Fast Facts: Referral/Resource Pages for

Cardiac Rehabilitation

What is cardiac rehab?

Identifying appropriate patients

Components of cardiac rehabilitation

What determines a quality program?

Where are these programs?

Expected outcomes

Payment for programs/cost of programs

Evidence of efficacy?

What is cardiac rehab?

Definition and scope:

The 2005 AHA/AACVPR scientific statement developed the following definition of cardiac rehabilitation: The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. As such, cardiac rehabilitation/secondary prevention programs provide an important and efficient venue in which to deliver effective preventive care. (Leon, 2005)

Identifying appropriate patients

Cardiac rehabilitation/secondary prevention programs are recognized as integral to the comprehensive care of patients with cardiovascular disease. Candidates for cardiac rehabilitation/secondary prevention services historically were patients who recently had had a myocardial infarction or had undergone coronary artery bypass graft surgery, but candidacy has been broadened to include patients who have undergone percutaneous coronary interventions; are heart transplantation candidates or recipients; or have stable chronic heart failure, peripheral arterial disease with claudication, or other forms of CVD. In addition, patients who have undergone other cardiac surgical procedures, such as those with valvular heart disease, also may be eligible. All patient referrals require a physician referral (or NP/PA in some states). Statistics document that only 10-20% of patients needing cardiac rehabilitation services receive them. (Suaya, 2007)

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Examples of conditions appropriate for cardiac rehabilitation

• Myocardial Infarction
• Stable angina
• Coronary Artery Bypass Graft Surgery (CABG)
• Percutaneous transluminal coronary angioplasty (PTCA)/stent procedures
• Valve surgery
• Chronic stable Heart Failure
• Ventricular Assist Devices
• Diabetes
• Cardiac Transplantation
• Peripheral Arterial disease
• High Risk for Coronary Artery Disease

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Components of cardiac rehabilitation

Cardiac rehabilitation should include a multidisciplinary approach to overall cardiovascular disease risk reduction. Although the core therapeutic modality is monitored and supervised exercise training, cardiac rehabilitation programs should contain specific components aimed at optimizing cardiovascular risk reduction, fostering healthy behaviors, and improving functional capacity and quality of life in patients with heart disease.

Contemporary components of cardiac rehabilitation include:

• Patient Assessment
• Exercise Training and other therapeutic exercise (aerobic strength)
• Education/Counseling
  • Physical Activity Counseling
  • Nutritional counseling
  • Lipid Management
  • Blood Pressure Management
  • Smoking Cessation
  • Weight Management
  • Diabetes Management
  • Psychosocial Management
• Facilitating a life-long committment to exercise and other lifestyle changes

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What determines a quality program?

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) instituted program certification in 1998 to recognize programs that were meeting the standards put forth in the published Guidelines for Pulmonary and Cardiac Rehabilitation. These documents reflect the standard of care for programs and are regularly updated. Programs can demonstrate their adherence to these nationally developed guidelines by undergoing the review process to become certified, and then recertifying every three years.

Documentation required for certification:

1. Annual staff competency skills review
2. Emergency equipment and supplies
3. Written policies and procedures
4. Regular staff meetings
5. Physician referral process
6. Informed consent form
7. Exercise prescription
8. Preparation for possible medical emergencies
9. Emergency equipment availability
10. Regular medical emergency inservices
11. Record of untoward events
12. Outcomes assessment/program evaluation
13. Risk stratification
14. Psychosocial assessment
15. Nutritional assessment
16. Educational assessment
17. Individualized care plan
18. Educational sessions
19. Feedback to physicians

Those applying for certification or recertification are also required to complete an extensive checklist related to the daily operation of their program. The national program certification committee works with local affiliate program certification committees to review the applications and mentor programs in the process.

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Where are these programs?

1. Program Directory Search click here
2. Certified Program Search click here

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Expected outcomes

Demonstrated Outcomes of Cardiac Rehabilitation

• Reduced symptoms (angina, dyspnea, fatigue)
• Increased exercise performance
• Increased knowledge about cardiac disease and its management
• Enhanced ability to perform activities of daily living
• Improved health-related quality of life
• Improved psychosocial symptoms (reversal of anxiety and depression, increased self-efficacy
• Reduced hospitalizations and use of medical resources
• Return to work or leisure activities

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Payment for programs

Payment for services is determined by the benefits that have been established in the contract between the insurance carrier and the enrollee.

