This chapter presents an account of cardiac rehabilitation that reflects both American and European perspectives. The authors find that the distinction between prevention and rehabilitation is becoming obsolete. The sections on risk estimation and prevention guidelines have a European flavor to complement Chap. 51. It should be stressed that the main objectives and targets are in close agreement. Both stress the need for total risk estimation as a first step in implementing practical preventive measures.

Atherosclerotic cardiovascular disease, particularly coronary heart disease (CHD) and stroke, is now the largest cause of death across the world except in sub-Saharan Africa.1 The creation of coronary care units in 1961 and associated advances in medical and nursing care are thought to be responsible for the decrease in mortality in patients with myocardial infarctions from 25%-30% to 18% in the prethrombolytic era of the mid-1980s2 to as low as 10% by 1997.2,3 In Europe, the annual incidence of non–ST-segment elevation myocardial infarction–acute coronary syndrome (NSTEMI-ACS) is higher than that of ST-segment elevation myocardial infarction (STEMI). Over time, the proportion of NSTEMI-ACS has increased compared with STEMI without any clear explanation for the reasons. The pattern of change could be related to improved diagnostics and management of CHD over the last 20 years,4,5 resulting in decreased 30-day mortality rates in NSTEMI-ACS of 3.4% and STEMI of 6.4%.5 In parallel with these changes, cardiac rehabilitation has evolved to meet the needs of patients with angina pectoris and acute coronary syndromes and of patients who are post cardiac surgery.

Substantial changes have occurred in our concepts of cardiac rehabilitation in recent years. In Eastern Europe, rehabilitation often involved inpatient assessment and care, whereas in North America and Western Europe, structured outpatient programs were favored. Comparatively, little communication existed between the disciplines of epidemiology, prevention, and rehabilitation, despite the fact that prevention requires advice on exercise and rehabilitation involves risk factor management. These issues have been addressed by many interested groups coming together to formulate guidelines that facilitate more integrated patient care.

The differentiation between primary and secondary prevention limits thinking on optimal public health and may be challenged. Pathologic studies indicated decades ago that atherosclerosis, the underlying cause of CHD, starts in childhood, develops insidiously over decades, and is generally advanced by the time symptoms occur. A person with asymptomatic plaque on carotid ultrasound or coronary artery calcification on computed tomography scanning should be managed no less vigorously than a patient who has had a clinical event.

Newer diagnostic tests for acute coronary syndromes have taught us that myocardial infarction represents a continuum of damage and does not occur suddenly when cardiac enzymes reach “two times the upper limit of normal.” Newer therapies, especially focusing on rapid reperfusion of occluded coronary arteries, mean that, at least for those who reach medical care in time, major heart muscle loss with consequent complications such as shock or heart failure with a high risk of death are becoming less frequent than in the past. The presentation of a person with angina, an acute coronary syndrome, or coincidental asymptomatic disease should trigger the initiation of a lifelong program of risk factor modification including physical exercise. Of course death is deferred, not prevented, and rehabilitation programs now tend to see both more young people with multiple risk factors and older persons who have developed heart failure. The increasing prevalence of obesity and premature glucose intolerance poses additional challenges for patient management and guidance.

Although the definitions of cardiac rehabilitation are several, many would accept the simple definition of return to normal life. Prolonged hospital attendance may create medical dependency and impede rather than assist such a return. Increasingly, hospital-based cardiac rehabilitation programs are seeking to integrate with community- and home-based programs. This is easier in medical systems that promote such an integration of health services.

A major advance has been the realization that no one individual or discipline owns rehabilitation. Newer rehabilitation programs are multidisciplinary, with all members participating in both the planning and delivery of programs with a sense of co-ownership. They are frequently nurse led and need to be patient or participant centric.

