Medicine:Cardiac rehabilitation

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Short description: Model of health care

Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life".[1] CR is a comprehensive model of care delivering established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life and reducing the risk of future heart problems.[2][3]

CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist.[4] Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.

Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology[5] and the European Society of Cardiology,[6] among other associations.[7][8] Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator).[9]

Cardiac rehabilitation setting

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies.[3] Hybrid programs are also increasingly being offered.[10][11]

Cardiac rehabilitation phases

Inpatient program (phase I)

Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises.[12]

Outpatient program (phase II)

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral.[13] It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery.[14][15][16] This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues.[17][15] Shorter time to start is associated with better outcomes.[18]

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use.[3] A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program.[13]

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.[13]

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered,[19] and it is well-established that the more the better.[20]

After CR is finished, there are long-term maintenance programs (phase III) available to interested patients,[21] as benefits are optimized with long-term adherence. Unfortunately however, patients generally have to pay out-of-pocket for these services.

Under-use of cardiac rehabilitation

CR is significantly under-used globally.[22] Rates vary widely.[23]

Under-use is caused by multi-level factors; a recent review is available.[24] At the health system level, this includes lack of available programs.[25] At the provider level, low referral rates are a major barrier.[26][27] At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible,[28] but most can be mitigated.[29] Women,[30] ethnocultural minorities,[31][32] older patients,[33] those of lower socio-economic status, with comorbidities, and living in rural areas[34] are less likely to access CR, despite the fact that these patients often need it most.[35] Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.

Strategies are now established on how we can mitigate these barriers to CR use.[36][37] It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html).[38] It is also key for healthcare providers to promote CR to patients at the bedside.[39] The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.

Training more healthcare professionals to deliver CR can also help.[40] CR programs can also join a registry to assess and improve their utilization --among other quality indicators.[41][42] Offering programs tailored to under-served groups such as women may also facilitate program participation.[43][44][45]

Benefits

Participation in CR may be associated with many benefits.[46] For acute coronary syndrome patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%.[47][48][needs update] The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence.[49]

CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity,[50] and is cost-effective.[51] In low and middle-income countries, there is some evidence that CR is effective in improving functional capacity, risk factors and quality of life as well.[52]

There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same.[53] Home-based CR is generally safe.[54] Home-based programs with technology are similarly shown to be effective.[55][56][57]

There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues,[58] atrial fibrillation,[59] heart transplant recipients,[60] and heart failure.[61]

Cardiac rehabilitation societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR.[62] The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR),[1] a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations,[63] ICCPR seeks to promote CR in low-resource settings,[64] among other aims outlined in their Charter.[65]

