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Cardiac Rehabilitation and exercise training recommendations

Cardiac rehabilitation: rationale, indications and core components.

Cardiovascular rehabilitation is a comprehensive, multi-factorial intervention recommended in international guidelines to patients with coronary artery disease. Cardiovascular rehabilitation consists of three phases and is shown to reduce mortality, rehospitalizations, health care use and to improve exercise capacity, quality of life and psychological well-being. Core components in cardiovascular rehabilitation include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, risk factor control, patient education, psychosocial management, vocational advice, and lifestyle behaviour change including patients´ adherence and self-management. In spite of cardiovascular rehabilitation recommendations, referral and uptake is often suboptimal.

Updated by Maria Bäck, 23 August 2021

Rationale

Cardiovascular rehabilitation (CR) is a multi-factorial and comprehensive intervention in secondary prevention, supervised and carried out by adequately trained health professionals, aimed at obtaining clinical stabilization, 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 and quality of life2-8 and is recommended in international guidelines for all patients with coronary artery disease (class I, level of evidence A).9-13 In spite of current recommendations, CR referral and uptake is often suboptimal and varies across Europe1,14-15 and differences in delivery persist amongst cardiovascular rehabilitation centres in Europe, despite the available scientific documents describing the evidence-based content.16

CR is traditionally divided into three phases.1 Phase I is typically an inpatient service, which consists of early mobilisation, brief counselling about the nature of the illness, the treatment, risk factors management and follow-up planning. Phase II is mostly a supervised ambulatory outpatient programme. Phase III is a lifetime maintenance phase where the goal is to continue the risk factor- and lifestyle modification and exercise training. Alternative modes of CR delivery include home based programmes and e-health interventions using e.g. the internet and mobile phones.17-19

Indications

CR should be offered to all patients with coronary heart disease including: 9-13

  • Patients with acute coronary syndrome—including ST-elevation myocardial infarction, non-ST elevation myocardial infarction, and unstable angina9-12
  • Patients undergoing reperfusion (such as coronary artery bypass surgery and percutaneous coronary intervention)9-12
  • Patients with chronic coronary syndromes13

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.1

Patient assessment with medical control

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

Physical activity counselling

It is recommended to perform at least 150-300 min a week of moderate-intensity or 75-150 min a week of vigorous-intensity aerobic PA or an equivalent combination thereof and to reduce sedentary time. Advise physical activity according to patient´s age, past habits, co-morbidities, preferences and goals.

Exercise training

Perform a pre-exercise screening, including maximal stress testing, either on bicycle ergometer or on the treadmill. If not applicable in a clinical setting sub-maximal exercise evaluation should be considered. Exercise prescription must be individually prescribed based on tests of physical capacity and preferably be prescribed according to the FITT (frequency, intensity, time (duration) and type of exercise) model.
Recommend continuous aerobic exercise at least 20-30 minutes (preferably 45-60 minutes/week), three days a week (preferably 6-7 days/week) at 50-80% of VO2max. High-intensity interval training at 90-95% of peak heart rate has been found equally effective as continuous aerobic exercise for patients with stable coronary artery disease. Resistance exercise should be recommended in addition to aerobic exercise, including 8-10 exercises at an intensity of 30-70% of the 1 repetition maximum (1RM) for upper body exercises and 40-80% of 1RM for lower body exercises, with 12-15 repetitions in at least 1 set, 2-3 times/week.

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 (18.5-24.9kg/m2). If weight circumference is ≥ 80 cm in women or ≥ 94 cm in men, it is recommended to initiate lifestyle changes and consider treatment strategies, particularly if associated with multiple risk factors, such as hypertension, hypercholesterolemia, insulin resistance or diabetes.

Assess lipid profile and modify diet, physical activity, and medication if appropriate. Target low-density lipoprotein (LDL) level is defined as < 1.4 mmol/l.

Measure blood pressure frequently at rest. If resting systolic blood pressure is 130-139 mmHg or diastolic blood pressure is 85-89 mmHg, lifestyle modifications are recommended. Aim for target blood pressure <140/90 mmHg in all patients, targeted to <130/80 mmHg or lower in most patients when treatment is tolerated.

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.

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 group small group education and counselling. Whenever possible, offer partners access to information sessions.

Vocational advice

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

References


1. Ambrosetti M, Abreu A, Corra U, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol. 2020, online ahead of print.
2. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; Jul 6;7: CD001800.
3. Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016 Jan 5;2016(1):CD001800.
4. Long L, Mordi IR, Bridges C, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019;1:CD003331.
5. Salzwedel A, Jensen K, Rauch B, et al. Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence-based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II). Eur J Prev Cardiol. 2020 Nov;27(16):1756-1774.
6. Sandercock G, Hurtado V and Cardoso F, et al. Changes in cardiorespiratory fitness in cardiac rehabilitation patients: a meta-analysis. Int J Cardiol. 2013; 167: 894-902.
7. Candelaria D, Randall S, Ladak L, et al. Health-related quality of life and exercise-based cardiac rehabilitation in contemporary acute coronary syndrome patients: a systematic review and meta-analysis. Qual Life Res. 2020; 29: 579-592.
8. Shields GE, Wells A, Doherty P, et al. Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart. 2018;104(17):1403-1410.
9. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease. Eur Heart J. 2021;42(1):17-96.
10. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2016;37(29):2315-2381.
11. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177.
12. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367.
13. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(3):407-477.
14. 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.
15. Kotseva K, De Backer G, De Bacquer D, et al. Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry. Eur J Prev Cardiol 2019; 26: 824-835.
16. Abreu A, Frederix I, Dendale P, et al. Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2020, online ahead of print.
17. Clark RA, Conway A, Poulsen V, et al. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol. 2015; 22: 35-74.
18. Jin K, Khonsari S, Gallagher R, et al. Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis. Eur J Cardiovasc Nurs. 2019;18(4):260-271.
19. Scherrenberg M, Wilhelm M, Hansen D, et al. The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology. Eur J Prev Cardiol. 2020, online ahead of print.

 

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.

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