The first attempt at cardiac rehabilitation was probably made by the Greek physician Asclepiades of Bithynia in 1124 BC. There have been various reports through the centuries by others such as William Stokes in 1854 who advocated early mobilization and walking for patients with heart disease. This view was contrary to the opinion of the early 20th century, which stressed the importance of absolute bed rest for 4 to 8 weeks. The main effect of advocating the need for long-term restrictive physical, social, and vocational measures was to lead to the development of the cardiac cripple.

It was not until the early 1950s that this practice was challenged. Samuel Levine and Bernard Lown demonstrated that sitting in a chair 7 days after the onset of acute coronary symptoms was safe and had physical and psychological benefits.6 The finding that prolonged rest causes deconditioned responses to exercises led to the use of physical training to aid recovery.7

Concurrent with gradual changes from sedentary convalescence to early mobilization, the importance of risk factors and lifestyles in the genesis of coronary disease was realized, and the concept of cardiac rehabilitation was born. The first structured rehabilitation program was pioneered in Israel in 1955.8

From these beginnings, cardiac rehabilitation has developed worldwide but differs widely among countries, from highly structured inpatient programs to informal home-based programs. Although there may be no ideal rehabilitation program, the majority consist of regular outpatient exercise and educational programs. Comprehensive rehabilitation involves a multidisciplinary team comprising the following: physician, nurse coordinator, cardiovascular nurses, physiotherapist, sports therapist, dietician, pharmacist, social worker, clinical psychologist, vocational advisor, occupational therapist, and as many other professionals as are available and relevant to the needs and goals of that particular program. The rationale for such a team approach is that disability in the cardiac patient arises for a number of different reasons that may be medical, psychological, nutritional, or social, in addition to the underlying cardiac complaint. These are most effectively tackled by using the skills of health professionals in these areas. The traditional aims of cardiac rehabilitation are to restore the patient to his or her rightful place in the social and family structure, to improve psychological well-being, and to improve the patient’s clinical prognosis through secondary prevention measures.

The delivery of the cardiac rehabilitation service depends on a partnership between the patient, family members, multidisciplinary team, and primary care services until such a time as the patient has the ability to take control of a healthy lifestyle. Cardiac rehabilitation is tailored to meet each patient’s needs with individual assessment of risk including age, sex, family history, diabetes, excessive alcohol intake, dyslipidemia, hypertension, smoking, obesity, physical inactivity, and psychological status. Delivered by the multidisciplinary team, cardiac rehabilitation facilitates behavioral change through exercise prescription, educational sessions, medication advice, healthy eating guidelines, stress management and relaxation, behavioral change, smoking cessation, and vocational counseling. By incorporating lifestyle management, the intention is to reduce the possibility of a subsequent cardiac event, slow or stop the progression of cardiovascular disease, and improve quality of life.9

Cardiac rehabilitation and secondary prevention programs are now accepted as an integral component of the comprehensive care of patients with cardiovascular disease. Typically, cardiac rehabilitation comprises exercise and educational programs with the aim to promote the uptake and maintenance of appropriate physical activity and healthier lifestyle changes, so as to positively influence the individual’s recovery and as a means of secondary prevention. Since the 1980s, a variety of working groups and committees have published guidelines and recommendations for cardiac rehabilitation.10-15

In 1982, the World Health Organization Expert Committee for the Prevention of Coronary Heart Disease recommended that planned preventive measures should be part of usual care for every coronary artery disease patient.16 Cardiac rehabilitation was subsequently defined as follows:

The sum of activities required to influence favourably the underlying cause of the disease, as well as to ensure the patients the best possible physical, mental and social conditions so that they may by their own efforts preserve, or resume when lost, as normal a place as possible in the life of the community. Rehabilitation cannot be regarded as an isolated form of therapy but must be integrated with the whole treatment, of which it only forms one facet.17

The medical goals of cardiac rehabilitation have been summarized by the World Health Organization as (1) the prevention of cardiac death, (2) a decrease in cardiac morbidity, and (3) the relief of symptoms such as angina and breathlessness.17

In 1995, the US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research issued guidelines10 that are still widely used, describing cardiac rehabilitation as:

Comprehensive long term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education and counselling, designed to limit the physiological and psychological effect of cardiac illness, reduce the risk of sudden death or reinfarction, control cardiac symptoms and enhance the psychological and vocational status of the individual patient.