References

  1. ↑ WHO Expert Committee on Rehabilitation after Cardiovascular Diseases, with Special Emphasis on Developing Countries.. Rehabilitation after cardiovascular diseases, with special emphsis on developing countries : report of a WHO expert committee.. Geneva. ISBN 9241208317. OCLC 28401958. 
  2. ↑ "Standards and core components for cardiovascular disease prevention and rehabilitation". Heart 105 (7): 510–515. April 2019. doi:10.1136/heartjnl-2018-314206. PMID 30700518. 
  3. ↑ 3.0 3.1 3.2 "Cardiac rehabilitation delivery model for low-resource settings". Heart 102 (18): 1449–1455. September 2016. doi:10.1136/heartjnl-2015-309209. PMID 27181874. 
  4. ↑ "Nature of Cardiac Rehabilitation Around the Globe" (in English). eClinicalMedicine 13: 46–56. August 2019. doi:10.1016/j.eclinm.2019.06.006. PMID 31517262. 
  5. ↑ "AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation". Circulation 124 (22): 2458–2473. November 2011. doi:10.1161/CIR.0b013e318235eb4d. PMID 22052934. 
  6. ↑ "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 (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)". European Heart Journal 37 (29): 2315–2381. August 2016. doi:10.1093/eurheartj/ehw106. PMID 27222591. 
  7. ↑ "Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India". Indian Heart Journal 69 (Suppl 1): S63–S97. April 2017. doi:10.1016/j.ihj.2017.03.006. PMID 28400042. 
  8. ↑ "Quality statement 7 (developmental): Options for cardiac rehabilitation | Chronic heart failure in adults | Quality standards". https://www.nice.org.uk/guidance/qs9/chapter/quality-statement-7-developmental-options-for-cardiac-rehabilitation. 
  9. ↑ "Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement". Progress in Cardiovascular Diseases. Controversies in Hypertension 59 (3): 303–322. 2016-11-01. doi:10.1016/j.pcad.2016.08.004. PMID 27542575. https://eprints.keele.ac.uk/10843/7/Grace%20et%20al.%2C%20CR%20in%20Low%20Resource%20ICCPR%20July%202016.pdf. 
  10. ↑ "A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE". Journal of Cardiopulmonary Rehabilitation and Prevention 42 (1): 1–9. January 2022. doi:10.1097/HCR.0000000000000634. PMID 34433760. 
  11. ↑ "Hybrid cardiac rehabilitation - The state of the science and the way forward". Progress in Cardiovascular Diseases 70: 175–182. 2022-01-01. doi:10.1016/j.pcad.2021.12.004. PMID 34958846. 
  12. ↑ "Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19". American Journal of Physical Medicine & Rehabilitation 99 (9): 769–774. September 2020. doi:10.1097/PHM.0000000000001505. PMID 32541352. 
  13. ↑ 13.0 13.1 13.2 "Nature of Cardiac Rehabilitation Around the Globe" (in English). eClinicalMedicine 13: 46–56. August 2019. doi:10.1016/j.eclinm.2019.06.006. PMID 31517262. 
  14. ↑ "Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study". Medicine 97 (8): e9785. February 2018. doi:10.1097/MD.0000000000009785. PMID 29465559. 
  15. ↑ 15.0 15.1 "Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study". The Journal of Nursing Research 29 (1): e131. November 2020. doi:10.1097/JNR.0000000000000408. PMID 33136697. 
  16. ↑ "Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation". The Canadian Journal of Cardiology 22 (11): 905–911. September 2006. doi:10.1016/s0828-282x(06)70309-9. PMID 16971975. 
  17. ↑ "Primary angioplasty for heart attack: mismatch between expectations and reality?". Journal of Advanced Nursing 65 (1): 72–83. January 2009. doi:10.1111/j.1365-2648.2008.04836.x. PMID 19032516. 
  18. ↑ "Cardiac rehabilitation wait times and relation to patient outcomes - European Journal of Physical and Rehabilitation Medicine 2015 June;51(3):301-9" (in en). https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2015N03A0301. 
  19. ↑ "Cardiac Rehabilitation Dose Around the World: Variation and Correlates". Circulation. Cardiovascular Quality and Outcomes 13 (1): e005453. January 2020. doi:10.1161/CIRCOUTCOMES.119.005453. PMID 31918580. 
  20. ↑ "Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis". Mayo Clinic Proceedings 92 (11): 1644–1659. November 2017. doi:10.1016/j.mayocp.2017.07.019. PMID 29101934. 
  21. ↑ "The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex". Heart & Lung 50 (4): 504–524. July 2021. doi:10.1016/j.hrtlng.2021.02.016. PMID 33836441. 
  22. ↑ "Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement". International Journal of Cardiology 298: 1–7. January 2020. doi:10.1016/j.ijcard.2019.06.064. PMID 31405584. 