In 2006, a revised Medicare National Coverage Determination expanded the covered diagnoses for cardiac rehabilitation. Effective for services performed on or after March 22, 2006, Medicare coverage of cardiac rehabilitation programs are considered reasonable and necessary only for patients who: (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; or (3) have stable angina pectoris; or (4) have had heart valve repair/replacement; or (5) have had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or (6) have had a heart or heart-lung transplant.

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Evidence of efficacy

Medical/clinical evidence

 

Clinical Condition	Class of Recommendation and Level of Evidence (LOE)	Relevant wording in text	Link to ACC/ AHA guideline
Coronary Artery Bypass Surgery	Class I, LOE: B	Cardiac rehabilitation should be offered to all eligible patients after CABG.	http://www.acc.org/qualityandscience/clinical/guidelines/cabg/index.pdf page 256
ST Elevation Myocardial Infarction	Class I, LOE: B	Patient counseling to maximize adherence to evidence-based post-STEMI treatments (e.g., compliance with taking medication, exercise prescription, and smoking cessation) should begin during the early phase of hospitalization, occur intensively at discharge, and continue at follow-up visits with providers and through cardiac rehabilitation programs and community support groups, as appropriate. Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.	http://www.acc.org/qualityandscience/clinical/guidelines/stemi/Guideline1/index.pdf pages 153, 155, 156
Unstable Angina/ Non ST Elevation Myocardial Infarction	Class I, LOE: B	Cardiac rehabilitation/secondary prevention programs are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is particularly warranted.	http://content.onlinejacc.org/cgi/reprint/50/7/e1 page 99
Chronic Stable Angina	Class I, LOE: B	Comprehensive cardiac rehabilitation program (including exercise).	http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf Page 64
Percutaneous Coronary Intervention	No class or LOE given	Cardiac rehabilitation programs are recommended, particularly for those patients with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.	http://www.acc.org/qualityandscience/clinical/guidelines/percutaneous/update/index.pdf Page 73
Chronic Heart Failure	No class or LOE given	Discussed in text, no formal recommendation given. Exercise training should be considered for all stable outpatients with chronic HF who are able to participate in the protocols needed to produce physical conditioning. Exercise training should be used in conjunction with drug therapy.	http://content.onlinejacc.org/cgi/reprint/46/6/e1 Page 39
Secondary Prevention	Class I, LOE: B	Advise medically supervised programs for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure).	http://content.onlinejacc.org/cgi/reprint/47/10/2130 Page 2131

 

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Definitions

Classification: Level of Evidence:

Class I: Intervention is useful and effective A Sufficient evidence from multiple randomized trials
Class IIa: Weight of evidence/opinion is in favor of B Limited evidence from single randomized trial or usefulness/efficacy other nonrandomized studies
Class IIb: Usefulness/efficacy is less well established by C Based on expert opinion, case studies, or evidence/opinion standard of care
Class III: Intervention is not useful/effective and may be harmful

Guidelines and Scientific Statements

American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4 th ed. Human Kinetics. Champaign, IL. 2004.

Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007;115:1481-1501. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.181546.

Williams MA, Haskell WL, Ades PA, et al. Resistance Exercise in Individuals With and Without Cardiovascular Disease: 2007 Update: A Scientific Statement From the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation 2007;116;572-584. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185214.

Balady GJ, Williams MA, Ades PA, et al. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update. A Scientific Statement From the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115;2675-2682. Available at: http://circ.ahajournals.org/cgi/reprint/115/20/2675.

Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol 2007;50:1400–33. Available at: http://www.acc.org/qualityandscience/clinical/pdfs/CardiacRehab_PM_sept20.pdf.

Thompson PD, Franklin BA, Balady GJ, et al. Exercise and Acute Cardiovascular Events: Placing the Risks Into Perspective: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007;115;2358-2368. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.181485.

King, ML, Williams MA, Fletcher GF, et al. Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs. A Scientific Statement From the American Heart Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;112:3354-3360. Available at: http://circ.ahajournals.org/cgi/reprint/112/21/3354.

Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines
(Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Circulation 2006, 113 (11): e463-654. Available at: http://circ.ahajournals.org/cgi/reprint/113/11/e463.

