What is cardiac rehabilitation?

What is Cardiac Rehabilitation?

Cardiac rehabilitation is a comprehensive, multicomponent intervention that includes exercise training, physical activity promotion, health education, cardiovascular risk factor management, and psychological support, personalized to individual patient needs with the primary goals of improving functional capacity, reducing mortality, and enhancing quality of life in patients with heart disease. 1

Core Components

Cardiac rehabilitation programs must include the following essential elements 1:

• Patient assessment - Foundation for individualizing all other program components, including medical evaluation and risk stratification 1, 2
• Physician-prescribed exercise training - Aerobic exercise using modalities such as treadmill, stationary bicycle, walking, or jogging, with intensity monitoring via ECG telemetry based on patient risk status 1, 3
• Cardiovascular risk factor modification - Mandatory blood pressure control, lipid management, diabetes control, and smoking cessation 1, 3
• Nutritional counseling - Focus on heart-healthy dietary patterns 1, 2
• Weight management and body composition - Strategies for achieving and maintaining healthy weight 1, 2
• Psychosocial management - Stress management techniques, depression screening, quality of life assessment, and emotional support 1, 3
• Patient education and counseling - Disease explanation, treatment rationale, medication adherence strategies, and lifestyle modification education 3
• Outcomes assessment - Regular monitoring and quality improvement processes 1

Program Structure and Requirements

Programs must be located in a hospital (on or off campus) or physician's office, have a physician medical director, and be supervised by a physician or nonphysician practitioner with cardiovascular expertise who is immediately available for consultation or emergencies. 1, 2

The multidisciplinary team must include cardiologists, general practitioners or physicians with special interest, physiotherapists, dietitians, and psychologists trained in core competencies. 1, 3

Each patient requires an individualized treatment plan signed by a physician and updated every 30 days. 1, 2

Eligible Patient Populations

All patients with the following diagnoses should be referred to cardiac rehabilitation (Class I recommendation, Level of Evidence A): 1, 3

• Acute myocardial infarction within the past 12 months 1, 2
• Acute coronary syndrome 1, 3
• Coronary artery bypass graft surgery 1, 2
• Coronary artery angioplasty or stenting (PCI) 1
• Heart valve repair or replacement 1, 2
• Heart or heart-lung transplantation 1, 2
• Stable angina 1
• Stable chronic heart failure with ejection fraction ≤35% and NYHA class II-IV symptoms despite optimal therapy for ≥6 weeks 1

Delivery Models

Three primary delivery models exist, with home-based programs now recognized as equivalent alternatives to traditional center-based programs for appropriate patients: 1, 3

• Center-based programs - Traditional medically supervised group sessions in hospital, physician's office, or community facility with direct ECG monitoring for high-risk patients 3
• Home-based programs - Appropriate for low-risk, clinically stable patients with remote coaching and indirect exercise supervision, requiring active ongoing contact through home visits, telephone consultations, or technology platforms 1, 3
• Hybrid models - Combining different approaches according to patient needs, including virtual (synchronous) and remote (asynchronous) sessions 2

Home-based cardiac rehabilitation achieves equivalent efficacy and safety compared to center-based programs with potentially higher adherence rates. 3, 4

Clinical Outcomes and Benefits

Cardiac rehabilitation reduces mortality and improves quality of life with strong evidence supporting its clinical and cost-effectiveness: 1

• All-cause mortality reduction - Comprehensive cardiac rehabilitation reduces all-cause mortality (OR 0.87,95% CI 0.71-1.05), with lower risk of death at 3 years (p<0.001) 3
• Exercise-only interventions - Reduce all-cause mortality (OR 0.73,95% CI 0.54-0.98) compared to usual care 3
• Recurrent myocardial infarction - Lower risk at 3 years (p=0.049) 3
• Functional capacity - Improved exercise duration and functional status 1
• Quality of life - Enhanced health-related quality of life, wellbeing, and psychosocial status 1, 3
• Cardiac symptoms - Reduced symptoms and disability 3

Program Duration

The initial phase should last at least 6 weeks, with typical programs consisting of 36 sessions over 12 weeks. 3, 5 Intensive programs may include up to 72 sessions lasting up to 18 weeks, though these are not widely available. 5 Long-term follow-up and comprehensive approach require ongoing program participation beyond the initial phase. 3

Critical Implementation Challenges

Despite strong guideline recommendations and proven benefits, cardiac rehabilitation remains severely underutilized globally: 1, 3

• Overall participation rates are only 20-30% of eligible patients 6
• Referral rates vary by diagnosis: post-MI 29%, post-PCI 51%, post-CABG 75%, heart failure <10% 3
• Poor access among older adults, women, non-white and ethnic minority groups, patients with multimorbidity, and those of lower socioeconomic status 3, 6
• The COVID-19 pandemic further reduced access to cardiac rehabilitation services 1

Common pitfall: Primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons, contributing to underutilization. 5 Referral should occur before hospital discharge or at the first follow-up visit for all eligible patients. 1, 3