Dr. Eduardo Alegria-Ezquerra
Mr Eduardo Alegria-Barrero
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.
1. Cardiac Rehabilitation. Maroto JM, ed. Madrid: Spanish Society of Cardiology, 2009.2. Exercise training for type 2 diabetes mellitus: impact on cardiovascular risk: a scientific statement from the American Heart Association. Circulation Marwick TH, Hordern MD, Miller T, Chyun DA, Bertoni AG, Blumenthal RS, et al; Circulation 2009;119:3244-62.3. Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association.Council on Clinical Cardiology, American Heart Associatin Exercise, Cardiac Rehabilitation, and Prevention Committee; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; Council on Nutrition, Physical Activity, and Metabolism; Interdisciplinary Council on Quality of Care and Outcomes Research. Exercise training for type 2 diabetes mellitus: impact on cardiovascular risk: a scientific statement from the American Heart Association. Myers J, Arena R, Franklin B, Pina I, Kraus WE, McInnis K, et al; American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention of the Council on Clinical Cardiology, the Council on Nutrition, Physical Activity, and Metabolism, and the Council on Cardiovascular Nursing. Circulation 2009;119:3144-61. 4. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing Arena R, Myers J, Williams MA, Gulati M, Kligfield P, Balady GJ, et al; Circulation 2007;116:329-43.5. American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology;American Heart Association Council on Cardiovascular Nursing. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Nutrition, Physical Activity, and Metabolism; American Association of Cardiovascular and Pulmonary Rehabilitation. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-82. 6. Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease.Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Mayo Clin Proc 2009;84:373-83. 7. Current status of cardiac rehabilitation. Wenger NK. J Am Coll Cardiol 2008;51:1619-31. 8. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, et alCirculation. 2007; 116: 572-584 9. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism.American Heart Association Council on Clinical Cardiology; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. . Circulation 2007;116:572-84Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol 2007;49:2329-36. 10. Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Nocon M, Hiemann T, Müller-Riemenschneider F, Thalau F, Roll S, Willich SN. Eur J Cardiovasc Prev Rehabil 2008;15:239-46. 11. Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies.Sofi F, Capalbo A, Cesari F, Abbate R, Gensini GF. Eur J Cardiovasc Prev Rehabil 2008;15:247-57. 12. The effects of changes in physical activity on major cardiovascular risk factors, hemodynamics, sympathetic function and glucose utilization in man: A controlled study of four levels of activity.Jennings J, Nelson L, Nestel P, Esler M, Korner P, Burton D. Circulation 1986;73:30-40.13. Improvement of treadmill capacity and collateral circulation as a result of exercise with heparin pretreatment in patients with effort angina.Fujita M, Sasayama S, Asanoi H, Nakajima H, Sakai O, Ahno A. Circulation 1988;77:1022-29.14. Martínez-Caro D, ed. Heart and exercise [Corazón y ejercicio]. Barcelona: Doyma, 1990.15. Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions.Hambrecht R, Niebauer J, Marburguer C, Grunze M, Kälberer B, Hauer K. J Am Coll Cardiol 1993;22:468-77.16. Relationship of distance run per week to coronary heart disease risk factors in 8283 male runners. The National Runners’ Health Study. Williams PT.Arch Intern Med 1997;157:191-98.17. Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction.Circulation. 2012 Sep 25;126(13):1587-95. Epub 2012 Aug 28.18. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from twenty two European countries. EUROASPIRE Study Group. Kotseva K el. Eur J Cardiovasc Prev Rehabil 2009; 16:121–13719. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery.Massimo F Piepoli et al. European Journal of Preventive Cardiology published online 20 June 2012.20 - Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise trainingKey components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and RehabilitationEACPR Committee for Science Guidelines, Ugo Corrà, (Chairperson), Massimo F. Piepoli, François Carré, Peter Heus/Eur Heart J. 2010 Aug;31(16):1967-74. Epub 2010 Jul 19.21. 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 Massimo Francesco Piepoli et al. European Journal of Cardiovascular Prevention & Rehabilitation 2010 17: 1
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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.
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