  23. ↑ "Cardiac Rehabilitation: Under-Utilized Globally". Current Cardiology Reports 23 (9): 118. July 2021. doi:10.1007/s11886-021-01543-x. PMID 34269894. 
  24. ↑ "Cardiac Rehabilitation Barriers Scale (CRBS)" (in en). International Handbook of Behavioral Health Assessment. Cham: Springer International Publishing. 2023. pp. 1–57. doi:10.1007/978-3-030-89738-3_39-1. ISBN 978-3-030-89738-3. 
  25. ↑ "Cardiac Rehabilitation Availability and Density around the Globe". eClinicalMedicine 13: 31–45. August 2019. doi:10.1016/j.eclinm.2019.06.007. PMID 31517261. 
  26. ↑ "Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review". Clinical Cardiology 36 (6): 323–335. June 2013. doi:10.1002/clc.22126. PMID 23640785. 
  27. ↑ "Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting". Rehabilitation Process and Outcome 9: 1179572720936648. 2020-01-01. doi:10.1177/1179572720936648. PMID 34497466. 
  28. ↑ "Psychometric validation of the cardiac rehabilitation barriers scale". Clinical Rehabilitation 26 (2): 152–164. February 2012. doi:10.1177/0269215511410579. PMID 21937522. 
  29. ↑ "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews 2019 (2): CD007131. February 2019. doi:10.1002/14651858.CD007131.pub4. PMID 30706942. 
  30. ↑ "Sex differences in cardiac rehabilitation enrollment: a meta-analysis". The Canadian Journal of Cardiology 30 (7): 793–800. July 2014. doi:10.1016/j.cjca.2013.11.007. PMID 24726052. 
  31. ↑ "Ethnocultural diversity in cardiac rehabilitation" (in en-US). Journal of Cardiopulmonary Rehabilitation and Prevention 34 (6): 437–444. November–December 2014. doi:10.1097/HCR.0000000000000089. PMID 25357126. 
  32. ↑ "Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A Systematic Review". Journal of Cardiopulmonary Rehabilitation and Prevention 36 (5): 320–330. September 2016. doi:10.1097/HCR.0000000000000183. PMID 27496250. 
  33. ↑ "Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE?". Journal of Cardiopulmonary Rehabilitation and Prevention 29 (3): 183–187. 2009. doi:10.1097/HCR.0b013e3181a3333c. PMID 19471138. 
  34. ↑ "Geographic issues in cardiac rehabilitation utilization: a narrative review". Health & Place 16 (6): 1196–1205. November 2010. doi:10.1016/j.healthplace.2010.08.004. PMID 20724208. 
  35. ↑ "Participation and adherence to cardiac rehabilitation programs. A systematic review". International Journal of Cardiology 223: 436–443. November 2016. doi:10.1016/j.ijcard.2016.08.120. PMID 27557484. 
  36. ↑ "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews 2019 (2): CD007131. February 2019. doi:10.1002/14651858.cd007131.pub4. PMID 30706942. 
  37. ↑ "Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers". Healthcare 11 (8): 1196. April 2023. doi:10.3390/healthcare11081196. PMID 37108029. 
  38. ↑ "Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study". Archives of Internal Medicine 171 (3): 235–241. February 2011. doi:10.1001/archinternmed.2010.501. PMID 21325114. 
  39. ↑ "Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course". BMC Health Services Research 20 (1): 768. August 2020. doi:10.1186/s12913-020-05619-2. PMID 32819388. 
  40. ↑ "Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers, and Impact". Journal of Cardiopulmonary Rehabilitation and Prevention 42 (3): 178–182. May 2022. doi:10.1097/hcr.0000000000000655. PMID 34840246. 
  41. ↑ "Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry". International Journal for Quality in Health Care 35 (3). July 2023. doi:10.1093/intqhc/mzad050. PMID 37421311. 
  42. ↑ "First report of the International Council of Cardiovascular Prevention and Rehabilitation's Registry (ICRR)". Expert Review of Cardiovascular Therapy 21 (5): 357–364. May 2023. doi:10.1080/14779072.2023.2199154. PMID 37024997. https://figshare.com/articles/journal_contribution/22573542. 
  43. ↑ "Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis". Maturitas 160: 32–60. June 2022. doi:10.1016/j.maturitas.2022.01.008. PMID 35550706. 
  44. ↑ "Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review". BMC Cardiovascular Disorders 21 (1): 459. September 2021. doi:10.1186/s12872-021-02267-0. PMID 34556036. 
  45. ↑ "Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline" (in English). The Canadian Journal of Cardiology 38 (12): 1786–1798. December 2022. doi:10.1016/j.cjca.2022.06.021. PMID 36085185. 
