Cardiac rehabilitation programs
- Lynne T Braun, PhD, RN, CNP
Lynne T Braun, PhD, RN, CNP
- UpToDate NP Advisory Board Member
- Professor of Nursing
- Rush University College of Nursing
- Nanette K Wenger, MD
Nanette K Wenger, MD
- Professor of Medicine (Cardiology)
- Emory University School of Medicine
- Robert S Rosenson, MD
Robert S Rosenson, MD
- Section Editor — Lipids
- Professor of Medicine
- Mount Sinai School of Medicine
- Director, Cardiometabolic Disorders
- Mount Sinai Heart
Outpatient cardiac rehabilitation programs provide supervised exercise training in conjunction with other secondary prevention interventions. They are designed to speed recovery from acute cardiovascular events such as myocardial infarction, myocardial revascularization, or hospitalization for heart failure and to improve quality of life. In addition, patients with stable coronary heart disease derive benefits. (See "Prevention of cardiovascular disease events in those with established disease or at high risk".)
This topic will discuss the organization and content of these programs. The indications for and the efficacy and safety of cardiac rehabilitation are discussed separately. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease".)
The components of cardiac rehabilitation programs are delivered by a dedicated team including a medical director, nurses, exercise specialists, nutritionists, and counselors. These programs include provision of comprehensive long-term services involving the following core components (table 1A-B) [1-4]:
●Medical evaluation/baseline patient assessment
●Exercise training and physical activity counselingTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation 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, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005; 111:369.
- Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol 2008; 51:1619.
- Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115:2675.
- Wenger NK, Froelicher ES, Smith LK, et al. Clinical Practice Guideline No. 17. AHCPR Publication No. 96-0672, U.S. Department of Health and Human Services, Agency for Healthcare Policy and Research, and the Nat, Rockville, MD 1995.
- Squires RW, Gau GT, Miller TD, et al. Cardiovascular rehabilitation: status, 1990. Mayo Clin Proc 1990; 65:731.
- Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694.
- Cardiac rehabilitation programs. A statement for healthcare professionals from the American Heart Association. Circulation 1994; 90:1602.
- Fletcher BJ, Thiel J, Fletcher GF. Phase II intensive monitored cardiac rehabilitation for coronary artery disease and coronary risk factors--a six-session protocol. Am J Cardiol 1986; 57:751.
- Fletcher BJ, Lloyd A, Fletcher GF. Outpatient rehabilitative training in patients with cardiovascular disease: emphasis on training method. Heart Lung 1988; 17:199.
- Zullo MD, Jackson LW, Whalen CC, Dolansky MA. Evaluation of the recommended core components of cardiac rehabilitation practice: an opportunity for quality improvement. J Cardiopulm Rehabil Prev 2012; 32:32.
- Russell KL, Holloway TM, Brum M, et al. Cardiac rehabilitation wait times: effect on enrollment. J Cardiopulm Rehabil Prev 2011; 31:373.
- Soga Y, Yokoi H, Ando K, et al. Safety of early exercise training after elective coronary stenting in patients with stable coronary artery disease. Eur J Cardiovasc Prev Rehabil 2010; 17:230.
- Pack QR, Mansour M, Barboza JS, et al. An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial. Circulation 2013; 127:349.
- Johnson DA, Sacrinty MT, Gomadam PS, et al. Effect of early enrollment on outcomes in cardiac rehabilitation. Am J Cardiol 2014; 114:1908.
- Gaalema DE, Savage PD, Rengo JL, et al. Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients. Prev Med 2016; 92:47.
- https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-20.html (Accessed on January 16, 2017).
- Thompson PD. Exercise prescription and proscription for patients with coronary artery disease. Circulation 2005; 112:2354.
- Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115:2358.
- American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription, 9th ed, Wolters Kluwer/Lippincott Williams & Wilkins, Baltimore 2014.
- Kenney WL, Humphrey RH, Bryant CX, et al. American College of Sports Medicine Guidelines for Exercise Testing and Prescription, 5th ed, Williams & Wilkins, Baltimore 1995.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Dimsdale JE, Hartley LH, Guiney T, et al. Postexercise peril. Plasma catecholamines and exercise. JAMA 1984; 251:630.
- Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873.
- Borg, G. Physical performance and perceived exertion. Gleerup, Lund, Sweden 1962.
