Cardiac Rehabilitation and exercise training recommendations

Rationale

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].

Indications

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.