Cardiac Rehabilitation
Tamara Beth Horwich
Amir Behzad Rabbani
James S. Lee
Arash B. Nayeri
INTRODUCTION
Cardiac rehabilitation (CR) is recognized as an essential component of the treatment and secondary prevention of coronary heart disease, and more recently has also become a vital part of treatment for heart failure with reduced ejection fraction (HFrEF). Cardiovascular disease is the number one cause of death in the United States; furthermore, approximately 20% of patients with myocardial infarction (MI) suffer an additional MI in the ensuing 5 years. CR programs improve quality of life (QoL) in patients with cardiovascular disease and also reduce cardiovascular mortality, hospitalizations, and events by approximately 25% in patients with coronary heart disease.1
CR programs were initially developed in the 1960s in response to seminal research demonstrating that exercise training significantly improved aerobic capacity and, conversely, inactivity and bed rest led to rapid deterioration of cardiovascular performance. Thus, physical activity restriction and bed rest, which had been standard of care post-MI since the 1930s, was realized to be a harmful treatment strategy.2,3 Thus, early CR programs focused on medically supervised aerobic exercise training. CR programs have now evolved to include components such as nutritional counseling, stress management, psychological support, and education regarding risk factor reduction and treatment adherence (Figure 101.1). Thus, modern multidisciplinary CR programs are individualized and personalized to optimize not only physical health but also the psychological and social functioning of participants with various forms of cardiovascular disease.4
 FIGURE 101.1 The core components of cardiac rehabilitation programs. |
Much remains to be done with regard to modifiable risk factors and health behaviors in the U.S. population. Obesity
and metabolic syndrome are present in up to 35% of adults. Nearly 60% of adults in the United States are not regularly physically active, and less than 20% to 25% of adults get the 150 minutes/week of aerobic activity recommended by the American Heart Association (AHA).5 Adequate fruit and vegetable intake (both of which lower the risk for heart disease and stroke) is seen in only 13% and 9% of the U.S. population, respectively, according to national surveys. Thus, the importance and relevance of CR in the treatment and prevention of cardiovascular disease is clearly evident. This chapter aims to define and describe components and types of CR, outline its indications and contraindications, as well as uncover its limitations and point in the direction of future research and development.
and metabolic syndrome are present in up to 35% of adults. Nearly 60% of adults in the United States are not regularly physically active, and less than 20% to 25% of adults get the 150 minutes/week of aerobic activity recommended by the American Heart Association (AHA).5 Adequate fruit and vegetable intake (both of which lower the risk for heart disease and stroke) is seen in only 13% and 9% of the U.S. population, respectively, according to national surveys. Thus, the importance and relevance of CR in the treatment and prevention of cardiovascular disease is clearly evident. This chapter aims to define and describe components and types of CR, outline its indications and contraindications, as well as uncover its limitations and point in the direction of future research and development.
INDICATIONS FOR CARDIAC REHABILITATION
Coronary Artery Disease
CR programs have become a standardized and essential secondary prevention tool for patients with coronary artery disease (CAD). Over time, indications have expanded from patients following acute MI and post-coronary artery bypass graft to patients who have undergone percutaneous coronary intervention and those with stable CAD with angina pectoris. Identification of physical inactivity as a major CAD risk factor has led CR to become a class I recommendation in this patient population.6 CAD is the predominant diagnosis of patients in CR programs across the United States. Multiple trials and meta-analyses have established the important role of CR as a therapy for patients with CAD.
Peripheral Artery Disease
In the United States, there are an estimated 8.5 million patients with peripheral arterial disease (PAD), resulting in significant morbidity, mortality, and impairment in QoL.7 PAD can result in claudication, which is defined as fatigue, discomfort, cramping, or pain of vascular origin in the muscles of the lower extremities that is induced by exercise and relieved by rest (usually within 10 minutes). Structured exercise therapies have been established as an important component of care for patients with PAD. Favorable data from multiple randomized controlled trials have established supervised exercise therapy as a class I recommendation and first-line treatment for intermittent claudication.8,9
The role of supervised exercise therapy compared with lower extremity revascularization has been studied in the CLEVER (Claudication: Exercise Versus Endoluminal Revascularization) trial, randomizing patients with symptomatic aortoiliac disease to either supervised exercise therapy or endovascular stenting. The trial showed comparable outcomes at 6 and 18 months between supervised exercise therapy and revascularization, while both were superior to medical therapy alone.9 The ERASE (Endovascular Revascularization and Supervised Exercise) trial randomized study subjects to either supervised exercise therapy alone or in combination with endovascular therapy. At 1 year, both groups showed improvement in walking times and QoL inventories; however, the combined supervised exercise therapy and endovascular arm showed greater improvement as compared to the supervised exercise therapy alone.10 The body of evidence collectively supports the Class I indication to offer supervised exercise therapy to patients with intermittent claudication, either as stand-alone treatment or in combination with an endovascular strategy.
Postvalve Surgery
The evidence supporting the benefits of CR after valve surgery is less robust than the evidence for CR in coronary heart disease. A 2016 systematic review of exercise-based CR for adults after heart valve surgery found only two randomized controlled trials (total n = 148).11 An improvement in exercise capacity was noted in the exercise groups, but no effect on other outcomes was found, likely because of the small numbers. A cohort study published in 2019 analyzed Medicare patients undergoing valve surgery in 2014 followed through 2015; this analysis found that CR was associated with a significant reduction in hospitalizations and a 4% absolute reduction in mortality in the 1 year following surgery.
Heart Failure and Heart Transplant
The HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial, which studied 2331 patients with HFrEF, showed that aerobic exercise training significantly improved QoL and produced a modest, but nonsignificant improvement in the primary outcome of death and/or hospitalization for heart failure.13 In another study of patients with chronic heart failure with severe systolic dysfunction, there was no excess of death and minimal nonfatal major cardiovascular events in the exercise group compared to control group.14 Hence, in 2014, the Centers for Medicare & Medicaid Services (CMS) started covering CR for stable patients with chronic HFrEF and ongoing symptoms despite optimal medical therapy for the treatment of congestive heart failure.
Exercise training in heart failure with preserved ejection fraction (HFpEF) has also been shown to be a safe therapy that may improve exercise capacity, cardiorespiratory fitness, and QoL,15 but it is not routinely covered for reimbursement at the time of this printing.
Although many orthotopic heart transplantation patients participate in CR, there are limited data behind the use of CR for these patients. The 2007 and 2011 statements from the
AHA on CR and the 2010 International Society of Heart and Lung Transplantation Guidelines recommend exercise training both prior to and after orthotopic heart transplantation, with formal CR as tolerated.
AHA on CR and the 2010 International Society of Heart and Lung Transplantation Guidelines recommend exercise training both prior to and after orthotopic heart transplantation, with formal CR as tolerated.
FUNDAMENTALS OF CARDIAC REHABILITATION
Table 101.1 shows the fundamental activities of the four phases of CR.
Supervised Exercise Therapy for Peripheral Arterial Disease
Supervised exercise therapy or intermittent claudication consists of a graded treadmill protocol spanning 36 sessions over 3 months, taking place usually in a hospital or outpatient facility directly supervised by qualified health care providers. Patients are asked to grade their claudication symptoms (Table 101.2) in a regular interval (eg, every 30 seconds), with documentation of claudication onset time and maximum walking times. Several standardized graded treadmill protocols can be used.16,17,18 All protocols incorporate graded treadmill therapy that starts at a 2 mph walk at 0% grade and increases at a regular interval while monitoring claudication severity.
TABLE 101.1 Traditional Cardiac Rehabilitation Program Components | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