- Centers for Disease Control and Prevention. Perceived exertion (Borg rating of perceived exertion scale). http://www.cdc.gov/nccdphp/dnpa/physical/measuring/perceived_exertion.htm (Accessed on March 31, 2015).
- Tang LH, Zwisler AD, Berg SK, et al. Is the Cardiovascular Response Equivalent Between a Supervised Center-Based Setting and a Self-care Home-Based Setting When Rating of Perceived Exertion Is Used to Guide Aerobic Exercise Intensity During a Cardiac Rehabilitation Program? Am J Phys Med Rehabil 2016.
- Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003; 107:3109.
- Pescatello LS, Arena R, Riebe D, Thompson PD. ACSM’s Guidelines for Exercise Testing and Prescription, Wolters Kluwer/Lippincott Williams & Wilkins, 2014.
- Brawner CA, Abdul-Nour K, Lewis B, et al. Relationship Between Exercise Workload During Cardiac Rehabilitation and Outcomes in Patients With Coronary Heart Disease. Am J Cardiol 2016; 117:1236.
- Miller NH, Haskell WL, Berra K, DeBusk RF. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation 1984; 70:645.
- DeBusk RF, Haskell WL, Miller NH, et al. Medically directed at-home rehabilitation soon after clinically uncomplicated acute myocardial infarction: a new model for patient care. Am J Cardiol 1985; 55:251.
- Ades PA, Pashkow FJ, Fletcher G, et al. A controlled trial of cardiac rehabilitation in the home setting using electrocardiographic and voice transtelephonic monitoring. Am Heart J 2000; 139:543.
- Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2014; 129:S102.
- Wenger NK, Hellerstein HK. Rehabilitation of the Coronary Patient, 3rd ed, 1992.
- Colantonio LD, Huang L, Monda KL, et al. Adherence to High-Intensity Statins Following a Myocardial Infarction Hospitalization Among Medicare Beneficiaries. JAMA Cardiol 2017.
- Milani RV, Lavie CJ, Cassidy MM. Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. Am Heart J 1996; 132:726.
- Mallik S, Spertus JA, Reid KJ, et al. Depressive symptoms after acute myocardial infarction: evidence for highest rates in younger women. Arch Intern Med 2006; 166:876.
- Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014; 129:1350.
- Blumenthal JA, Sherwood A, Smith PJ, et al. Enhancing Cardiac Rehabilitation With Stress Management Training: A Randomized, Clinical Efficacy Trial. Circulation 2016; 133:1341.
- Lamberti M, Ratti G, Gerardi D, et al. Work-related outcome after acute coronary syndrome: Implications of complex cardiac rehabilitation in occupational medicine. Int J Occup Med Environ Health 2016; 29:649.
- King M, Bittner V, Josephson R, et al. Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: 2012 update: a statement for health care professionals from the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association. Circulation 2012; 126:2535.
- Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 2011; 124:2951.
- Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2010; :CD007130.
- Lear SA, Singer J, Banner-Lukaris D, et al. Randomized trial of a virtual cardiac rehabilitation program delivered at a distance via the Internet. Circ Cardiovasc Qual Outcomes 2014; 7:952.
- Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2015; :CD007130.
- Buckingham SA, Taylor RS, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis. Open Heart 2016; 3:e000463.
- Turk-Adawi K, Grace SL. Smartphone-based cardiac rehabilitation. Heart 2014; 100:1737.
- Varnfield M, Karunanithi M, Lee CK, et al. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart 2014; 100:1770.
- Rawstorn JC, Gant N, Direito A, et al. Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis. Heart 2016; 102:1183.
- Minneboo M, Lachman S, Snaterse M, et al. Community-Based Lifestyle Intervention in Patients With Coronary Artery Disease: The RESPONSE-2 Trial. J Am Coll Cardiol 2017; 70:318.
- INITIATION OF REHABILITATION
- EXERCISE TRAINING
- Risk stratification for exercise
- Frequency and duration
- Rating of perceived exertion (Borg scale)
- Exercise progression
- Resistance training
- Long-term exercise
- HEART FAILURE AND CARDIAC TRANSPLANTATION PATIENTS
- Nutritional counseling and weight management
- Cessation of smoking
- Diabetes management
- Management of hypertension and hyperlipidemia
- PSYCHOSOCIAL SUPPORT
- MEDICAL DIRECTOR RESPONSIBILITIES
- ALTERNATE APPROACHES
- SUPPLEMENTAL APPROACHES
- INFORMATION FOR PATIENTS