New Concepts in Cardiac Rehabilitation and Secondary Prevention After Myocardial Infarction




Introduction


Evidence-based treatments for patients with myocardial infarction (MI) have improved outcomes, with substantive reductions in mortality rates ( Chapter 2 ). Nevertheless, patients who survive an acute MI remain at increased risk for recurrent MI and death and also suffer from clinical symptoms and loss of physical, psychological, or social functioning after discharge that can lead to impaired health-related quality of life. The effectiveness and accessibility of cardiac rehabilitation and secondary prevention services after MI have therefore never been more important. Current international clinical guidelines, including those of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology, endorse rehabilitation and secondary prevention as key elements of standard post-MI management.


Our approach to post-MI rehabilitation has changed radically in the last 80 or so years. In the 1930s, restriction of physical activity and prolonged bed rest were standard of care for patients suffering from an MI. Subsequent evolution of practices such as chair therapy (1940s), brief daily walks of 3 to 5 minutes (1950s), and structured inpatient cardiac rehabilitation programs for early ambulation after MI (1960s) led to the development of today’s multidisciplinary, comprehensive cardiac rehabilitation and secondary prevention programs for a broad group of patients with atherosclerotic cardiovascular disease.


The following definition from the Agency for Health Care Policy and Research encompasses these contemporary concepts:


Cardiac rehabilitation [and secondary prevention] services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counselling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients. 6a


Although exercise training remains a cornerstone of intervention, current practice guidelines consistently recommend “comprehensive rehabilitation” programs that should contain the necessary core components to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle.


Cardiac rehabilitation and secondary prevention services should begin in the inpatient setting for patients who have survived an acute MI and continue into the early-outpatient and late-outpatient phases of follow-up ( Figure 34-1 ). Although in many countries this inpatient and early-outpatient care is covered by health care providers and insurers, the costs of late-outpatient or “maintenance” programs often need to be met by the patients themselves.




FIGURE 34-1


The trajectory of cardiac rehabilitation and secondary prevention after acute coronary syndrome.


This chapter presents the evidence for cardiac rehabilitation and secondary prevention after MI, focusing on the findings of systematic reviews and meta-analyses; details the components of cardiac rehabilitation and secondary prevention delivery using current high-profile international practice and policy statements; and finally, considers current and future key challenges facing rehabilitation and secondary prevention services.




Evidence for Cardiac Rehabilitation and Secondary Prevention


The first systematic reviews and meta-analyses of cardiac rehabilitation were published more than 20 years ago and reported a 20% to 25% reduction in all-cause and cardiovascular mortality in pooled data from 22 randomized controlled trials (RCTs) in more than 4300 post-MI patients, comparing exercise-based cardiac rehabilitation with a no-exercise rehabilitation approach in the control group. A number of updated versions of this systematic review/meta-analysis of cardiac rehabilitation and secondary prevention have since been published.


The 2016 Cochrane systematic review and meta-analysis “Exercise-based cardiac rehabilitation for coronary heart disease” provides a useful summary of the available evidence. The inclusion and exclusion criteria for the 2016 Cochrane review are summarized in Table 34-1 . Bibliographic databases of Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Science Citation Index Expanded were searched to July 2014. The study authors identified a total of 63 RCTs ( Table 34-e1 ). Although this update included a total of 14,486 patients, most trials were relatively small in size (median number of patients, 126; range, 28 to 2304). Greater than 80% of the trial populations were post-MI patients, with the remainder consisting of patients who had undergone coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI); in more than one half of the patients in these cohorts, previous MI was the exclusive diagnosis. The median follow-up period was 12 months. Programs typically were conducted in a supervised outpatient hospital/center-based setting, either exclusively or in combination with some maintenance home exercise sessions. Although it was noted that the quality of reporting had improved in more recently published RCTs, overall, the authors judged the various individual categories of study risk of bias as either high or unclear.



TABLE 34-1

Inclusion and Exclusion Criteria for 2016 Cochrane Review

From Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.











