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Cardiac Rehabilitation: An Underutilized Class I Treatment for Cardiovascular Disease

  • Joseph S. Alpert
    Correspondence
    Requests for reprints should be addressed to Joseph S. Alpert, MD, University of Arizona College of Medicine, Sarver Heart Center, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037.
    Affiliations
    Department of Medicine, University of Arizona College of Medicine, Sarver Heart Center, Tucson

    Editor in Chief, The American Journal of Medicine
    Search for articles by this author
Published:February 04, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.01.008
      What is cardiac rehabilitation? Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program designed to improve the physical and emotional condition of patients with heart disease. It is prescribed to control symptoms and improve exercise tolerance and overall quality of life. The primary goal of cardiac rehabilitation is to enable the participant to achieve his/her optimal physical, psychological, social, and vocational functioning through exercise training and lifestyle change.
      • Lawler PR
      • Filion KB
      • Eisenberg MJ
      Efficacy of exercise based cardiac rehabilitation post myocardial infarction: a systematic review and meta- analysis of randomized controlled trials.
      • McMahon SR
      • Ades AA
      • Thompson PD
      The role of cardiac rehabilitation in patients with heart disease.
      • Milani RV
      • Lavie CJ
      • Cassidy MM
      Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.
      • Milani RV
      • Lavie CJ
      Impact of cardiac rehabilitation on depression and its associated mortality.
      • Anderson L
      • Oldridge N
      • Thompson DR
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane Systematic Review and Analysis.
      • Taylor RS
      • Brown A
      • Ebrahim J
      • et al.
      Exercise-based rehabilitation for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials.
      • Doll JA
      • Hellkamp A
      • Ho PM
      • et al.
      Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction.
      The core components of cardiac rehabilitation include:
      • Prescribed exercise to improve cardiovascular fitness without exceeding safe limits.
      • Education about heart disease along with counseling on ways to stabilize or reverse heart disease by improving the following risk factors:
        • Reduction/cessation of smoking
        • Lipid management
        • Controlling high blood pressure
        • Weight loss and eating a heart-healthy diet
        • Controlling diabetes
        • Increasing physical activity
      In addition, cardiac rehab seeks to improve psychological well-being.
      American Heart Association/American College of Cardiology Class 1 Guideline recommendations for referral to cardiac rehabilitation include the following conditions:
      • Myocardial infarction
      • Percutaneous coronary intervention
      • Coronary artery bypass grafting
      • Chronic stable angina
      • Heart failure
      • Peripheral arterial disease
      • Cardiovascular disease prevention in women
      There is strong evidence supporting the guideline level 1 indication for referral to cardiac rehab in that active participation in this intervention decreases mortality at 5 years post participation.
      • Lawler PR
      • Filion KB
      • Eisenberg MJ
      Efficacy of exercise based cardiac rehabilitation post myocardial infarction: a systematic review and meta- analysis of randomized controlled trials.
      • McMahon SR
      • Ades AA
      • Thompson PD
      The role of cardiac rehabilitation in patients with heart disease.
      • Milani RV
      • Lavie CJ
      • Cassidy MM
      Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.
      • Milani RV
      • Lavie CJ
      Impact of cardiac rehabilitation on depression and its associated mortality.
      • Anderson L
      • Oldridge N
      • Thompson DR
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane Systematic Review and Analysis.
      • Taylor RS
      • Brown A
      • Ebrahim J
      • et al.
      Exercise-based rehabilitation for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials.
      In addition, attendance in a cardiac rehab program decreases cardiovascular events following an acute myocardial infarction.
      • Lawler PR
      • Filion KB
      • Eisenberg MJ
      Efficacy of exercise based cardiac rehabilitation post myocardial infarction: a systematic review and meta- analysis of randomized controlled trials.
      Cardiac rehab also improves modifiable risk factors, adherence with primary and secondary preventive medications, functional status and exercise capacity, and quality of life.
      • Lawler PR
      • Filion KB
      • Eisenberg MJ
      Efficacy of exercise based cardiac rehabilitation post myocardial infarction: a systematic review and meta- analysis of randomized controlled trials.
      • McMahon SR
      • Ades AA
      • Thompson PD
      The role of cardiac rehabilitation in patients with heart disease.
      • Milani RV
      • Lavie CJ
      • Cassidy MM
      Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.
      • Milani RV
      • Lavie CJ
      Impact of cardiac rehabilitation on depression and its associated mortality.
      • Anderson L
      • Oldridge N
      • Thompson DR
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane Systematic Review and Analysis.
      • Taylor RS
      • Brown A
      • Ebrahim J
      • et al.
      Exercise-based rehabilitation for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials.
      Patients who are referred by their physician to a cardiac rehab program often become chronic users with resultant improved quality of life and persistent physiological and psychological benefits. Individuals who complete the full course of therapy often relate that the program was a major factor in fostering continued beneficial life-long healthy behaviors.
      • Lawler PR
      • Filion KB
      • Eisenberg MJ
      Efficacy of exercise based cardiac rehabilitation post myocardial infarction: a systematic review and meta- analysis of randomized controlled trials.
      • McMahon SR
      • Ades AA
      • Thompson PD
      The role of cardiac rehabilitation in patients with heart disease.
      • Milani RV
      • Lavie CJ
      • Cassidy MM
      Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.
      • Milani RV
      • Lavie CJ
      Impact of cardiac rehabilitation on depression and its associated mortality.
      • Anderson L
      • Oldridge N
      • Thompson DR
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane Systematic Review and Analysis.
      • Taylor RS
      • Brown A
      • Ebrahim J
      • et al.
      Exercise-based rehabilitation for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials.
      Unfortunately, despite evidence showing benefit, cardiac rehabilitation is underutilized. Of eligible patients, only 14%-35% of myocardial infarction survivors and 31% of patients after coronary artery bypass grafting participate in cardiac rehab.
      • Doll JA
      • Hellkamp A
      • Ho PM
      • et al.
      Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction.
      Participation is lowest in women, minorities, socioeconomically disadvantaged patients, and the elderly—categories that commonly demonstrate substantial and ongoing cardiovascular morbidity and mortality.
      The message from this commentary is evident: Both cardiologists and primary care physicians need to refer their patients frequently to cardiac rehab and to encourage the patients to complete the program.
      Essentially all health insurance carriers cover the cost of cardiac rehabilitation, and it is one of the least expensive items in the cardiovascular therapeutic armamentarium. So, let's get behind this important intervention and encourage our patients to “stay the course” by attending all the sessions allowed by their health insurance.
      As always, I am happy to hear from readers of The American Journal of Medicine about this commentary as well as others at [email protected], or on our blog at amjmed.org.

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