Early in the 21st century, the Scottish Intercollegiate Guideline Network15 and European Society of Cardiology12 published guidelines regarding evaluation and intervention in all aspects of cardiac rehabilitation. These initiatives were aimed at assisting cardiac rehabilitation staff with the development of cardiac rehabilitation programs in Europe. The Scottish Intercollegiate Guidelines Network Guideline 5715 states that:

Cardiac rehabilitation is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health.

The American Heart Association (AHA) consensus statement11 on “core components” of cardiac rehabilitation recognizes the role cardiac rehabilitation has to play in risk factor management, defining specific goals for lifestyle targets; these have similarly been adopted by the European Society of Cardiology.6 Physical activity is also strongly emphasized in the current European guidelines on cardiovascular disease prevention.18

The current European guidelines on cardiovascular disease prevention in clinical practice18 give the highest priority to those with established cardiovascular disease. The priorities in terms of patient selection for cardiovascular disease prevention in clinical practice are as follows:

1. 
   

   Patients with established atherosclerotic cardiovascular disease

   
   
2. 
   

   Asymptomatic individuals who are at high risk of developing atherosclerotic disease because of:

• 
  
  
  
  1. 
     

     Multiple risk factors resulting in a 10-year risk of >5% now (or if extrapolated to age 60) for developing a fatal cardiovascular disease event

     
     
  2. 
     

     Markedly raised levels of single risk factors, especially if associated with end-organ damage

     
     
  3. 
     

     Diabetes type 2 and diabetes type 1 with microalbuminuria

3. 
   

   Close relatives of:

• 
  
  
  
  1. 
     

     Patients with early-onset atherosclerotic cardiovascular disease

     
     
  2. 
     

     Asymptomatic individuals at particularly high risk

These people have declared themselves to be at high risk of further cardiovascular disease and to need intensive risk factor advice; once more, we stress that the aims of prevention and rehabilitation are the same. There is a trend to offer rehabilitation services to asymptomatic high-risk persons. Such people can be identified by using risk scoring systems such as those advocated in Chap. 51 or by using the European SCORE system (Figs. 67–1 and 67–2), which illustrates graphically that, in most people, risk is the product of multiple interacting risk factors.

Risk factor targets for those at very high risk, which includes all people who have had an atherosclerotic clinical event, in the European guidelines18 are relatively straightforward conceptually, although many can be difficult to successfully implement:

• No tobacco
  
• Make healthy food choices
  
• 30 minutes of moderate physical activity a day
  
• Body mass index <25 kg/m2 and avoidance of central obesity
  
• Blood pressure <140/90 mm Hg, <130/80 mm Hg in diabetics
  
• Total cholesterol <175 mg/dL (4.5 mmol/L) with an option of <155 mg/dL (<4 mmol/L) if feasible
  
• Low-density lipoprotein (LDL) cholesterol <100 mg/dL (2.5 mmol/L) with an option of <80 mg/dL (<2 mmol/L) if feasible
  
• Fasting blood glucose <110 mg/dL (<6 mmol/L); hemoglobin A1c <6.5% if feasible
  
• Consideration of cardioprotective drug therapy in high-risk patients, especially those with atherosclerotic cardiovascular disease

Early randomized trials of cardiac rehabilitation after acute myocardial infarction show consistent trends toward a survival benefit among patients enrolled in such cardiac rehabilitation programs. Meta-analyses of these randomized trials suggest a significant 20% to 25% reduction in cardiovascular death but no change in the occurrence of nonfatal reinfarction in patients assigned to medically supervised and prescribed exercise programs.19,20 A more recent meta-analysis of exercise-based rehabilitation by Jolliffe et al21 demonstrated a 27% decrease in all-cause mortality with exercise-only cardiac rehabilitation and a 13% decrease with comprehensive cardiac rehabilitation but could not conclude that exercise alone was significantly better than a comprehensive approach. Total cardiac mortality was reduced by 31% with exercise-only cardiac rehabilitation and by 26% with comprehensive cardiac rehabilitation. The populations studied were male, middle-aged, and low risk and thus may not reflect the entire population suitable for cardiac rehabilitation, including those who present with comorbidities or who are female, older, or of different ethnicity. The majority of these studies did not report details of medications or fibrinolysis, which may have affected mortality rates.

