Phase II Cardiac Rehabilitation Candidates
Patients who have experienced myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, or have stable angina within the previous 12 months are candidates for Phase II cardiac rehabilitation, which should be initiated within 3-6 months of the qualifying event. 1
Core Qualifying Diagnoses
Phase II cardiac rehabilitation eligibility includes patients with the following primary diagnoses occurring within the past year:
- Myocardial infarction/acute coronary syndrome - Class I recommendation 1
- Coronary artery bypass graft surgery (CABG) - Class I recommendation 1
- Percutaneous coronary intervention (PCI) - Class I recommendation 1
- Stable angina pectoris - Class I recommendation 1
- Heart valve surgical repair or replacement - appropriate and beneficial 1
- Heart or heart/lung transplantation - appropriate and beneficial 1
Expanding Indications with Growing Evidence
Chronic heart failure with reduced ejection fraction represents an expanding indication with Class I, Level B evidence supporting cardiac rehabilitation participation. 1, 2 The evidence demonstrates that ambulatory patients with current or prior heart failure symptoms and reduced LVEF benefit from exercise training as an adjunctive approach to improve clinical status. 1
Peripheral arterial disease has growing evidence supporting cardiac rehabilitation benefits, though formal coverage recommendations depend on ongoing research and policy decisions. 1
Timing and Program Structure
Phase II cardiac rehabilitation is defined as early outpatient rehabilitation delivered within the first 3-6 months after a cardiovascular event, though programs may continue for up to 1 year post-event. 1, 2 This phase has the most substantive evidence base demonstrating a 33% reduction in cardiovascular mortality and 36% reduction in recurrent myocardial infarction. 2
The program must include comprehensive services: medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling designed to limit physiologic and psychological effects of cardiac illness. 1
Patient Selection Considerations
Risk stratification determines program intensity but not eligibility. High-risk patients with minimal functional capacity (3-5 METs) benefit most from supervised programs, while low-risk patients with functional capacity of 7-9 METs have minimal need but remain eligible. 3 Intermediate-risk patients benefit but may not require the full 12-week program duration. 3
Absolute contraindications that exclude patients include:
- Medically unstable, life-threatening conditions 1
- Absolute contraindications to exercise 1
- Recent myocardial infarction (<3 weeks) 4
- Unstable angina 4
- Uncontrolled hypertension or arrhythmias 4
Referral Requirements
All eligible patients must be referred either before hospital discharge or during the first follow-up office visit. 1, 2 The referral constitutes official communication between the healthcare provider and patient, including provision of all necessary enrollment information and written/electronic communication to the cardiac rehabilitation program containing the patient's cardiovascular history, testing, and treatments. 1
Critical Implementation Points
Women and elderly patients are significantly underrepresented in cardiac rehabilitation despite eligibility, with only 5-50% of eligible patients globally receiving services. 2, 5 The evidence base has focused predominantly on low-risk, middle-aged males post-MI, creating an equity gap. 6
Home-based cardiac rehabilitation represents a reasonable alternative for selected clinically stable low- to moderate-risk patients who cannot attend traditional center-based programs, with evidence showing similar 3-12 month clinical outcomes. 7 However, this requires remote coaching with indirect exercise supervision and is not appropriate for high-risk patients requiring direct physician supervision. 7
Phase II requires direct physician supervision with the physician immediately available and accessible in the exercise area at all times, though not necessarily physically present in the exercise room itself. 2 All professional staff must have basic life support training, with at least one staff member holding advanced cardiac life support certification. 2
Outcome Benefits Supporting Candidacy
The mortality reduction achieved through Phase II cardiac rehabilitation justifies broad referral: 27% reduction in all-cause mortality with exercise-only rehabilitation and 26% reduction in cardiac mortality with comprehensive cardiac rehabilitation compared to usual care. 6 Each 1-MET increase in exercise capacity confers an 8-17% reduction in mortality. 1, 8
Beyond mortality, Phase II produces significant improvements in health-related quality of life (−5.7 points on Minnesota Living with Heart Failure questionnaire, p=0.025), reduced hospitalization risk, and improved cardiovascular risk factor profiles. 2