  46. ↑ "The role of cardiac rehabilitation in improving cardiovascular outcomes". Nature Reviews. Cardiology 19 (3): 180–194. March 2022. doi:10.1038/s41569-021-00611-7. PMID 34531576. 
  47. ↑ "Exercise-based rehabilitation for coronary heart disease" (in en). https://www.cochrane.org/CD001800/VASC_exercise-based-rehabilitation-coronary-heart-disease. 
  48. ↑ "Home-based versus centre-based cardiac rehabilitation". The Cochrane Database of Systematic Reviews 6 (6): CD007130. June 2017. doi:10.1002/14651858.CD007130.pub4. PMID 28665511. 
  49. ↑ "Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis". Journal of Clinical Medicine 7 (12): 514. December 2018. doi:10.3390/jcm7120514. PMID 30518047. 
  50. ↑ "The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis". The Canadian Journal of Cardiology 35 (3): 352–364. March 2019. doi:10.1016/j.cjca.2018.11.013. PMID 30825955. 
  51. ↑ "Cost-effectiveness of cardiac rehabilitation: a systematic review". Heart 104 (17): 1403–1410. September 2018. doi:10.1136/heartjnl-2017-312809. PMID 29654096. 
  52. ↑ "Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials". Progress in Cardiovascular Diseases 70: 119–174. 2021-07-13. doi:10.1016/j.pcad.2021.07.004. PMID 34271035. 
  53. ↑ McDonagh, Sinead Tj; Dalal, Hasnain; Moore, Sarah; Clark, Christopher E.; Dean, Sarah G.; Jolly, Kate; Cowie, Aynsley; Afzal, Jannat et al. (2023-10-27). "Home-based versus centre-based cardiac rehabilitation". The Cochrane Database of Systematic Reviews 2023 (10): CD007130. doi:10.1002/14651858.CD007130.pub5. ISSN 1469-493X. PMID 37888805. 
  54. ↑ "Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology". Circulation 140 (1): e69–e89. July 2019. doi:10.1161/CIR.0000000000000663. PMID 31082266. 
  55. ↑ "Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis". International Journal of Nursing Studies 124: 104087. December 2021. doi:10.1016/j.ijnurstu.2021.104087. PMID 34562846. 
  56. ↑ "Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis". European Journal of Preventive Cardiology 29 (7): 1017–1043. May 2022. doi:10.1093/eurjpc/zwab106. PMID 34254118. 
  57. ↑ "Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis". European Journal of Cardiovascular Nursing 18 (4): 260–271. April 2019. doi:10.1177/1474515119826510. PMID 30667278. https://napier-repository.worktribe.com/file/1488219/1/Telehealth%20interventions%20for%20the%20secondary%20prevention%20of%20coronary%20heart%20disease. 
  58. ↑ "Exercise-based cardiac rehabilitation for adults after heart valve surgery". The Cochrane Database of Systematic Reviews 2021 (5): CD010876. May 2021. doi:10.1002/14651858.CD010876.pub3. PMID 33962483. 
  59. ↑ "Exercise-based cardiac rehabilitation for adults with atrial fibrillation". The Cochrane Database of Systematic Reviews (Chichester, UK: John Wiley & Sons, Ltd) 2 (2): CD011197. February 2017. doi:10.1002/14651858.cd011197. PMID 28181684. 
  60. ↑ "Exercise-based cardiac rehabilitation in heart transplant recipients". The Cochrane Database of Systematic Reviews 2017 (4): CD012264. April 2017. doi:10.1002/14651858.CD012264.pub2. PMID 28375548. 
  61. ↑ "Cardiac rehabilitation and physical activity: systematic review and meta-analysis". Heart 104 (17): 1394–1402. September 2018. doi:10.1136/heartjnl-2017-312832. PMID 29654095. 
  62. ↑ Grace, Sherry L (2023-01-02). "Evidence is indisputable that cardiac rehabilitation provides health benefits and event reduction: time for policy action". European Heart Journal 44 (6): 470–472. doi:10.1093/eurheartj/ehac690. ISSN 0195-668X. PMID 36746185. http://dx.doi.org/10.1093/eurheartj/ehac690. 
  63. ↑ "The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go?". eClinicalMedicine 61: 102092. July 2023. doi:10.1016/j.eclinm.2023.102092. PMID 37528847. 
  64. ↑ Grace, Sherry L.; Taylor, Rod S.; Gaalema, Diann E.; Redfern, Julie; Kotseva, Kornelia; Ghisi, Gabriela (July 2023). "Cardiac Rehabilitation". JACC: Advances 2 (5): 100412. doi:10.1016/j.jacadv.2023.100412. ISSN 2772-963X. https://eprints.gla.ac.uk/305174/1/305174.pdf. 
  65. ↑ "International Charter on Cardiovascular Prevention and Rehabilitation: a call for action" (in en-US). Journal of Cardiopulmonary Rehabilitation and Prevention 33 (2): 128–131. March–April 2013. doi:10.1097/HCR.0b013e318284ec82. PMID 23399847. 



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