In a systematic review of randomized controlled trials conducted up to March 2003, Taylor et al22 found a decrease in all-cause mortality of 20% and a decrease in cardiac mortality of 26% with no significant differences between exercise-only cardiac rehabilitation and comprehensive cardiac rehabilitation. This analysis included more randomized controlled trials from the fibrinolysis era and the period of intensive lipid-lowering therapies.

Taken collectively, these studies suggest that reported mortality reductions associated with exercise-based rehabilitation may apply to both subjects with acute coronary syndromes and those who have undergone revascularization. Psychological benefits, improved coronary blood flow, functional capacity, and reductions in risk factors and inducible ischemia have also been reported.

The indications and contraindications for cardiac rehabilitation are summarized in Table 67–1. It should be appreciated that such lists are for guidance only and should be tempered by clinical judgment. Clearly, some of the listed contraindications, such as acute systemic illness, may be temporary.23

Phases

Worldwide, cardiac rehabilitation is structured in different ways. The term phase is used to describe the varying time frames following a cardiac event. There are four phases of cardiac rehabilitation in both Europe and the United States (Table 67–2), but variations in the structure of these phases exist between the two continents. In some European countries, residential cardiac rehabilitation is the common practice for more complicated, disabled patients, and outpatient cardiac rehabilitation is used for more independent, lower risk, and clinically stable patients.

Phase I traditionally begins on admission to the coronary care unit. The patient is reviewed by the cardiac rehabilitation team members. Individual risk factors are discussed, and the patient is first introduced to the concept of lifelong lifestyle changes. Pain and anxiety may impede effective communication, and advice must be simple and repetitive. As soon as it is deemed safe, simple breathing and leg exercises are commenced with a program of gradual mobilization. The emphasis at this stage is to counteract the negative effects of deconditioning after a cardiac event rather than to promote training adaptations.24 The patient may require intervention from other members of the multidisciplinary team at this stage, for example, the dietician, social worker, psychologist, or smoking cessation counselor. This is an ideal opportunity to commence education and psychological support. Following discharge from the coronary care unit, the cardiac rehabilitation team continues patient education and counseling. A discharge plan is formulated taking into account individual needs (eg, return to work, medications, exercise program). Prior to discharge, the patient may visit the rehabilitation facility and may meet recovering patients.

Phase II usually consists of an educational program, exercise advice given by the physiotherapist, and plans for the patient to attend phase III are consolidated. The patient may have ongoing review by various members of the multidisciplinary team, such as the dietician or psychologist, at this stage.

Phase III usually consists of an 8- to 12-week program of structured or supervised exercise and education. When a 4-week program was compared with a usual-care, 10-week program, a higher attendance in the 4-week group (96% vs 84%) was noted.25 This suggests that brief and intense cardiac rehabilitation is acceptable to patients. This phase involves the expertise of the multidisciplinary team and the commitment of the patient to attend the program. Traditionally, this program was always hospital based, but community-led or independent programs are also available. In the United Kingdom and Ireland, there are some home-based programs that are ideal for the rural population who have too far a distance to travel to commit to a hospital-based program.

Phase IV is a maintenance program often in the form of a gym or health club facility membership, ideally with occasional sessions to help sustain lifestyle change.