Inclusion



  • Study design : RCTs of exercise-based CR with a follow-up period of at least 6 months post randomisation



  • Population : Patients of all gender or ages who have had an MI, or who have undergone revascularization (coronary artery bypass grafting [CABG], percutaneous coronary intervention [PCI]) or who have angina pectoris or coronary heart disease defined by angiography



  • Intervention : Exercise-based CR, defined as a supervised or unsupervised inpatient, outpatient, or community- or home-based intervention that includes some form of exercise training, either alone or in addition to psychosocial and/or educational interventions



  • Control : Standard medical care, such as drug therapy, but without any form of structured exercise training program



  • Outcomes : One or more of the following outcomes: death (total and cardiovascular-related); MI (fatal and nonfatal); revascularizations (CABG and PCI); hospitalizations; health-related quality of life assessed using validated instruments (e.g., Short-Form-36, EQ-5D); or costs and cost-effectiveness

Exclusion



  • Studies exclusively recruiting patients with heart failure, with atrial fibrillation, after heart valve surgery, with heart transplants, or implanted with cardiac resynchronization device or with implantable cardioverter-defibrillator; or patients who completed a cardiac rehabilitation program before randomization


CR, Cardiac rehabilitation; MI, myocardial infarction; RCTs, randomized controlled trials.




TABLE 34-e1

Cochrane 2016 Review Summary of Study and Patient Characteristics

Adapted from Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.








































































































































Category No. of Studies (%)
or Median (Range)
Study Characteristics
Publication year
1970-1979 2 (3)
1980-1989 12 (19)
1990-1999 20 (32)
2000-2009 21 (33)
2010 onward 8 (13)
Study location
Europe 37 (59)
North America 12 (19)
Asia 6 (10)
Australasia 5 (8)
Other 2 (3)
Not reported 1 (2)
Single center 45 (71)
Sample size 126 (28-2304)
Duration of follow-up 12 months (6-120)
Population Characteristics
Gender
Males only 18 (29)
Females only 1 (2)
Both males and females 41 (65)
Not reported 3 (5)
Age (years) 56.0 (49.3-71.0)
Diagnosis
Post–myocardial infarction only 31 (49)
Revascularization only 2 (3)
Angina only 5 (8)
Mixed-CHD population 25 (40)
Intervention Characteristics
Intervention type
Exercise-only programs 25 (38)
Comprehensive programs 39 (60)
Duration of intervention (months) 6 (1-48)
Dose of intervention
Duration 6 months (1-48)
Frequency 1-7 sessions/week
Length 20-90 minutes/session
Intensity


  • 50%-85% of maximal heart rate



  • 50%-95% of maximal oxygen uptake (VO 2 max)



  • Borg rating of 11-15

Setting
Center-based only 33 (52)
Combination of center- and home-based 13 (21)
Home-based only 15 (24)
Not reported 2 (3)

CHD, Coronary heart disease.

Median of study means.


One study includes both exercise-only and comprehensive cardiac rehabilitation (CR) arms.



Meta-analyses showed that cardiac rehabilitation had no effect on total mortality compared with that for the control group but led to a reduction in cardiovascular mortality (relative risk, 0.74; 95% CI, 0.64 to 0.86) ( Table 34-2 and Figure 34-2 ). Exercise-based rehabilitation reduced the risk of hospital admissions (relative risk, 0.82; 95% CI, 0.70 to 0.96) ( Figure 34-e1 ). No significant impact on either the risk of recurrent MI or revascularization was noted. In view of the variation in health-related quality of life outcome measures across trials, meta-analysis for this aspect of outcomes was not possible. Of 20 studies that reported quality of life, however, a majority (13 trials, 65%) showed higher outcome levels in one or more quality of life domains after rehabilitation compared with those for control groups. With data from multiple RCTs and meta-analyses of RCTs, the efficacy of cardiac rehabilitation fulfills grade A/level I evidence.



TABLE 34-2

Summary of Meta-analysis of Effects of Exercise-Based Cardiac Rehabilitation on Clinical Event Outcomes

Adapted from Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev (1):CD001800, 2016.































































