a 'Salvatore Maugeri' Foundation, Institute for Clinical Care and Research (IRCCS), Scientific Institute of Veruno Via per Revislate 13, 28010 (NO),Veruno Italy
b Leitender Arzt Cardiac Rehabilitation and Prevention Inselspital Bern, Freiburgstrasse CH-3010 Bern, Switzerland
c Heart Department, Haukeland Sykehus, NO-5021 Bergen, Norway
d Cardiology Institute, Azienda Ospedaliera, S. Maria della Misericordia, P. le S. Maria d. Misericordia 15, IT-33100 Udine, Italy
e Instituto Do Coraçao, Hospital Santa Cruz, Av. Prof. Reinaldo Dos Santos, 27, PT-2795 Carnaxide, (Linda-a-Velha), Portugal
f Service de Cardiologie, Hôpital Beaujon, 100, Bd du Gal Leclerc, FR-92118 ClinchyCedex, France
g Wellness Medical Centre, Adidas Centre Ltd, Pepper Road, Hazel Grove, PO Box 39, SK7 5SD StockportUK
h University of Leipzig-Herzzentrum, Department of Internal, Medicine/Cardiology, Russenstrasse 19, D-04289 Leipzig, Germany
i Thoraxcentrum, Dijikzigt Ziekenhuis, Molenwaterplein 40, Box #2040, beeper: 5171, 3000 CA Rotterdam, USA
j Health Services Research Cenre, Department of Psychology, Royal College of Surgeons in Ireland, Mercer Sto Lower, Dublin 2, Ireland
k Department of Internal Medicine, Oskarshamns Hospital, 57228 Oskarshamn, Sweden
l UZ Leuven, Herestraat 59, 3000 Leuven, Belgium
m State Hospital for Cardiology, (S.H.o.C.Bf.), Gyógy Square 2, 8230 Balatonfüred, Hungary
* Corresponding author: Pantaleo Giannuzzi, MD, Salvatore Maugeri Foundation, Institute for Clinical Care and Research (IRCCS), Scientific Institute of Veruno, Via per Revislate 13, 28010 VERUNO (NO), Italy
E-mail address: pgiannuzzi{at}fsm.it
E-mail address: hugo.saner{at}insel.ch
E-mail address: hansbioe{at}online.no
E-mail address: fioretti.paolo{at}aoud.sanit.fvg.it
E-mail address: Miquel.mendes{at}ono.com
E-mail address: a.cohen.solal{at}wanadoo.fr
E-mail address: Dorian.dugmore{at}adidas.co.uk
E-mail address: hamr{at}medizin.uni-leipzig.de
E-mail address: ihellema{at}afd.knmg.nl
E-mail address: hmcqee{at}rcfsi.ie
E-mail address: chiopeerk{at}hotmail.com
E-mail address: luc.vanhees{at}uz.kuleuven.ac.be
E-mail address: veress{at}elso.bfkor.hu
Received 18 November 2002; revised 27 January 2003; accepted 6 March 2003
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key Words: Cardiac rehabilitation Secondary prevention Lifestyle changes Cardiovascular riskfactors
![]() |
1. Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The purpose of this statement is to provide specific recommendations on the core components of CR with special emphasis on the design and development of a multifactorial, integrated approach for comprehensive cardiovascular risk reduction and effective secondary prevention.
![]() |
2. Evolution of cardiac rehabilitation and definition |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The World Health Organization (WHO) has defined CR as the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life'.2 The goals of CR and secondary prevention are: (a) to prevent disability resulting from coronary disease, particularly in older persons and those with occupations that involve physical exertion, and (b) to prevent subsequent cardiovascular events, hospitalization, and death from cardiac causes. This is achieved through a programme of prescribed exercise and interventions designed to modify coronary risk factors with the use of optimised drug therapy and appropriate lifestyle changes. Thus, CR is not only indicated for incapacitated disabled patients but for all patients with a diagnosis of acute myocardial infarction, those who have undergone coronary revascularization (coronary artery by-pass graft -CABG-, percutaneous transluminal coronary angioplastyPTCA), those with chronic stable angina, those with intermittent claudication, and those with documented coronary risk factors including hypertension, hypercholesterolemia and other abnormal conditions or diseases related to circulatory system. It is also appropriate for patients with chronic heart failure and those who have undergone cardiac transplantation.1,2,4,5,7,1012,16,2022
During the past three decades, changes in the delivery of rehabilitative care for cardiac patients have reflected changes in demography and characteristics of the patients, and predominantly reflect changes in clinical care. In the early years of CR, most patients enrolled in exercise training programmes were those who had recovered from uncomplicated myocardial infarction. In subsequent years, post-infarction patients with complications were also included and considered for more limited and gradual exercise rehabilitation. Many patients who currently receive rehabilitation services are recovering from CABG, PTCA or other forms of myocardial revascularization. With ageing of the population, cardiac rehabilitative care is now provided to a sizeable number of older-patients, many of whom have severe and complicated coronary illness and serious associated pathologies.4,5,12 Furthermore, many patients once considered to be too high risk for structured rehabilitation programmes, such as patients with residual myocardial ischaemia, compensated heart failure, serious arrhythmias, and implanted cardiac devices (pacemaker, ventricular resynchronization, ICD) currently derive benefit from more gradual and more protracted and often supervised exercise training.4,7,9,10,12,22 This is combined with education, counselling, behavioural strategies and other psychosocial interventions and vocational counselling strategies to assist the patient to achieve coronary risk reduction and other cardiovascular health-related goals.4,12
There is convincing evidence that the combination of regular exercise with interventions for lifestyle changes and modification of risk factors favourably alter the clinical course of cardiovascular diseases. With continuing shortening of length of hospital stay, deconditioning is usually minimal but the time spent in hospital is no longer adequate to teach the skills required to monitor exercise activity, to cover the educational materials adequately and to adapt to the lifestyle changes necessary for these chronic conditions. Thus, the opportunity to counsel patients about risk reduction, exercise and healthy lifestyle is diminished, especially after PTCA and for young uncomplicated patients where length of hospital stay is particularly short. In this context, national clinical practice guidelines and reports of authoritative agencies of health care policy and research, have broadened the scope of CR programmes in regard to assessment and modification of risk factors, and have emphasised the greater need for structured outpatient rehabilitation programmes in the hospital, in the community environment or at home so that these programmes function as comprehensive secondary-prevention services.3,7,1012,14
