In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.
ACVC Clinical Decision-Making Toolkit

One of the best tools to help practitioners make the best bedside clinical decisions when managing patients with acute cardiovascular disease.

See more
Be Guidelines Smart

A comprehensive guidelines implementation toolkit especially for Nurses & Allied Professionals. 

See more
Expert tool

The EXPERT tool offers digital, interactive decision support tool for exercise prescription. 

See more

Cardiac Rehabilitation and exercise training recommendations

Cardiac rehabilitation: rationale, indications and core components.

Cardiac rehabilitation is a multi-factorial intervention recommended by international guidelines to patients with coronary artery disease. Cardiac rehabilitation consists of three phases and is shown to reduce mortality, hospitalisation, health care, and to improve exercise capacity, quality of life and psychological well-being. Core components in cardiac rehabilitation include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, risk factor control, patient education, psychosocial management, and vocational advice. In spite of cardiac rehabilitation recommendations, referral and uptake are often suboptimal.


Cardiac rehabilitation (CR) is a multi-factorial and comprehensive intervention in secondary prevention, designed to limit the physiological and psychological effects of cardiovascular disease, manage symptoms, and reduce the risk of future cardiovascular events.[1] CR is shown to reduce mortality, hospital readmissions, costs and to improve exercise capacity, quality of life and psychological well-being[2-5], and is recommended in international guidelines[6]  for patients with a ST-elevation acute myocardial infarction (Class I, Level B), a non ST-elevation myocardial infarction (Class IIa, Level A) and stable coronary artery disease (Class I, Level A). In spite of these recommendations, CR referral and uptake is often suboptimal and varies across Europe[1,7-8].

CR is traditionally divided into three phases[7]. Phase I is typically an inpatient service, which consists of early mobilisation, brief counselling about the nature of the illness, the treatment, risk factor management and follow-up planning. Phase II is mainly a supervised ambulatory outpatient programme. Phase III is a lifetime maintenance phase where the goal is to continue the risk factor- and lifestyle change and exercise training. Alternative modes of CR delivery include home-based programmes and e-health programs using e.g. the Internet and mobile phones[9].


CR should be offered to all patients with coronary heart disease including[10-12]: 

  • Patients with acute coronary syndrome — including ST elevation myocardial infarction, non-ST elevation myocardial infarction, and unstable angina[10-11]
  • Patients undergoing reperfusion (such as coronary artery bypass surgery and percutaneous coronary intervention)[10-12]
  • Patients with stable coronary artery disease[12]

Core components

Core components of CR include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, risk factor control, patient education, psychosocial management and vocational advice, with exercise training as a central component [6,10,12].

Patient assessment with medical control

Includes screening for cardiovascular risk-factors, co-morbidities, psychological stress, symptoms, adherence to medical treatment, and a physical examination including e.g. measuring body mass index, waist circumference, blood pressure, heart rate, ECG and blood testing.

Physical activity counselling

A minimum of 2.5 hours a week of moderate intensity aerobic activity, in multiple bouts each lasting ≥ 10 minutes, on 5 days a week is recommended. Prescribe physical activity according to the patient´s age, past habits, co-morbidities, preferences and goals.

Exercise training

Assess exercise capacity by symptom-limited stress testing, either on bicycle ergometer or on treadmill. If not applicable in a clinical setting, sub-maximal exercise evaluation should be considered. Exercise must be individually prescribed based on tests of physical capacity. Please visit the Physical Exercise webpage for detailed recommendations.

Diet/Nutritional counselling

Assessment of daily caloric intake and dietary content of fat, saturated fat, sodium, and other nutrients.

Risk factor control

Encourage weight control through an appropriate balance of physical activity and caloric intake to achieve and maintain healthy BMI (20–25 kg/m2). If weight circumference is ≥ 80 cm for women or ≥ 94 cm for men, it is recommended to initiate lifestyle changes and consider treatment strategies for metabolic syndrome.

