Cardiac Rehabilitation

Heart Disease

Outcomes of Cardiac Rehabilitation Training

Cardiac rehabilitation provides many benefits for patients. The most important of these are discussed in this section.

Improved exercise tolerance
Cardiac rehabilitation exercise training for patients with coronary heart disease or congestive heart failure (CHF) leads to objectively verifiable improvement in exercise capacity in men and women, regardless of age.[12] Adverse outcomes or complications of exercise are exceedingly rare. The nonfatal infarction rate is 1 patient per 294,000 patient-hours; the cardiac mortality rate is 1 patient per 784,000 patient-hours. The benefits are even greater in patients with diminished exercise tolerance. This beneficial effect does not persist long-term after completion of cardiac rehabilitation without a long-term maintenance program. Therefore, exercise training must be maintained long-term to sustain the improvement in exercise capacity.

Control of symptoms
In patients with coronary heart disease, angina significantly improves during the cardiac rehabilitation exercise program. Objective evidence of improvement in ischemia has been seen by performing interval stress ECG or radionuclide testing. Similarly, patients with LV failure or dysfunction show improvement in the symptoms of heart failure.[18] Use of gas analysis (CPX) has shown that patients’ exertional tolerance improves significantly with exercise training.

Improvement in the blood levels of lipids
Improvements in lipid and lipoprotein levels are observed in patients undergoing cardiac rehabilitation exercise training and education.[19] Exercise must be combined with dietary and medical interventions for required lipid control.

Effect on body weight
Exercise training as a sole intervention has an inconsistent effect on controlling excess weight. Optimal management of obesity requires multifactorial rehabilitation, including nutritional education and counseling, behavioral modification, and exercise training.[20]

Effect on blood pressure
Rehabilitation exercise training as a sole intervention has minimal effect; however, multifactorial intervention has been shown to have beneficial effects. Inconsistencies with this theory remain unresolved.

Reduction in smoking
Cardiac rehabilitation services with well-designed educational, counseling, and behavioral modification programs result in cessation of smoking in a significant number of patients. Cessation of smoking can be expected in 16-26% of patients. This reduction is combined with the spontaneously high smoking cessation rates following acute coronary events.

Improved psychosocial well-being
Cardiac rehabilitation exercise and educational services enhance measures of psychological and social functioning.[3, 4]

Reduction of stress
In multifactorial cardiac rehabilitation programs, improvement in emotional-stress measurements occurs, as does a reduction of type A behavior patterns. This reduction of stress is consistent with improvement in psychosocial outcomes that occurs in nonrehabilitation settings.

Enhanced social adjustment and functioning
Cardiac rehabilitation exercise training improves social adjustment and functioning.

Return to work
Cardiac rehabilitation exercise training exerts less influence on rates of return to work than on other aspects of life. Many nonexercise variables also affect this outcome (eg, prior employment status, employer attitude, economic incentives).

Reduced mortality
Scientific data suggest a survival benefit for patients who participate in cardiac rehabilitation exercise training, but it is not attributable to exercise alone. This survival benefit is due to multifactorial interventions. A meta-analysis of post–myocardial infarction (MI), randomized, controlled trials of exercise showed a 25% reduction in mortality at 3-year follow-up. The magnitude of this benefit is as large as that seen with the post-MI use of beta blockers or with the use of ACE inhibitors in LV dysfunction along with MI. Trials that involve exercise alone still show a 15% mortality reduction.

The scientific evidence pertaining to the relationship between cardiac rehabilitation exercise training and mortality also includes scientific reports that have appeared on the US National Institutes of Health Web site. Among the data in these reports was the finding, through randomized trial, that 3-year coronary mortality and sudden death rates were significantly lower (P < .02) in patients who, after suffering myocardial infarction, underwent multifactorial cardiac rehabilitation, starting 2 weeks after hospital discharge. This beneficial outcome persisted at the 10-year follow-up.

The larger center from a multicenter European trial of exercise-only rehabilitation in males (post-MI) reported significant mortality reduction in the rehabilitation group (P < .01).

Pathophysiologic measures
When combined with intensive dietary intervention, with or without lipid-lowering drugs, exercise training may result in the limitation of progression or in the regression of angiographically documented coronary atherosclerosis.

Exercise training in patients with heart failure and compromised LV ejection fraction produces favorable hemodynamic changes in the skeletal musculature. Therefore, cardiac rehabilitation exercise training is recommended for the improvement of skeletal muscle functioning. However, such training does not seem to improve cardiac hemodynamic function or collateral circulation to any significant degree.

Patients following cardiac transplantation
Following orthotropic cardiac transplantation, rehabilitation exercise training is recommended to improve patients’ exercise tolerance measurements.[16]

Elderly patients and women
Coronary patients who are elderly have exercise trainability comparable to that of younger patients participating in similar rehabilitation programs. Elderly patients (male and female) show comparable improvements. Unfortunately, referrals to cardiac rehabilitation are made less frequently for elderly patients, particularly for elderly women; participation in cardiac rehabilitation also is less frequent among the elderly. No complications or adverse outcomes for elderly patients have been described in any study. Elderly male and female patients should be encouraged to participate in cardiac rehabilitation.

Patients on dialysis and following coronary artery bypass grafting surgery
Patients who are on renal dialysis are at high risk for cardiac death and have a large burden of cardiovascular disease and cardiovascular disease risk factors. Cardiac rehabilitation can promote improved survival of nondialysis patients after coronary artery bypass grafting (CABG) surgery and is covered by Medicare,[15] but no studies have investigated whether dialysis patients’ survival after CABG may be improved as a function of cardiac rehabilitation.

In a 2006 study by Kutner and colleagues, it was found that, in comparison with dialysis patients who did not undergo cardiac rehabilitation, there was a 35% risk reduction for all-cause mortality, as well as a 36% risk reduction for cardiac death, in dialysis patients who had cardiac rehabilitation following CABG; the findings were independent of sociodemographic and clinical risk factors, such as recent hospitalization.[21] In the study, 10% of patients received cardiac rehabilitation after CABG, less than half the estimated share of patients in the general pouplation who such rehabilitation. Women and black patients aged 65 or older, along with lower-income patients of all ages, were significantly less likely to receive cardiac rehabilitation services. This observational study suggests that following CABG, cardiac rehabilitation increases a dialysis patient’s likelihood of survival.