The way in which cardiac rehabilitation is delivered may differ nationally and internationally, but certain standard core components, including baseline patient assessment, psychosocial interventions, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), physical activity counseling, and exercise training, have been adopted by Europe and the United States.11,14

Target Population

Traditionally, cardiac rehabilitation is offered to patients after uncomplicated myocardial infarction or after successful revascularization with coronary artery bypass surgery or percutaneous coronary intervention.24 Now, higher risk subjects and those with complex cardiac histories often participate in tailored cardiac rehabilitation programs. Elderly patients who have additional comorbidities, heart failure patients, patients with implantable cardioverter-defibrillators, and post–cardiac transplantation patients make up the majority of this high-risk group. Insurance and reimbursement patterns differ between the United States and Europe; in the United Kingdom and Ireland, for example, the service is offered within the public hospital sector at no charge.

Multidisciplinary Components and Roles

All current recommendations on prevention and rehabilitation acknowledge that patient management should be based on an assessment of total risk. Because the highest risk individuals gain most from intervention, current European guidelines18 define priorities for cardiovascular disease prevention and also rehabilitation (Table 67–3). The various components addressed by cardiac rehabilitation programs will generally include attention to the following aspects:

• Communication skills
  
• Behavior change
  
• Smoking
  
• Exercise
  
• Weight management
  
• Nutrition
  
• Lipids
  
• Blood pressure
  
• Psychosocial factors
  
• Cardiopulmonary resuscitation training

Communication Skills

Over many years, we have examined aspects of our communications with our patients and have learned the following:

1. 
   

   Reading skills are often poor, and illiteracy (often concealed) is more common than expected.

   
   
2. 
   

   Patients who are in the hospital are often frightened and may not recollect even focused and repeated advice when assessed after discharge; their recollection and understanding need to be repeatedly assessed throughout the rehabilitation process.

   
   
3. 
   

   When tested, much of our written material was too complex. Booklets were replaced with subject-specific cards that have been repeatedly tested to ensure easy understanding.

Behavior Change

Strategies to make behavioral counseling more effective have been summarized18 and include:

• Developing a sympathetic alliance with the patient
  
• Ensuring the patient understands the relationship between lifestyle and disease
  
• Gaining commitment from the patient to achieve lifestyle change
  
• Involving the patient in identifying the risk factor(s) to change
  
• Helping the patient overcome barriers to lifestyle change
  
• Helping design a lifestyle modification plan
  
• Being realistic and encouraging
  
• Reinforcing the patient’s efforts to change
  
• Monitoring progress of lifestyle change through follow-up contacts
  
• Involving other health care staff wherever possible

Smoking

Cigarette smoking is the world’s leading cause of preventable death26 and needs to be eradicated in the interest of the public health. Approximately 1.1 billion people smoke worldwide. This figure is expected to increase to >1.6 billion by 2025.27 The causal relationship between smoking and cardiovascular disease is well established. Cigarette smoking is a major risk factor for the development of coronary artery disease and increases the risk of mortality and morbidity among people with established coronary artery disease.9 There are a multitude of cardiovascular toxins in tobacco smoke, and the effects of smoking on the cardiovascular system are summarized in Table 67–4. Smoking cessation will reduce the subsequent risk of mortality by up to 9% in absolute terms.27 Observational studies in post–myocardial infarction patients suggest that this may be reflected as a halving of long-term mortality.28

Cardiac rehabilitation is the ideal setting in which to promote smoking cessation. Educating patients about the association between smoking and heart disease at this vulnerable period may be the trigger to motivate smoking cessation. Numerous nonpharmacologic and pharmacologic agents are available to aid the patient and health professional with this campaign. Both group therapy and individual counseling to instigate behavioral change are useful in helping the patient to quit smoking. Nicotine replacement therapy in the form of transdermal patches, chewing gum, nasal spray, oral inhalers, and sublingual tablets is safe and may augment the process of smoking cessation.

Strategies that may help include the five A’s29:

• Ask: Systematically identify all smokers at every opportunity.
  