Outcome No. of Participants
(with No. of Studies)
No. of Events/ Participants Relative Risk (with 95% CI) Statistical Heterogeneity I statistic Chi-Square Test
(with P value)
GRADE/Quality of Evidence
Intervention Comparator
All-cause mortality (all studies) 12,455 (47) 838/6424 865/6031 0.94 (0.87-1.02) 0% (0.58) + + + −
Moderate
CV mortality (all studies) 7469 (27) 292/3850 375/3619 0.74 (0.64-0.85) 0% (0.70) + + + −
Moderate
Fatal and/or nonfatal MI (all studies) 971 (36) 356/4951 387/4766 0.89 ( 0.78-1.02) 0% (0.48) + + − −
Low ∗†
CABG (all studies) 5891 (29) 208/3021 212/2870 0.94 ( 0.78-1.12) 0% (0.86) + + + −
Moderate
PCI (all studies) 4012 (16) 171/2013 197/1999 0.86 (0.71-1.04) 0% (0.59) + + + −
Moderate
Hospital admissions (all studies) 3030 (15) 407/1556 453/1474 0.86 (0.77-0.95) 34.5% (0.10) + + − −
Low ∗†

CABG, Coronary artery bypass grafting; CV, cardiovascular; GRADE, Grades of Recommendation, Assessment, Development and Evaluation [with plus or minus assigned for each of the four grading categories]; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Funnel plots and/or Egger test suggest evidence of asymmetry.















Grade Working Group Quality of Evidence
High quality : Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality : Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality : Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality : We are very uncertain about the estimate.

Random sequence generation, allocation concealment, and blinding of outcome assessors were poorly described in greater than 50% of included studies; bias likely.





FIGURE 34-2


Meta-analysis of cardiovascular mortality.

(From Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.)


In addition to efficacy, two key additional key evidence considerations for rehabilitation and secondary prevention are safety and cost-effectiveness. Exercise-based rehabilitation appears to be very safe. An observational study of more than 25,000 patients in a French registry of rehabilitation-related complications reported one cardiac event for 50,000 hours of exercise training—equivalent to 1.3 cardiac arrests per 1 million patient-hours. An earlier American study reported only one case of ventricular fibrillation per 111,996 patient-hours of exercise and one MI per 294,118 patient-hours. A systematic review of economic evaluations of cardiac rehabilitation and secondary prevention reported a cost per life-year gained ranging from US$2193 to US$28,193. In 2007, the National Institute of Health and Care Excellence (NICE) in the United Kingdom estimated the incremental cost-effectiveness ratio for rehabilitation after MI at approximately £7860 and £8360 per quality-adjusted life-year (QALY) gained for men and women, respectively. NICE’s current funding threshold is £20,000/QALY, indicating the provision of cardiac rehabilitation and secondary prevention to be cost-effective.




Components of Cardiac Rehabilitation and Secondary Prevention


Systematic Referral


All eligible patients with acute MI and all patients in the immediate postoperative period after CABG or PCI should be referred to a comprehensive outpatient rehabilitation and secondary prevention program either before hospital discharge or during the first immediate follow-up visit. The services should be instituted as soon as possible after hospital admission. Cardiac rehabilitation and secondary prevention generally are considered most beneficial when delivered soon after the index hospitalization. In certain situations, however, clinical, social, and logistic reasons can delay enrollment in a structured program. To ensure effective access to rehabilitation and preventive services, referral should be considered by all health care practitioners with responsibility for the care of post-MI patients in the 12 months after their acute event or cardiac surgery.


Despite the substantive evidence for the benefits of such services, implementation of and patient enrollment in cardiac rehabilitation and secondary prevention programs remain below desired levels. Studies in Europe, North America, and Australia have reported participation rates of 20% to 50%. The gap in delivery is especially large in older patients, women, and members of ethnic minorities. Reasons behind these gaps in participation are generally classified into three categories: (1) patient-based, especially lack of sufficient financial resources and/or health care insurance coverage to participate or lack of interest in participating in the program; (2) provider-based, especially lack of physician referral of patients; and (3) system-based barriers, especially lack of resources to fund rehabilitation/preventive services or lack of services within close proximity to a patient’s home. A Cochrane systematic review assessed the efficacy of interventions to improve uptake of and adherence to cardiac rehabilitation and secondary prevention. However, this review found only weak evidence (11 RCTs) supporting specific interventions to increase uptake. Systematic referral procedures and interventions targeting patient-identified barriers may increase the likelihood of success. At referral, clinicians need to be aware of potential patient barriers ( Table 34-3 ). Some particular approaches to overcoming these barriers are presented later under Innovative and Models of Rehabilitation and Prevention (in the section on maintaining long-term behavioral changes).



