Can home-based rehabilitation be performed in phase 2 of cardiac rehabilitation?

Home-Based Cardiac Rehabilitation in Phase 2

Yes, home-based cardiac rehabilitation (HBCR) can be performed in Phase 2 and is a reasonable alternative to center-based programs for selected clinically stable, low- to moderate-risk patients who cannot attend traditional center-based cardiac rehabilitation. 1

Evidence-Based Recommendation

The American Heart Association, American College of Cardiology, and American Association of Cardiovascular and Pulmonary Rehabilitation jointly endorse HBCR as an alternative delivery model for Phase 2 cardiac rehabilitation. 1 This represents a significant shift in recognizing that the traditional center-based model, while effective, leaves over 80% of eligible patients without rehabilitation services. 1

Key Eligibility Criteria for HBCR

HBCR should be offered specifically to:

• Clinically stable patients with low to moderate cardiovascular risk 1
• Patients who cannot access center-based programs due to distance, transportation barriers, or time constraints 2
• Patients who are unwilling to participate in traditional center-based programs 3
• Those without significant arrhythmias, uncontrolled ischemia, or advanced heart failure requiring close monitoring 1

The guidelines explicitly recommend providing the option of HBCR at hospital discharge for appropriate low- to moderate-risk patients. 1

Clinical Effectiveness: HBCR vs Center-Based CR

The evidence demonstrates non-inferiority of HBCR compared to center-based programs:

• Functional capacity improvements are equivalent between HBCR and center-based CR, with both showing similar increases in peak oxygen uptake (VO2peak) 4, 5
• Quality of life outcomes including physical functioning, social functioning, and mental health components improve similarly in both settings 6, 5
• Exercise adherence rates are comparable, with HBCR showing 80-84% adherence versus 81% for center-based programs 3, 4
• Safety profile is excellent, with no major adverse cardiac events reported during supervised home-based exercise sessions 3, 6

A 2025 randomized controlled trial in heart failure patients demonstrated that home-based CR was non-inferior to center-based programs, with no significant differences in VO2peak changes, 6-minute walk distance, or quality of life measures. 4

Implementation Components

Effective HBCR programs include:

• Remote coaching with indirect exercise supervision rather than direct on-site monitoring 1
• Transtelephonic monitoring with simultaneous voice and ECG transmission to nurse coordinators for higher-risk patients 6
• Wearable technology (smartwatches) for asynchronous monitoring of exercise sessions 4
• Hybrid models combining limited supervised sessions (typically 4) with home-based sessions (typically 20) over 12 weeks 4
• Real-time videoconferencing for supervised high-intensity exercise sessions 3

Important Caveats and Limitations

Patient selection is critical:

• HBCR is not appropriate for high-risk patients requiring continuous ECG monitoring or those with unstable cardiac conditions 1
• Patients with significant arrhythmias, severe heart failure (NYHA Class IV), or uncontrolled ischemia should receive center-based care 1, 3
• Technical literacy is necessary, as approximately 50% of patients report minor technical issues with videoconferencing software 3

Evidence gaps remain for:

• Older adults, women, and underrepresented minority groups require additional study 1
• Long-term outcomes beyond 12 months need further investigation 1
• Optimal hybrid models combining center-based and home-based elements require more research 1

Practical Barriers to Address

Common obstacles to HBCR implementation include:

• Reimbursement policies that favor center-based programs over home-based alternatives 1
• Distance and transportation remain barriers even for home programs requiring initial assessments 2
• Cost concerns for equipment and technology 2
• Lack of organizational experience with HBCR delivery models in US healthcare systems 1

Clinical Algorithm for Phase 2 CR Delivery

Step 1: Assess cardiovascular risk stratification at hospital discharge 1

Step 2: For low-to-moderate risk patients:

• Offer both center-based and home-based options based on patient preference and access 1
• Consider HBCR as first-line for patients with transportation, distance, or time barriers 2

Step 3: For high-risk patients:

• Mandate center-based CR with continuous monitoring 1
• Consider hybrid models after initial stabilization period 1

Step 4: Implement structured HBCR with:

• Initial supervised assessment and training 4
• Remote monitoring technology 3, 6
• Regular follow-up and outcome tracking 1

The evidence strongly supports that HBCR achieves similar clinical outcomes to center-based programs for appropriately selected patients, with the added benefit of potentially increasing overall CR participation rates from the current dismal 10-16% to more acceptable levels. 1