• Assess: Determine the person’s degree of addiction and his/her readiness to cease smoking.
  
• Advise: Unequivocally urge all smokers to quit.
  
• Assist: Agree on a smoking cessation strategy including behavioral counseling, nicotine replacement therapy, and/or pharmacologic intervention.
  
• Arrange a schedule of follow-up visits.

Exercise

The evidence base for exercise-based and comprehensive cardiac rehabilitation programs has been considered earlier. Meta-analyses suggest that both may be associated with a reduction in mortality, both after acute coronary syndromes and after revascularization procedures, and with other psychological and physical benefits.21

Phase I (Inpatient)

The major components of the inpatient stage are evaluation of the patient’s condition, assessment of the patient’s motivation, risk factor assessment, education, mobilization, and discharge planning.13,20 It can be difficult for the health care professional to address all components adequately because the time spent in a medical facility may only be a few days for a patient with an uncomplicated myocardial infarction. Exercise is gradually introduced to the patient on day 2, and the intensity of exercise up to discharge usually does not exceed four metabolic equivalents (METS). Ideally, by day 4, the patient will have progressed to walking 5 to 10 minutes in the corridor three or four times per day.

Phase II (After Discharge)

Phase II is the period after discharge from the medical facility and prior to the commencement of phase III (outpatient). The length of time between discharge and commencement of the phase III program varies between countries and facilities. Contact between the patient and the rehabilitation team can vary from a telephone call to home visits. Therefore, it is imperative that the patient has clear instructions on his or her individualized exercise prescription. The usual mode of exercise prescribed initially is walking on level ground. The intensity should be maintained between 2 and 4 METS or a score of 11 to 12 on the Rating of Perceived Exertion Scale in the early stages.30 In practical terms, we advise patients to stay indoors for the first day or two because they may expect to feel somewhat fatigued and perhaps anxious. Uncomplicated cases are advised to increase their walking distance progressively to 3 to 5 km daily after 4 to 6 weeks.

Phase III (Outpatient Exercise Program)

The aim of this phase of the cardiac rehabilitation program is to enable the patient to exercise safely in a structured environment and to understand the benefits of exercise. Prior to commencing an exercise program, it is usual for a patient to undergo a symptom-limited exercise stress test. Exercise testing can be used as either a diagnostic or prognostic tool or as a test of functional capacity. It is mainly for the latter reason that exercise testing is recommended in cardiac rehabilitation. This information aids assessment for exercise prescription and return to work evaluation and helps in an estimation of prognosis. Not all patients referred for cardiac rehabilitation may require an exercise test, but the absence of a test may lead to an inappropriate exercise prescription.31 Furthermore, there are absolute and relative contraindications to exercise testing, and these are shown in Table 67–5.

Recommended intensities for the structured exercise in phase III (outpatient phase) vary depending on the technique used to prescribe exercise intensity. Cardiac patients should exercise in the low to moderate range of exercise intensity, corresponding to 60% to 75% of maximum heart rate (HRmax)15 or 60% to 70% of maximum heart rate reserve,30 corresponding to a score of 12 to 14 on the Rating of Perceived Exertion Scale.15 Although most accurately measured using a cardiac stress test, the most common way of calculating the HRmax is to subtract the patient’s age from 220. The heart rate reserve is calculated by subtracting the resting heart rate from the HRmax. The duration of the program may vary from 8 to 12 weeks, and patients attend two to three times per week. This is deemed sufficient to achieve both physiologic and psychosocial adaptations.15 It is important to stress to participants that it is necessary to exercise on nonprogram days to achieve maximal potential.23

The types of exercises used during the exercise program should promote total physical conditioning, including treadmills, cycle and arm ergometers, stair climbers, and rowing machines.23 These exercises are mainly aerobic in nature, but resistance training can be used in lower to moderate risk cardiac patients. However, it is recommended that patients spend some time on aerobic-type exercises first before progressing to resistance exercise. This allows them to become used to monitoring their own exercise intensity.15

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