include an improvement in exercise tolerance, improvement in symptoms, improvement in blood lipid levels, reduction in
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Cardiac Rehabilitation: United States
Nanette K. Wenger
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6. Cardiac Rehabilitation: United States 35
cigarette smoking, improvement in psychosocial well-being and reduction of stress, and reduction in mortality. These are addressed in turn.
Appropriately prescribed and conducted exer- cise training is an integral component of cardiac rehabilitation, particularly for patients with de- creased exercise tolerance. Specific activity re- commendations are available for women, for older adults, for patients with chronic heart failure and after cardiac transplantation, for stroke survivors, and for patients with claudication as a reflection of peripheral arterial disease. Strength training can improve skeletal muscle strength and endurance.
Smoking cessation can be achieved by specific strategies. Lipid management requires intensive nutrition education, counseling, and behavioral interventions to improve dietary fat and choles- terol intake. Optimal lipid control typically entails pharmacologic management, in addition to diet and exercise training. Diet and exercise are recom- mended for weight management. A multifactorial education, counseling, behavioral, and pharmaco- logic approach is the recommended strategy for the management of hypertension. Increased atten- tion is currently directed to management of dia- betes and the precise control of other coronary risk factors in diabetic patients. Specific national guidelines address the goals and recommended strategies for lipid management, blood pressure control, management of diabetes, and of obesity and smoking cessation.2–6
Common psychosocial problems in patients referred for cardiac rehabilitation include depres- sion, anger, anxiety disorders, and social isolation.
Education, counseling, and/or psychosocial inter- ventions, either alone or as a component of multi- factorial cardiac rehabilitation, can improve psychosocial well-being and quality of life; these are recommended to complement the psychosocial benefits of exercise training. To date, psychosocial interventions have not been documented to alter the prognosis of coronary patients.
Rehabilitation of Elderly Patients
Specific attention has been directed to the rehabilitation of elderly coronary patients; they have exercise trainability comparable to younger patients, with elderly women and men showing
comparable improvement. Unfortunately, referral to and participation in exercise rehabilitation is less frequent at elderly age, especially among elderly women, suggesting that elderly patients of both genders should be strongly encouraged to partici- pate in exercise-based cardiac rehabilitation.
2005 AHA Scientific Statement
A 2005 Scientific Statement of the American Heart Association,7in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation, updates prior scientific statements from these professional organizations and reviews the recommended components for effective cardiac rehabilitation/secondary prevention pro- grams, including alternative ways to deliver these services.
It reinforces that the safety of medically-super- vised cardiac rehabilitation exercise training is well established, with contemporary risk strati- fication procedures guiding the intensity of required surveillance. The benefits of both exercise training and regular daily physical activities are defined as improvement in peak oxygen uptake by 11–36%, with the greatest improvement occurring in the most deconditioned individuals. Improved fitness increases the activity threshold before the onset of myocardial ischemia in patients with advanced coronary heart disease. Resistance train- ing can improve muscular strength.
Clinical Trial Data
Meta-analyses of randomized trials of exercise training in patients with coronary heart disease, alone or as a component of a multidisciplinary cardiac rehabilitation program, have been updated in a recent review. The current study8 involved women as one-fifth of the cohort and included an increased number of patients older than 65 years and those following myocardial revascularization procedures. Exercise-based cardiac rehabilitation was associated with lower total and cardiac mortality rates compared with usual medical care, with favorable trends for non- fatal myocardial infarction and the need for myocardial revascularization procedures. Poten- tially cardioprotective mechanisms presented
36 N.K. Wenger
Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, and the National Heart, Lung, and Blood Institute,AHCPR Publication No. 96-0672, October 1995.
2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detec- tion, Evaluation, and Treatment of High Blood Cho- lesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143–3421.
3. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Com- mittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC7 Report. JAMA 2003;289:2560–2572. [Published erratum in: JAMA 2003;290:197.]
4. NHLBI Obesity Education Initial Expert Panel. Clin- ical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Rockville, MD: National Heart, Lung and Blood Institute in cooperation with the National Institutes of Diabetes and Digestive and Kidney Diseases; September 1998. NIH Publication 98-4083.
5. American Diabetes Association. Clinical practice rec- ommendations 2004. Diabetes Care 2004;27:S1–S145.
6. Murray EW. Smoking cessation clinical practice guidelines update and Agency for Healthcare Research and Quality tobacco resources. Tob Control 2000;9(Suppl 1):I72–I73.
7. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabil- itation and secondary prevention of coronary heart disease. An American Heart Association Scientific Statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Phys- ical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the Ameri- can Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005;111:369–376.
8. Taylor RS, Brown A, Ebrahim S, et al. Exercise- based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of ran- domized trials. Am J Med 2004;116:682–697.
9. Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004;116:693–706.
included improvement in endothelial function, decrease in the biomarkers of inflammation, favorable effects on multiple coronary risk factors including all components of the metabolic syn- drome, potential anti-ischemic effects, ischemic preconditioning, and favorable hemostatic effects.
In addition to the exercise benefits for patients with coronary heart disease, a recent meta-analysis of patients with stable heart failure documented an improvement in functional capacity, reduction in cardiorespiratory symptoms and a trend toward increased survival to result from exercise training.9
Alternative Modes of Delivery of Cardiac Rehabilitation Services
Alternative approaches to the delivery of cardiac rehabilitation services, other than tradi- tional supervised group interventions, were con- sidered effective and safe for stable cardiac patients.1 Transtelephonic and other means of monitoring and surveillance were advocated to extend cardiac rehabilitation services beyond the setting of supervised, structured, and group- based rehabilitation. The American Heart Associ- ation 2005 Scientific Statement7 further offered models that included home-based programs for which a nurse serves as a case manager to super- vise and monitor patient care and progress; and community-based group program guidance by nurses or non-physician healthcare providers.
Electronic media programs are also considered an alternative method for home-based comprehen- sive risk modification education and instruction, as well as for guidance of a structured exercise regimen. An unmet need is the long-term assess- ment of the effectiveness of these approaches and determination of the optimal mode of delivery of these services. The attractiveness of these alterna- tive approaches is the potential to provide cardiac rehabilitation to low- and moderate-risk patients, who comprise the majority of contemporary US patients with stable coronary heart disease, most of whom currently do not participate in struc- tured, supervised cardiac rehabilitation.
References
1. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17.
