What is the effectiveness of cardiac rehabilitation when structured according to its distinct phases?

Effectiveness of Cardiac Rehabilitation by Phase

Cardiac rehabilitation is most effective when delivered through a structured three-phase approach, with Phase 2 (early outpatient rehabilitation) demonstrating the strongest evidence for reducing cardiovascular mortality by 33% and recurrent myocardial infarction by 36%, while Phases 1 and 3 provide essential but less robustly evidenced support for initial mobilization and long-term maintenance. 1, 2

Phase-Specific Effectiveness

Phase 1: Inpatient Cardiac Rehabilitation

• Phase 1 is delivered during hospitalization following acute cardiovascular events such as myocardial infarction, acute coronary syndrome, or cardiac surgery 2
• This phase focuses on basic patient education regarding cardiac events and recovery expectations, initial cardiovascular risk factor identification, and psychological support initiation 2
• Phase 1 protocols lack strong evidence-based exercise prescription principles and serve primarily as a bridge to more intensive outpatient rehabilitation 2
• The primary goal is clinical stabilization and preparation for discharge rather than mortality reduction 2

Phase 2: Early Outpatient Cardiac Rehabilitation (Most Effective Phase)

Phase 2 has the most substantive evidence base supporting clinical effectiveness and cost-effectiveness, with Class I, Level of Evidence A recommendations from major cardiology societies. 1, 2

Mortality and Morbidity Benefits

• Comprehensive Phase 2 cardiac rehabilitation reduces cardiovascular mortality, non-fatal myocardial infarction, and stroke by 33% (P = 0.02) 1
• Cardiac death plus non-fatal myocardial infarction are reduced by 36% (P = 0.02) 1
• Total stroke is reduced by 32%, and total mortality by 21% 1
• All-cause mortality is reduced with an odds ratio of 0.87 (95% CI 0.71-1.05) 3
• Exercise-only interventions within Phase 2 reduce all-cause mortality with an odds ratio of 0.73 (95% CI 0.54-0.98) 3

Quality of Life Improvements

• Phase 2 cardiac rehabilitation significantly improves health-related quality of life, as demonstrated by the REACH-HF programme showing a -5.7 point improvement on the Minnesota Living with Heart Failure questionnaire (95% CI −10.6 to −0.7 points, P = 0.025) 1
• Participants experience reduced cardiac symptoms and disability at 3 years (p<0.001) 3
• Improved psychosocial status and stress management are consistently demonstrated 3

Timing and Structure

• Phase 2 begins within the first 3 to 6 months after a cardiovascular event but may continue for up to 1 year 2
• The initial phase should last at least 6 weeks with ongoing follow-up 3
• This phase requires direct physician supervision with the physician immediately available in the exercise area, though not necessarily physically present in the exercise room itself 2

Cost-Effectiveness

• Cardiac rehabilitation is considered a cost-effective intervention following an acute coronary event, improving prognosis by reducing recurrent hospitalizations and healthcare expenditure while prolonging life 1
• The REACH-HF home-based programme demonstrated acceptable cost-effectiveness with an incremental cost-effectiveness ratio (ICER) of £1,720 per quality-adjusted life year (QALY) 1

Delivery Models for Phase 2

• Traditional center-based programs remain the standard, but home-based models achieve equivalent efficacy and safety with potentially higher adherence 1, 3
• Home-based cardiac rehabilitation can be substituted for supervised, center-based programs in low-risk patients (Class I recommendation) 1
• Hybrid approaches that initially offer center-based rehabilitation and then evolve to technology-supported, home-based sessions are increasingly effective 1
• The effectiveness of innovative models depends on active, ongoing contact between patients and healthcare professionals through home visits, telephone consultations, or technology-based solutions 1

Phase 3/4: Long-Term Maintenance Cardiac Rehabilitation

• Phase 3/4 provides longer-term outpatient delivery of preventive and rehabilitative services with less intensive supervision than Phase 2 2
• This phase focuses on independent exercise and physical activity promotion rather than supervised sessions 2
• Phase 3/4 evidence focuses more on quality of life maintenance than mortality reduction, representing a critical gap compared to Phase 2 2
• Direct physician supervision with immediate availability is not required in Phase 3/4, unlike Phase 2 2

Critical Implementation Considerations

Adherence and Long-Term Effectiveness

• Long-term adherence to prescribed medications and lifestyle improvements is essential, as compliance starts to decline within 6 months of hospital discharge in usual care settings 1
• A 3-year multicentre RCT demonstrated that long-term, reinforced, multifactorial educational and behavioral intervention coordinated by a cardiologist after standard cardiac rehabilitation proved effective in improving risk factors and increasing medication adherence over time 1
• Adherence to behavioral advice (diet, exercise, and smoking cessation) after acute coronary syndrome is associated with substantially lower risk of recurrent cardiovascular events compared with non-adherence 1

Common Pitfalls

• Older and female patients, and those with specific comorbid conditions (transient ischemic attack, stroke, chronic obstructive pulmonary disease, chronic renal failure) represent particular challenges for rehabilitation programs 1
• Despite robust evidence, cardiac rehabilitation remains severely underutilized globally, with only 5-50% of eligible patients receiving rehabilitation services 2
• Poor participation represents a critical loss of potential gains in health-related quality of life and increased pressures on healthcare systems from unplanned hospitalization 1

Quality Assurance Requirements Across Phases

• A multidisciplinary team including cardiologists, general practitioners, nurse specialists, physiotherapists, dietitians, and psychologists trained in core competencies is required for comprehensive program delivery across all phases 1, 2
• Programs must demonstrate delivery of all comprehensive program elements including exercise training, cardiovascular risk factor modification, nutritional counseling, and psychosocial interventions 3
• Detailed initial patient assessment, individualized treatment plans, and outcomes-based long-term assessment mechanisms are mandatory 3

Specific Patient Populations

Strongest Evidence

• All eligible patients with acute coronary syndrome should be referred to comprehensive outpatient cardiovascular rehabilitation either before hospital discharge or during the first follow-up office visit (Class I, Level of Evidence A) 1
• Patients post-coronary artery bypass surgery or post-percutaneous coronary intervention should receive the same referral (Class I, Level of Evidence A) 1
• Exercise training is safe and effective for patients with heart failure with reduced ejection fraction (Class I, Level of Evidence A) 3

Emerging Evidence

• Further research is needed to strengthen the evidence base for cardiac rehabilitation in patients with heart failure with preserved ejection fraction, atrial fibrillation, congenital heart disease, and after cardiac valve surgery or heart transplantation 1