Cardiac Rehabilitation

Heart Disease

Cardiac rehabilitation aims to reverse limitations experienced by patients who have suffered the adverse pathophysiologic and psychological consequences of cardiac events.

Cardiovascular disorders are the leading cause of mortality and morbidity in the industrialized world, accounting for almost 50% of all deaths annually. The survivors constitute an additional reservoir of cardiovascular disease morbidity. In the United States alone, over 14 million persons suffer from some form of coronary artery disease (CAD) or its complications, including congestive heart failure (CHF), angina, and arrhythmias. Of this number, approximately 1 million survivors of acute myocardial infarction (MI), as well as the more than 300,000 patients who undergo coronary bypass surgery annually, are candidates for cardiac rehabilitation.

The image below depicts cardiac rehabilitation after bypass surgery.

Phase 1: A patient walking in the hallway with a physical therapist following bypass surgery.

Phase 1: A patient walking in the hallway with a physical therapist following bypass surgery.

Traditionally, cardiac rehabilitation has been provided to somewhat lower-risk patients who could exercise without getting into trouble. However, astonishingly rapid evolution in the management of CAD has now changed the demographics of the patients who can be candidates for rehabilitation training. Currently, about 400,000 patients who undergo coronary angioplasty each year make up a subgroup that could benefit from cardiac rehabilitation. Furthermore, approximately 4.7 million patients with CHF are also eligible for a slightly modified program of rehabilitation, as are the ever-increasing number of patients who have undergone heart transplantation.[1]

This review addresses the objectives, indications, program components, exercise training, monitoring, benefits, risks, safety issues, outcome measures, and cost-effectiveness of cardiac rehabilitation.

Objectives
The identification of the patients at risk for a cardiac event’s recurrence (ie, risk stratification) is central to formulating an appropriate medical, rehabilitative, and surgical strategy to prevent such a recurrence. Patients who are at low or moderate risk typically undergo early rehabilitation. The major goals of a cardiac rehabilitation program are:

Curtail the pathophysiologic and psychosocial effects of heart disease
Limit the risk for reinfarction or sudden death
Relieve cardiac symptoms
Retard or reverse atherosclerosis by instituting programs for exercise training, education, counseling, and risk factor alteration
Reintegrate heart disease patients into successful functional status in their families and in society
Cardiac rehabilitation programs have been consistently shown to improve objective measures of exercise tolerance and psychosocial well being without increasing the risk of significant complications.

Utilization
The Agency for Health Care Policy and Research (AHCPR); the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and the National Heart, Lung and Blood Institute (NHLBI) have recognized the wide variation in awareness and understanding of the role of cardiac rehabilitation among physicians, ancillary health care providers, third-party payers, and patients with heart disease.

In the past, it was found that only 11% of patients participated in such programs following an acute coronary event. However, there is evidence that participation has increased. Approximately 38% of US patients and 32% of Canadian patients with acute MI who were involved in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial were enrolled in cardiac rehabilitation programs.

Outcome Measures
Current cardiac care has already reduced early acute coronary mortality so much so that further exercise training, as an “isolated” intervention, may not be able to cause significant reduction in the morbidity and mortality.[2] Nonetheless, exercise training has the potential to act as a catalyst for promoting other aspects of rehabilitation, including risk factor modification through therapeutic lifestyle changes (TLC) and optimization of psychosocial support. Therefore, the outcome measures of cardiac rehabilitation now include improvement in quality of life (QOL), such as the patient’s perception of physical improvement, satisfaction with risk factor alteration, psychosocial adjustments in interpersonal roles, and potential for advancement at work commensurate with the patient’s skills (rather than simply return to work).[3, 4]

Similarly, among patients who are elderly, such outcome measures may include the achievement of functional independence, the prevention of premature disability, and a reduction in the need for custodial care.[5, 6, 7, 8] Despite limited data, older male and female patients in observational studies have shown improvement in their exercise tolerance comparable to that of younger patients participating in equivalent exercise programs. In addition, the safety of exercise within cardiac rehabilitation programs, as studied in over 4,500 patients, is well accepted and established.

Cardiac rehabilitation services are, therefore, an effective and safe intervention. These services are undoubtedly an essential component of the contemporary treatment of patients with multiple presentations of coronary heart disease and heart failure.

Related eMedicine topics:

Angina Pectoris (Cardiology)
Angina Pectoris (Emergency Medicine)
Complications of Myocardial Infarction
Myocardial Infarction (Cardiology)
Myocardial Infarction (Emergency Medicine)
Myocardial Infarction in Childhood
Unstable Angina
Vascular Diseases and Rehabilitation

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