Agency for Health Care Policy and Research: Cardiac Rehabilitation: Clinical Practice Guideline No. 17 (AHCPR Publication No. 96-0672). Bethesda, Md, National Heart, Lung, and Blood Institute, 1995. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.6677.

Williams MA, Fleg JL, Ades PA, et al: Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or = 75 years of age): An American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 105:1735, 2002. Available at: http://www.circ.ahajournals.org/cgi/reprint/105/14/1735.

Jolliffe JA, Rees K, Taylor RS, et al: Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev, 2003. Abstract available at: http://www.cochrane.org/colloquia/abstracts/capetown/capetownPC01.html.

Leon, AS et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111:369-376.

Cost effectiveness evidence:

Oldridge NB, Furlong W, Feeny D, et al. Economic evaluation of cardiac rehabilitation after acute myocardial infarction Am J Cardiol 1993;72:154-61.

Reid RD, Dafoe WA, Morrin L et al. Impact of program duration and contact frequency on efficacy and cost of cardiac rehabilitation: Results of a randomized trial. Am Heart J 2005, 149:862-8.

Other resources:

Ades PA, Savage PD, Brawner CA, Lyon CE, Ehrman JK, Bunn JY, Keteyian SJ. Aerobic capacity in patients entering cardiac rehabilitation. Circulation. 2006 Jun 13;113(23):2706-12.

Austin J, Williams R, Ross L, Moseley L, Hutchison S. Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. Eur J Heart Fail. 2005 Mar 16;7(3):411-7.

Baessler A, Hengstenberg C, Holmer S, Fischer M, Mayer B, Hubauer U, Klein G, Riegger G, Schunkert H. Long-term effects of in-hospital cardiac rehabilitation on the cardiac risk profile. A case-control study in pairs of siblings with myocardial infarction. Eur Heart J. 2001 Jul;22(13):1111-8.

Blair SN, Kampert JB, Kohl HW 3rd, et al: Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 276:205, 1996.

Caulin-Glaser T, Falko J, Hindman L, La Londe M, Snow R. Cardiac rehabilitation is associated with an improvement in C-reactive protein levels in both men and women with cardiovascular disease. J Cardiopulm Rehabil. 2005 Nov-Dec;25(6):332-6; quiz 337-8.

Dendale P, Berger J, Hansen D, Vaes J, Benit E, Weymans M. Cardiac rehabilitation reduces the rate of major adverse cardiac events after percutaneous coronary intervention. Eur J Cardiovasc Nurs. 2005 Jun;4(2):113-6. Epub 2004 Dec 21.

Detry JR, Vierendeel IA, Vanbutsele RJ, Robert AR. Early short-term intensive cardiac rehabilitation induces positive results as long as one year after the acute coronary event: a prospective one-year controlled study. J Cardiovasc Risk. 2001 Dec;8(6):355-61.

Edwards DG, Schofield RS, Lennon SL, Pierce GL, Nichols WW, Braith RW. Effect of exercise training on endothelial function in men with coronary artery disease. Am J Cardiol. 2004 Mar 1;93(5):617-20.

Franklin BA, Bonzheim K, Gordon S, Timmis GC: Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: A 16-year follow-up. Chest 114:902, 1998.

Freimark D, Shechter M, Schwamenthal E, Tanne D, Elmaleh E, Shemesh Y, Motro M, Adler Y. Improved exercise tolerance and cardiac function in severe chronic heart failure patients undergoing a supervised exercise program. Int J Cardiol. 2007 Apr 4;116(3):309-14.

Gayda M, Brun C, Juneau M, Levesque S, Nigam A. Long-term cardiac rehabilitation and exercise training programs improve metabolic parameters in metabolic syndrome patients with and without coronary heart disease. Nutr Metab Cardiovasc Dis. 2006 Dec 1;

Gayda M, Juneau M, Levesque S, Guertin MC, Nigam A. Effects of long-term and ongoing cardiac rehabilitation in elderly patients with coronary heart disease. Am J Geriatr Cardiol. 2006 Nov-Dec;15(6):345-51.

Hage C, Mattsson E, Ståhle A. Long-term effects of exercise training on physical activity level and quality of life in elderly coronary patients--a three- to six-year follow-up. Physiother Res Int. 2003;8(1):13-22.

