Cardiac Rehabilitation: Improving Function and Reducing Risk

 

Cardiac rehabilitation is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. The overall goals focus on improving daily function and reducing cardiovascular risk factors. Cardiac rehabilitation includes interventions aimed at lowering blood pressure and improving lipid and diabetes mellitus control, with tobacco cessation, behavioral counseling, and graded physical activity. The physical activity component typically involves 36 sessions over 12 weeks, during which patients participate in supervised exercise under cardiac monitoring. There are also intensive programs that include up to 72 sessions lasting up to 18 weeks, although these programs are not widely available. Additional components of cardiac rehabilitation include counseling on nutrition, screening for and managing depression, and assuring up-to-date immunizations. Cardiac rehabilitation is covered by Medicare and recommended for patients following myocardial infarction, bypass surgery, and stent placement, and for patients with heart failure, stable angina, and several other conditions. Despite proven benefits in mortality rates, depression, functional capacity, and medication adherence, rates of referral for cardiac rehabilitation are suboptimal. Groups less likely to be referred are older adults, women, patients who do not speak English, and persons living in areas where cardiac rehabilitation is not locally available. Additionally, primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons.

Cardiac rehabilitation was initially developed in the 1950s. Through the 1970s, programs consisted mainly of structured exercise after myocardial infarction (MI). In 1995, the U.S. Department of Health and Human Services published a clinical practice guideline on cardiac rehabilitation, which prompted a transition from an exercise program to a holistic combination of exercise training, lifestyle modification, and behavioral therapy.1

WHAT IS NEW ON THIS TOPIC: CARDIAC REHABILITATION

Home-based exercise programs result in clinical improvements that are at least comparable with those from center-based programs. Home-based cardiac rehabilitation participants also had improved adherence to program recommendations.

In a study of patients with heart failure undergoing cardiac rehabilitation, completion of an exercise training program was associated with a 40% decrease in the presence of depression. Only small improvements in functional capacity appear to be needed to decrease depression.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should recommend cardiac rehabilitation for patients who have had a myocardial infarction within the previous 12 months.

A

24, 12, 15

Physicians should recommend cardiac rehabilitation for patients with chronic stable angina pectoris.

C

4, 12

Physicians should recommend cardiac rehabilitation for patients who have heart failure with reduced left ventricular ejection fraction.

B

10, 12, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should recommend cardiac rehabilitation for patients who have had a myocardial infarction within the previous 12 months.

A

24, 12, 15

Physicians should recommend cardiac rehabilitation for patients with chronic stable angina pectoris.

C

4, 12

Physicians should recommend cardiac rehabilitation for patients who have heart failure with reduced left ventricular ejection fraction.

B

10, 12, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

What Is Cardiac Rehabilitation?

Cardiac rehabilitation is a comprehensive multidisciplinary approach to care that is systematically applied and individually tailored to the needs of patients with cardiovascular disease (CVD). The American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association (AHA) emphasize that cardiac rehabilitation is designed to optimize physical, psychological, vocational, and social functioning while slowing or reversing the CVD process.2,3 Standard

The Authors

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JESSICA T. SERVEY, MD, is an associate professor in the Department of Family Medicine and assistant dean of faculty development at the Uniformed Services University of the Health Sciences, Bethesda, Md....

MARK STEPHENS, MD, is a professor and chair of the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jessica T. Servey, MD, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814. Reprints are not available from the authors.

REFERENCES

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