TABLE 34-3

Barriers to Participation in Cardiac Rehabilitation and Secondary Prevention










Patient-Related Barriers Provider- and System-Related Barriers



  • Older age, female sex



  • Smoking



  • Depression



  • Social isolation



  • Family obligations



  • Limited finances



  • Lack of transportation



  • Patient refusal




  • Lack of services



  • Distance to services



  • Lack of systematic referral



  • Lack of physician endorsement




FIGURE 34-e1


Meta-analysis of hospital admission.

(From Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.)




Patient Risk Assessment and Tailored Planning


Formulation of an individually tailored, patient-specific plan for cardiac rehabilitation and secondary prevention should be based on a careful risk assessment at discharge or as soon as possible after hospital admission and before initiation of the program. This risk assessment should systematically collect and document the clinical information as listed in Table 34-4 .



TABLE 34-4

Patient Risk Assessment and Clinical Data Collection

Adapted from 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 115:2675-2682, 2007; and Piepoli MF, Corra U, Adamopoulos S, et al: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664-681, 2014.








































Assessment Component Description
Clinical history Screening for cardiovascular risk factors, comorbid conditions and disabilities, psychological stress, vocational situation
Symptoms Cardiovascular disease—NYHA functional class for dyspnea and Canadian Cardiovascular Society (CCS) class for symptoms of angina
Medication Including dose, frequency, side effects
Adherence To medical regimen and self-monitoring (weight, BP, symptoms)
Physical examination General health status, body mass index (BMI), waist circumference, heart failure signs, cardiac and carotid murmurs, pulse, BP control, extremities for presence of arterial pulses and orthopedic pathology, neurological abnormalities
ECG Heart rate and rhythm, repolarization
Cardiac imaging 2D and Doppler echocardiography when appropriate—in particular, ventricular function, valvular heart disease, presence of effusion
Blood testing For routine biochemical assay: including full blood count, electrolytes, renal and liver function, fasting blood glucose (HbA 1C if fasting blood glucose is elevated or with known diabetes), total cholesterol, LDL-C, HDL-C, triglycerides
Physical activity level by history Domestic, occupational, and recreational needs; activities relevant to age, gender, and daily life; readiness to change behavior; self-confidence; barriers to increased physical activity; and social support in making positive changes
Peak exercise capacity Symptom-limited exercise testing, either on bicycle ergometer or on treadmill. If this is not feasible (e.g., because of recent surgery), submaximal exercise evaluation and/or six-minute walk test should be considered.
Education Clear, comprehensible information on the basic purpose of the CR program and the role of each component (including optimal medical therapy compliance)
Education on self-monitoring protocols (weight, blood pressure, warning symptoms and signs of instability, e.g., angina, dyspnea) and self-management

BP, Blood pressure; CR, cardiac rehabilitation; 2D, two-dimensional; ECG, electrocardiogram; HbA 1C , , A 1C hemoglobin (glycosylated); HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NYHA, New York Heart Association.


Exercise Testing and Training


Symptom-limited exercise testing before participation in an exercise-based cardiac rehabilitation program is strongly recommended (see also Chapter 30 ). Exercise test parameters should include assessment of heart rate and rhythm, signs and symptoms, ST-segment changes, hemodynamics, perceived exertion, and exercise capacity. On the basis of this exercise test, patients can then be risk-stratified to select the appropriate level of supervision and monitoring required during their exercise-based rehabilitation program. Exercise training should incorporate an individualized exercise prescription for aerobic training that should be regularly reviewed by the program team and modified if necessary. Current recommendations for exercise prescription are as follows:




  • Frequency: 3 to 5 sessions per week



  • Intensity: 50% to 80% of maximal exercise capacity



  • Duration: 20 to 60 minutes per session



  • Modality: walking, treadmill, cycling, rowing, stair climbing, arm/leg ergometry, and other modalities, using continuous or interval training as appropriate



Exercise-based rehabilitation programs also can include resistance exercise.


Education


A Cochrane review identified 13 RCTs examining patient education interventions among 68,556 subjects with coronary heart disease, with a follow-up period of 6 to 60 months. The meta-analysis from this review showed weak evidence of an effect of education compared with usual care on all-cause mortality (relative risk [RR], 0.79; 95% CI, 0.55 to 1.13) and cardiac morbidity (recurrent MI: RR, 0.63; 95% CI, 0.26 to 1.48; revascularization: RR, 0.58; 95% CI, 0.19 to 1.71; and hospitalization: RR, 0.83; 95% CI, 0.65 to 1.07). After education, some evidence indicates that quality of life scores were higher than those in control groups. These findings generally are supportive of cardiac rehabilitation and secondary prevention, including some form of education, either in groups or as individual consultations. Further research into different models of education is needed, however, to inform future more specific recommendations on the nature and content of this education delivery.