Assess the lipid profile and modify diet, physical activity, and medication, if appropriate. The target low-density lipoprotein (LDL) level is defined as < 1.8 mmol/l (< 70 mg/dL).

Measure the blood pressure at rest on a regular basis. If resting systolic blood pressure is 140 mmHg or diastolic blood pressure is 90 mmHg, life-style changes are recommended. If resting systolic blood pressure is ≥ 140mmHg or diastolic blood pressure is ≥ 90mmHg, despite life style changes, initiate drug therapy.

Smokers should be encouraged to stop smoking all forms of tobacco permanently. Follow-up, referral to special programmes, and/or pharmacotherapy are recommended.

Patient education

Offer patient education to help patients cope with their illness, improve their health-related quality of life and ensure compliance with pharmacological and non-pharmacological treatment [17].

Psychosocial management

Screen for psychological distress as indicated by clinically significant levels of depression, anxiety, anger or hostility, social isolation, occupational or marital distress, sexual dysfunction. If appropriate, offer individual and/or small group education and counselling. Whenever possible, make information sessions available to the partners.

Vocational advice

Before discharge, discuss with patients and their partners and promote return to prior activities. Offer procedures to help patients to overcome barriers to return to work, such as re-training, capacity-building and reasonable adjustments.


[1] Piepoli MF, Corrà U, Dendale P, et al. Challenges in secondary prevention after acute myocardial infarction: A call for action. Eur J Prev Cardiol 2016; 23: 1994-2006.

[2] Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, Taylor RS: Exercise-based cardiac rehabilitation for coronary heart disease. The Cochrane database of systematic reviews 2016, 1:CD001800

[3] Rauch B, Davos CH, Doherty P, et al. The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol 2016; 23: 1914-1939.

[4] Whalley B, Rees K, Davies P, et al. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev 2011; Aug 10; 8: CD002902.

[5] Wong WP, Feng J, Pwee KH, et al. A systematic review of economic evaluations of cardiac rehabilitation. BMC Health Serv Res 2012; 8: 243.

[6] Piepoli MF, Corrà U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B, Cupples M, 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 2014; 21: 664-81.

[7] Bjarnason-Wehrens B, McGee H, Zwisler AD, et al.; Cardiac Rehabilitation Section European Association of Cardiovascular Prevention and Rehabilitation. Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010; 17: 410–418.

[8] Kotseva K, De Bacquer D, De Backer G, et al. Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions. Eur J Prev Cardiol 2016; 23: 2007-2018.

[9] Clark RA, Conway A, Poulsen V, et al. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2015; 22: 35-74.

[10] Steg G, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33: 2569-2619.

[11] Roffi M, Patrono C, Collet J, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 267–315.

[12] Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013; 34: 2949–3003.

[13] Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts) * Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation. Eur Heart J 2012; 33: 1635-1670.

[14] Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010; 17: 1-17.

[15] Marzolini S, Oh PI, Brooks D. Effect of combined aerobic and resistance training versus aerobic training alone in individuals with coronary artery disease: a meta-analysis. Eur J Prev Cardiol 2012; 19: 81.

[16] Conraads VM, Pattyn N, De Maeyer C, et al. Aerobic interval training and continuous training equally improve aerobic exercise capacity in patients with coronary artery disease: the SAINTEX-CAD study. Int J Cardiol. 2015;179:203-10.

[17] Brown JP, Clark AM, Dalal H, et al. Patient education in the management of coronary heart disease. Cochrane Database Syst Rev 2011;12:CD008895.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer for good, and Sanofi and Regeneron in the form of educational grants.

Related links

Secondary Prevention: unmet medical needs

This masterclass was held in April 2017 at EuroPrevent in Malaga, Spain.

See more
Challenges in secondary prevention after acute myocardial infarction

A consensus statement by EAPC, ACVC and ACNAP

See more
Challenges in Secondary Prevention after acute myocardial infarction

Watch the webinar recording

See more
Key recommendations

 Read Secondary Prevention after Myocardial Infarction key recommendations

See more