![]() |
3. Cardiac rehabilitation services for secondary prevention |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The benefits and the preventive effects of CR as documented in the scientific literature are: reduction in symptoms, improvement in exercise tolerance and physical work capacity, improvement in blood lipid levels and global risk profile, reduction in cigarette smoking, improvement in psychosocial well-being and stress management, attenuation of the atherosclerotic process, decreased rates of subsequent coronary events, reduced hospitalization and decreased morbidity and total mortality. Despite these prominent benefits, fewer than one-third of patients eligible for CR currentlyparticipate in formal rehabilitation programmes in most European countries.6,19 Barriers to participation in CR include resources, attitudinal and structural problems, the geographic maldistribution of available programmes, large distances, the lack of access to appropriate services and reimbursement issues for services or individual patients. Further barriers include the failure of physicians to assess the motivation of patients to lifestyle changes coupled with the poor ability to track the effective progress of prescribed lifestyle interventions, and the failure of physicians to refer patients, particularly older persons and women, to the available programmes. This is true despite the fact that physicians generally do not have the appropriate skills or the time to provide effective dietary interventions, weight management, smoking cessation, exercise prescriptions, psychosocial management and vocational counselling. Indeed CR is not yet a part of the core medical curriculum at many universities, either in basic medical education or in cardiology education. The provision of all these services at specialised CR units incorporating an integrated professional team approach (including cardiologists, nurses, exercise therapists, physiologists and/or sport teachers, psychologists, behavioural specialists, dieticians-all with appropriate training and experience) and setting goals for risk reduction in coordination with the primary care physician is both an efficient and effective way to deliver CR services.
Different patterns of rehabilitative care are currently delivered by specialised hospital-based teams: residential CR for more complicated, disabled patients; and outpatient CR for more independent, low risk and clinically stable patients requiring less supervision. There may be variations of individual or group programmes and centre-based or home-based programmes.
While the objectives are identical to those of the outpatient CR programmes, residential rehabilitation programmes are specifically structured to provide more intensive and/or complex interventions, and have the advantage being able to start early after the acute event, to include more complicated high risk or clinically unstable patients, to include more severe incapacitated and/or elderly patients (especially those with co-morbidity), and thus, to facilitate the transition from the hospital phase to a more stable clinical condition which may allow the maintenance of an independent life at home. One major disadvantage of residential programmes is the relatively short duration of intervention with regard to risk factor management and lifestyle changes. Therefore, residential CR programmes should be followed up by a long-term outpatient risk reduction and secondary prevention programme, with appropriate clinical and functional monitoring. Home-based rehabilitation programmes directed by physicians and coordinated by nurses have also been developed as a way of expanding the delivery of secondary prevention services.
This panel strongly emphasises that CR programmes should consist of a multifaceted and multidisciplinary approach to overall cardiovascular risk reduction, and that programmes that consist of exercise training alone are not considered CR. It should be also recognised that exercise is often the vehicle for facilitating other aspects of CR, including coronary risk reduction and optimization of psychosocial support. Thus, evaluation of the overall quality of life impact should become an integral part of outcome measures of rehabilitation.
Core components of cardiac rehabilitation/secondary prevention programmes are: baseline patient assessment; physical activity counselling and exercise training, nutritional counselling; risk factor management (lipids, hypertension, weight, diabetes, and smoking); psychosocial management, vocational counselling and optimised medical therapy. The way CR is delivered varies depending on national circumstances and resources. The provision of these services by specialised hospital-based teams in an out-patient setting is recommended, and a period of 812 weeks isconsidered adequate to cover the core components of cardiac rehabilitation/secondary prevention programmes appropriately. Shorter programmes may be considered under special circumstances but their efficiency is not proven in the literature. All patients after an acute cardiovascular event should be entered into a comprehensive, multidisciplinary intensive CR programme. On completion of this introductory programme of secondary prevention, they should be oriented to a long-term maintenance regimen with the use of support systems such as coronary clubs, gymnasia or other facilities to promote long-term prevention strategies in the community.
|
Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR. The provision of such services, and provision to all who could benefit, is a standard of care that is now required on the basis of evidence for both service need for CR and service effectiveness. What is now needed at each levelEuropean, national and localis an action plan. While CR is widely agreed in an aspirational sense as a useful and evidence-based service, it needs an implementation plan if it is to become a reality for all patients who can benefit across Europe.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|