Current guidelines for education include its role in providing a positive impact on healthy behavior ( Table 34-5 ), risk factor modification ( Table 34-6 ) and improving adherence to cardioprotective medications ( Table 34-7 ), as well as psychosocial support including vocational guidance and sexual functioning ( Table 34-8 ).



TABLE 34-5

Assessment, Clinical Interventions, and Expected Outcomes for Behavioral Interventions after Acute Myocardial Infarction

Adapted from Smith SC Jr, Benjamin EJ, Bonow RO, et al: AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 124:2458-2473, 2011; 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 115:2675-2682, 2007; and Piepoli MF, Corra U, Adamopoulos S, et al: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664-681, 2014.





























Area of Interest, with Treatment Goals Evaluation/Assessment Intervention Expected Outcomes
Physical activity counseling


  • E : Moderate aerobic activity, minimum 2.5 hours/week, in multiple bouts each lasting ≥10 minutes



  • U : Moderate aerobic activity, 30 minutes/day, 5-7 days/week



  • U : Complementary resistance training, 2 days/week

Assess current physical activity level and determine domestic, occupational, and recreational needs.

Assess readiness to change behavior, self-confidence, and barriers.
Recommend gradual increases in daily lifestyle activities over time, and how to incorporate it into daily routine and evenly spread throughout the week, i.e., minimum 5 days a week.
Emphasize sedentary lifestyle as risk factor and the benefits of physical activity: Any increase in activity has a positive health benefit.
Advise : Individualize physical activity according to patient’s age, past habits, comorbid conditions, preferences, and goals.
Reassure regarding the safety of the recommended protocol.
Encourage involvement in leisure activities that are enjoyable.
Forewarn : Inform patients on the risk of relapses; education should underline how benefits may be achieved and the need for lifelong continuation.
If physical activity interruption has occurred, physical, social, and psychological barriers should be explored, and alternative approaches suggested.
Increased participation physical activities.
Improved psychosocial well-being
Prevention of disability
Improved aerobic fitness and body composition
Smoking cessation


  • Nonsmoker status

Smoking status and use of other tobacco products
Amount of smoking (per day) (number of years)
Determine readiness to change; if ready, choose a date for quitting.
All smokers should be encouraged professionally to stop smoking all forms of tobacco permanently.
Follow-up : Referral to special programs and/or pharmacotherapy (including nicotine replacement) are recommended, as is a stepwise strategy for smoking cessation. Provide structured follow-up. Offer behavioral advice and group or individual counseling.
Consider nicotine replacement therapy, combined with bupropion or varenicline if not contraindicated.
Long-term abstinence from smoking
Nutritional counseling


  • Heart-healthy diet

Daily caloric intake and dietary content of fat, saturated fat, sodium, and other nutrients
Assess eating habits.
Education regarding dietary goals and how to attain them


  • Healthy food choices:




    • Wide variety of foods; low-salt foods



    • Mediterranean diet: fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy products



    • Replace saturated fat with the above foods and with monounsaturated and polyunsaturated fats from vegetable (oleic acid as in olive oil and rapeseed oil) and marine sources to reduce total fat to <30% of energy, of which less than 1/3 is saturated



    • Avoid : beverages and foods with added sugars and salty food




  • Integrate behavior-change models and compliance strategies into counseling sessions.

Patient understands basic principles of dietary content.
Patient adheres to prescribed diet.
Weight control management


  • Body mass index (BMI) : 18.5-24.9 kg/m 2



  • Waist circumference : 80 cm in women, 94 cm in men

Measure weight, height, and waist circumference. Calculate BMI. BMI : It is useful to consistently encourage weight control through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated.
Waist circumference : It is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.
To lose 5%-10% of body weight in 6 months.
Consider referring patient to specialist obesity clinic if goal not reached.

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Aug 10, 2019 | Posted by in CARDIOLOGY | Comments Off on New Concepts in Cardiac Rehabilitation and Secondary Prevention After Myocardial Infarction
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