Hambrecht R, Wolf A, Gielen S, et al: Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 342:454, 2000.

Haskell WL, Alderman EL, Fair JM, et al.: Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation.1994 89:975.

Hedbäck B, Perk J, Hörnblad M, Ohlsson U. Cardiac rehabilitation after coronary artery bypass surgery: 10-year results on mortality, morbidity and readmissions to hospital. J Cardiovasc Risk. 2001 Jun;8(3):153-8.

Hevey D, Brown A, Cahill A, Newton H, Kierns M, Horgan JH. Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program. J Cardiopulm Rehabil. 2003 Jan-Feb;23(1):17-21.

Izawa K, Hirano Y, Yamada S, Oka K, Omiya K, Iijima S. Improvement in physiological outcomes and health-related quality of life following cardiac rehabilitation in patients with acute myocardial infarction. Circ J. 2004 Apr;68(4):315-20.

Jobin J. Long-term effects of cardiac rehabilitation and the paradigms of cardiac rehabilitation. J Cardiopulm Rehabil. 2005 Mar-Apr;25(2):103-6.

Klecha A, Kawecka-Jaszcz K, Bacior B, Kubinyi A, Pasowicz M, Klimeczek P, Banyś R. Physical training in patients with chronic heart failure of ischemic origin: effect on exercise capacity and left ventricular remodeling. Eur J Cardiovasc Prev Rehabil. 2007 Feb;14(1):85-91.

Lavie CJ, Milani RV: Benefits of cardiac rehabilitation and exercise training. Chest.2000 17:5.

Lavie C, Milani R. Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavior characteristics, and quality of life in obese coronary patients. Am J Cardiol 1997;79:397-401.

Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, Burgisser C, Masotti G. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial.Circulation. 2003 May 6;107(17):2201-6.

Pierson LM, Herbert WG, Norton HJ, Kiebzak GM, Griffith P, Fedor JM, Ramp WK, Cook JW. Effects of combined aerobic and resistance training versus aerobic training alone in cardiac rehabilitation. J Cardiopulm Rehabil. 2001 Mar-Apr;21(2):101-10.

Simchen E, Naveh I, Zitser-Gurevich Y, Brown D, Galai N. Is participation in cardiac rehabilitation programs associated with better quality of life and return to work after coronary artery bypass operations? The Israeli CABG Study. Isr Med Assoc J. 2001 Jun;3(6):399-403.

Smart N, Haluska B, Jeffriess L, Marwick TH. Exercise training in systolic and diastolic dysfunction: effects on cardiac function, functional capacity, and quality of life. Am Heart J. 2007 Apr;153(4):530-6.

Song R, Lee H. Effects of a 12-week cardiac rehabilitation exercise program on motivation and health-promoting lifestyle. Heart Lung. 2001 May-Jun;30(3):200-9.

Streuber SD, Amsterdam EA, Stebbins CL. Heart rate recovery in heart failure patients after a 12-week cardiac rehabilitation program. Am J Cardiol. 2006 Mar 1;97(5):694-8.

Suaya JA, Shepard DS, Normand ST, Ades PA, Prottas J, Stason WB. Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery. Circulation. 2007;116:1653-1662.

Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682-92.

Taylor RS, Unal B, Critchley JA, Capewell S. Mortality reductions in patients receiving exercise-based cardiac rehabilitation: how much can be attributed to cardiovascular risk factor improvements? Eur J Cardiovasc Prev Rehabil. 2006 Jun;13(3):369-74.

Williams MA, Ades PA, Hamm LF, Keteyian SJ, LaFontaine TP, Roitman JL, Squires RW. Clinical evidence for a health benefit from cardiac rehabilitation: an update. Am Heart J. 2006 Nov;152(5):835-41.

Yu CM, Lau CP, Chau J, McGhee S, Kong SL, Cheung BM, Li LS. A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Arch Phys Med Rehabil. 2004 Dec;85(12):1915-22.

Yu CM, Li LS, Lam MF, Siu DC, Miu RK, Lau CP. Effect of a cardiac rehabilitation program on left ventricular diastolic function and its relationship to exercise capacity in patients with coronary heart disease: experience from a randomized, controlled study. Am Heart J. 2004 May;147(5):e24.

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