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Cardiac rehabilitation aims to improve cardiopulmonary capacity of cardiac patients. Here we review the indications and positive cardiovascular effects that come as a result of a controlled training program from a brief review of available literature, while also considering contra-indications, as well as potential complications and larger context.
Cardiac rehabilitation programs were first initiated in the ’60s for patients recovering from acute myocardial infarction and then expanded to other cardiac patients - postoperative, myocardiopathies and heart failure patients as well. It is the process by which cardiac patients recover and readapt to reach and maintain optimal physical, sensory, intellectual, psychological and social functional levels through strategies such that they are provided with the tools to resume their ordinary activities as soon as possible after a cardiac event. (1) Aims of cardiac rehabilitation are to attain 1) improved cardio-pulmonary capacity 2) risk factor management to delay or possibly reverse atherothrombosis (secondary and primary prevention) 3) psychological support and 4) insertion into social and employment activities (1).
Numerous animal and clinical studies have reported positive cardiovascular effects after a controlled training programme. (2-5). 1) Risk factors
2) Coronary arteries, myocardium and systolic function and rhythm disorders
3) Symptoms and mortality
Initially, cardiac rehabilitation was designed to reduce hospitalisations after myocardial infarction. The experience showed a low incidence of complications. Further on, the concept expanded to include patients with several conditions (summary in Table 1). Table 1: Indications for Cardiac Rehabilitation (1-5, 7)
Thus, indications are not restricted to post-acute myocardial infarction patients:
A better understanding of the results and potential risks of physical training has increased the indications for cardiac rehabilitation and limited contraindications, provided it is performed progressively and under surveillance. Nevertheless, there are absolute contraindications to cardiac rehabilitation (See Table 2 for summary). They include all scenarios where physical exercise has a potential risk such as unstable angina, severe hypertension, aortic aneurysm and dissection, recent pulmonary embolism, severe aortic stenosis and documented inappropriate response of blood pressure to exercise together with symptoms suggesting severe left ventricular dysfunction. Additionally, several conditions can be considered temporary contraindications, such as decompensated heart failure and supraventricular arrhythmias. Others are febrile illnesses or severe systemic diseases.Table 2: Contraindications for Cardiac Rehabilitation (2-5)
Most complications are the result of incorrect indication or inappropriate surveillance - especially regarding exercise levels.
However incidence of complications during cardiac rehabilitation programs is lower than the one described for the standard treadmill exercise test. Ventricular fibrillation incidence can vary from 1/9000 to 1/32000 per patient or per hour. Other authors have reported one episode after 113,583 hours of cardiac rehabilitation. In a hospital facility, this complication can be treated immediately and death for this cause is rare. Accidents can be divided into moderate or severe, as Table 3 summarises. Moderate accidents might force to quit cardiac rehabilitation temporarily.Table 3: Accidents during Cardiac Rehabilitation (1, 2-5)
Although the value of cardiac rehabilitation is not generally disputed, obstacles to cardiac rehabilitation are many (17).
However the increased number of men and women who now survive acute events leave society with a heavier burden of chronic conditions and clinical need, which rehabilitation can help to reduce. The European Association of Cardiovascular Prevention and Rehabilitation EACPR has issued the following documents:
We hope that if they are given the evidence, physicians will believe in the indications and beneﬁts of cardiac rehabilitation, and this will help overcome the lack of referrals and to also identify and motivate the patients who need cardiac rehabilitation. Indeed, a well controlled training programme aims to improve cardiopulmonary capacity of coronary heart disease: it will have a positive effect on lipid levels, smoking status, and insulin profiles, coronary arteries, myocardial and systolic function, heart rhythm, myocardial perfusion and coronary vasodilation capacity, myocardial performance, heart rate and blood pressure, oxygen consumption, peripheral artery disease, psychological state, productivity and mortality.Contra-indications include scenarios where physical exercise has a potential risk and complications derive mainly from inappropriate surveillance during exercise - special care for example is needed during resting periods and 15 minutes after physical training and it is also important to know that risk also increases when 80% of maximal aerobic functional capacity or 85% of maximal heart rate is exceeded. For a detailed view on whether and how to establish an exercise plan in cardiac patients, see previous article by French sports cardiologist, François Carré.
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E Alegría Ezquerra*, A Alegría Barrero**, E Alegría Barrero****Cardiology Unit. Policlinica Guipuzcoa, San Sebastian, Spain.**Cardiology Unit. Monteprincipe University Hospital, Madrid, Spain. ***Interventional Cardiology. Torrejon Hospital. Madrid, Spain.Authors' disclosures: None declared.