When should patients be referred to cardiac rehab after an Acute Coronary Syndrome (ACS) Non-ST-Elevation Myocardial Infarction (NSTEMI) with revascularization?

When to Refer to Cardiac Rehabilitation After NSTEMI with Revascularization

All patients with NSTEMI who undergo revascularization should be referred to cardiac rehabilitation either before hospital discharge or during the first outpatient visit. 1

Timing of Referral

Optimal Referral Window

• Referral should occur before hospital discharge as the preferred timing, as this is when patients are most engaged and the healthcare system can facilitate enrollment most effectively 1
• If not completed before discharge, referral must occur during the first outpatient follow-up visit (typically within 2-6 weeks for low-risk patients, within 14 days for higher-risk patients) 1

When Physical Activity Can Begin

• After uncomplicated PCI, physical activity counseling can start the following day, with patients able to walk on flat surfaces and climb stairs within a few days 1
• After revascularization in patients with significant myocardial damage, physical rehabilitation should start only after clinical stabilization 1

Clinical Criteria for Timing

Safety Assessment Before Starting Exercise

The following parameters must be stable before initiating exercise-based rehabilitation 1:

• Clinical stability (no ongoing chest pain or hemodynamic instability)
• Hemodynamic parameters (stable blood pressure and heart rate)
• Rhythmic parameters (no life-threatening arrhythmias)
• Ischemic threshold assessment (particularly important with incomplete revascularization)
• Degree of left ventricular impairment

Risk-Stratified Approach

• High-risk patients (persistent clinical, hemodynamic, or arrhythmic instability, severe complications or comorbidities) benefit from structured in-hospital residential cardiac rehabilitation programs 1
• Low-risk patients after uncomplicated procedures can begin with outpatient programs immediately after discharge 1

Evidence Supporting Early Referral

Mortality and Morbidity Benefits

• Cardiac rehabilitation after ACS with revascularization reduces deaths and hospital readmissions and improves quality of life 1
• A 10-year follow-up study demonstrated that patients who completed cardiac rehabilitation had 46% lower mortality compared to those who did not complete the program (adjusted HR 0.54; 95% CI 0.42-0.70) 2
• Even patients who participated but did not complete cardiac rehabilitation had 39% lower mortality than non-participants 2

Underutilization Problem

• Despite strong evidence, cardiac rehabilitation services are used in less than 30% of eligible patients 1
• Automatic referral systems with strong provider guidance significantly improve enrollment rates 1

Practical Implementation

What Constitutes a Proper Referral

A complete referral includes 1:

• Official communication between healthcare provider and patient recommending enrollment
• Provision of all necessary information allowing the patient to enroll
• Written or electronic communication to the cardiac rehabilitation program with patient enrollment information
• Patient's cardiovascular history, testing results, and treatments
• All communications must maintain HIPAA confidentiality 1

Program Options

• Traditional center-based programs with face-to-face interactions 1
• Home-based programs for patients unable or unwilling to attend in person 1
• Both approaches should meet appropriate safety standards 1

Common Pitfalls to Avoid

• Do not delay referral until follow-up visits—the highest enrollment occurs with pre-discharge referrals 1
• Do not assume revascularization eliminates the need for rehabilitation—patients require counseling that revascularization does not obviate lifestyle changes 1
• Do not forget to assess baseline physical capacity when entering a rehabilitation program after revascularization 1
• Do not overlook medical contraindications such as unstable life-threatening conditions or discharge to long-term nursing care facilities 1