Cardiovascular disease (CVD) is one of the leading causes of death worldwide and is the leading cause of death in the United States. Cardiac rehabilitation, or cardiac rehab, is a complex, multidisciplinary intervention customized to individual patients with various cardiovascular diseases such as ischemic heart disease, heart failure, and myocardial infarctions, or patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting. Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, reduce the risk of mortality secondary to CVD, and improve cardiovascular function to help patients achieve their highest quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence through gradual conditioning.
Several organizations including the American Heart Association (AHA), The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and the Agency for Health Care Policy and Research agree that a comprehensive cardiac rehabilitation program should contain specific core components. These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:
The indications for cardiac rehabilitation are :
Contraindications to cardiac rehabilitation only apply to the exercise aspect. They include :
Cardiac rehabilitation consists of three phases.
Phase I: Clinical phase
Phase II: Outpatient cardiac rehab
Phase III: Post-cardiac rehab
There is also a pre-surgery phase, where the patient starts cardiovascular rehabilitation. A small number of studies demonstrate that the post-surgical pathway is better tolerated by patients.
A study in France reviewing the safety of cardiac rehabilitation found the cardiac arrest rate was 1.3 per million patient hours of exercise. Rakhshan et al. studied the potential complications of heart rhythm device malfunction after eight weeks of cardiac rehabilitation, but the study revealed a decrease in physical complications in patients who received cardiac rehabilitation versus a control group.
Overall cardiac rehabilitation increases quality of life and decreases health care costs. Cardiac rehabilitation has many physiologic benefits due to its exercise component. Exercise training has been shown to increase maximal oxygen uptake (VO2max), improve endothelial function, and improve myocardial reserve flow. Additionally, cardiac rehabilitation can reduce smoking, body weight, serum lipids, and blood pressure. Milani et al. found that cardiac rehabilitation decreased depression in heart disease patients who suffered a major coronary event. A Cochrane review noted that cardiac rehabilitation reduced hospital admissions and showed a long-term decrease in all-cause mortality in patients heart failure patients with preserved ejection fraction. However, there was no short-term (less than 12 months) benefit to all-cause mortality.
As stated above, cardiac rehabilitation goals can be designated into two broad categories :
In a systematic review of 19 random clinical trials, complex e-coaching was found to be an effective method of delivering therapies targeting physical capacity, clinical status, and psychosocial health; however, detailed protocols were not well described. Therefore, determining which aspects of e-coaching have the most benefit and need to be further developed have not been determined. In addition, basic e-coaching was not found to be effective. Studies on the effects of cardiac rehabilitation for congenital heart disease (CHD) patients is lacking. Randomized clinical trials in adult and pediatric populations are needed to establish specific guidelines and the current evidence.
Even though there is an overwhelming body of evidence to support the benefits of cardiac rehabilitation, patient participation is unusually low. Data from Medicare and the CDC reveal 14-35% of heart attack survivors and about 31% coronary bypass grafting surgery patients utilized or enrolled in cardiac rehabilitation or secondary prevention programs. Leon et al. noted that low utilization correlated to a low referral rate, lack of insurance coverage, poor patient motivation, and limited program site accessibility. A 2017 qualitative study on the patients’ perspectives of cardiac rehabilitation revealed psychosocial barriers to attending cardiac rehabilitation were lack of time and fear of exercise. Patients’ perceptions of cardiac rehabilitation (and subsequent participation) were also affected by prior exercise experience, physiotherapist communication, the severity of the cardiovascular disease or event, and the patient's’ future goals after rehabilitation. Therefore, the cardiac rehabilitation team should take these points into consideration when creating rehabilitation programs for patients.
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