Cardiac rehabilitation

Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "The sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life". CR is a comprehensive model of care including established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life while helping to reduce the risk of future heart problems.
CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are very patient-centered.
Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology and the European Society of Cardiology, among other associations. Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator). CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies.
CR Phases.
Inpatient program (phase I).
Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms and legs. Heart rate is monitored and continues being monitored as the patient begins to walk.
Outpatient program (phase II).
It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, or 4–6 weeks after cardiac surgery. In order to participate in an outpatient program, the patient generally must first obtain a physician's referral.
Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipid measures, blood pressure, body composition, depression / anxiety, and tobacco use. An exercise stress test is usually performed both to determine if exercise is safe and to allow for the development of a customized exercise program.
Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained Registered Nurse, Physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.
The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered, and it is well-established that the more the better.
After CR is finished, there are long-term maintenance programs (phase III) available to interested patients, as benefits are optimized with long-term adherence; unfortunately however patients generally have to pay out-of-pocket for these services.
Under-use.
CR is significantly under-used globally. Rates vary widely.
Under-use is caused by multi-level factors. At the health system level, this includes lack of available programs. At the provider level, there are low referral rates by physicians, who often focus more attention on better reimbursed cardiac intervention procedures than on long-term lifestyle treatments. At the patient level, factors such as transportation, distance, cost, competing responsibilities, lack of awareness and other health conditions are responsible, but most can be mitigated. Women, ethnocultural minorities, older patients, those of lower socio-economic status, with comorbidities, and living in rural areas are less likely to access CR, despite the fact that these patients often need it most. Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.
Strategies are now established on how we can mitigate these barriers to CR use. It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR. It is also key for healthcare providers to promote CR to patients at the bedside.
Benefits.
Participation in CR is associated with many benefits. A Cochrane review of 147 studies demonstrated that for myocardial infarction and heart failure patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%. However, there was no benefit in all-cause mortality. A more recent network meta-analysis however, where the complex components of CR are better considered, showed significant reductions in all-cause mortality with CR.
CR is also associated with improved quality of life, as well as better psychosocial well-being, and functional capacity. CR is cost-effective.
There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same.
Another Cochrane review of six randomised controlled trials in adults with atrial fibrillation found that CR may improve physical exercise capacity, but there was no effect on quality of life. Due to the limited number of trials, the authors could not estimate the impact on mortality or serious adverse events. There are also Cochrane reviews on effects in valve patients, among others.
CR Societies.
CR professionals work together in many countries to optimize service delivery and increase awareness of CR. The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, ICCPR seeks to promote CR in low-resource settings, among other aims outlined in their Charter.