FACTS

Cardiac Rehabilitation
Putting More Patients on the Road to Recovery
Nevertheless, new delivery models, such as
OVERVIEW automatic in-patient CR referral systems, offer
Each year, over 800,000 Americans die from opportunities to address patient barriers and to lower
cardiovascular disease, accounting for 1 of treatment costs.12,13 The Million Hearts® initiative
every 3 deaths in the US.1 However, there is has developed a roadmap to increase participation in
hope. The goal of cardiac rehabilitation (CR) is cardiac rehabilitation which includes referrals,
to reduce the risk of a future cardiac event by increased enrollment, and adherence of CR.10
stabilizing, slowing, or even reversing the Researchers have predicted that the Million Hearts®
progression of cardiovascular disease (CVD).2 initiative to increase cardiac rehabilitation could save
As a result, CR reduces hospital readmissions, 25,000 lives and prevent 180,000 hospitalizations
as well as all-cause and CVD mortality.3,4 annually in the US.10
Patients with other cardiovascular conditions,
such as heart failure can also benefit from CR WHAT IS CARDIAC REHABILITATION?
programs.5,6 Cardiac rehabilitation is a medically-supervised
Despite its clear and tangible benefits, CR remains program consisting of exercise training,
underutilized, particularly among women and education on heart-healthy living, counseling to
reduce stress, and helping patients return to an
minorities.7,8,9 A 2016 report estimated that only 19-
active lifestyle and recover sooner. CR offers a
34% of patients subsequently participate in a CR
multifaceted and highly tailored approach to
program.10 A 2015 study reported that just over 20% boost the overall physical, mental, and social
of eligible Medicare patients with acute myocardial functioning of people with heart-related
infarction used CR services.11 So, why aren’t more problems. It is recommended for both inpatient
patients and their physicians making greater use of and outpatient settings for the following
cardiac rehabilitation? Unfortunately, there are many conditions:13,14
barriers that contribute to low participation rates
(Table 1). • Acute myocardial infarction (heart attack)
• Chronic stable angina
• Coronary artery bypass grafting (CABG)
Table 1. BARRIERS TO UTILIZATION1,2 • Percutaneous coronary intervention (PCI)
• Lack of referral to participate from the patient’s • Cardiac valve surgery
physician • Stable, chronic heart failure
• Lack of perceived need for rehabilitation/awareness
of CR • Cardiac transplantation
• Limited, or no health care coverage (cost) Medicare reimbursement guidelines limit CR to a
• Limited follow-up or facilitation of enrollment after maximum of two one-hour sessions per-day, up to
referral 36 sessions provided over a period of up to 36
• Work or home responsibilities weeks with the option for an additional 36 sessions.18
• Hours of operation conflicting with work demands Programs must include five basic components.18
• Scarcity of programs in rural areas and/or low-
income communities • Physician-prescribed exercise
• Distance to CR facility from patient’s home • Cardiac risk factor modification (education,
• Access to public transportation or parking issues counseling, and behavioral intervention)
• Male gender-dominated programs and little racial • Psychosocial assessment
staff diversity
• Outcomes assessment
• Language problems and cultural beliefs
• Individual treatment plans

American Heart Association Advocacy Department 1150 Connecticut Ave. NW Suite 300 Washington, DC 20036
Phone: (202) 785-7900 Fax: (202) 785-7950 www.heart.org/advocacy
Medicare provides reimbursement for all the component is to ensure that those who need CR
recommended conditions, although coverage for are properly referred and increase CR
heart failure (HF) is limited to patients with enrollment and adherence.10
compromised ejection fraction – the ability of the • Support CMS’ CR Incentive Payment Model
heart to pump out blood (about half of the HF patient which encourages improved participation among
population).15,16 hospitals, physicians, and post-acute care
providers.
• Support alternative models to traditional CR that
HEALTH BENEFITS address transportation barriers and
Studies have shown that cardiac rehabilitation can responsibilities at home or work.
improve the health and recovery of those who suffer • Encourage the creation and dissemination of
from CVD. The following benefits of CR have been information on the benefits of CR to physicians
reported: and health plans to enhance referral, follow-up,
• 45-47% reduction in all-cause mortality in and reduce costs.
patients who participated in CR after 1
Blaha B, et al. 2017. Heart Disease and Stroke Statistics 2017 Update: A Report From the
percutaneous coronary intervention compared to American Heart Association. Circulation. 2017; e205. 135:00–00. DOI:
10.1161/CIR.0000000000000485
non-participants.3 2
Balady GJ., et al.2011. Referral, enrollment, and delivery of cardiac rehabilitation/secondary
prevention programs at clinical centers and beyond: a presidential advisory from the American
• 31% lower hospital readmissions.30 Heart Association. Circulation; 124:2951-2960.
3
Goel, K., et al. 2011. Impact of cardiac rehabilitation on mortality and cardiovascular events
• Improved adherence with preventive after percutaneous coronary intervention in the community. Circulation 123(21): 2344-2352.
medication.17 4
Dunlay, SM et al. 2014. Participation in cardiac rehabilitation, readmissions, and death after
acute myocardial infarction.The American journal of medicine. 127.6: 538-546
• Increased exercise performance.18 5
O’Connor, CM, et al. 2015. Efficacy and safety of exercise training in patients with chronic
heart failure: HF-ACTION randomized controlled trial. JAMA.2009.301.14: 1439-1450.
• Improved health factors, such as blood pressure, 6
Centers for Disease Control and Prevention (CDC). 2008. Receipt of outpatient cardiac
rehabilitation among heart attack survivors—United States, 2003. MMWR Morb Mortal Wkly
exercise capacity,19 and lipid profiles.31 Rep.;57:89 –94.
• Enhanced ability to perform daily activities.21 8
Colbert, J. D., et al. 2015. Cardiac rehabilitation referral, attendance and mortality in women.
Eur J Prev Cardiol 22(8): 979-986.
• Improved psychosocial symptoms and health- 9
Menezes, AR., et al. 2014. Gender, race and cardiac rehabilitation in the United States: Is there
a difference in care?.The American journal of the medical sciences .348.2: 146-152.
related quality of life.22 10
Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the
Million Hearts Cardiac Rehabilitation Collaborative
11
Doll, JA., et al. 2015. Participation in Cardiac Rehabilitation Programs Among Older Patients
After Acute Myocardial Infarction. JAMA Intern Med 175(10): 1700-1702.
FINANCIAL BENEFITS 12
Sanderson BK, et al. 2003. Factors associated with the failure of patients to complete cardiac
rehabilitation for medical and nonmedical reasons. J Cardiopulm Rehabil;23:281–289.
A 2011 analysis reported that better health outcomes 13
Arena, R., et al. (2012). Increasing referral and participation rates to outpatient cardiac
rehabilitation: the valuable role of healthcare professionals in the inpatient and home health
from cardiac rehabilitation were associated with settings: a science advisory from the American Heart Association. Circulation 125(10): 1321-
reduced hospitalizations and use of medical 1329.
14
Sandesara, P, et al. 2015.Cardiac Rehabilitation and Risk Reduction: Time to “Rebrand and
resources.3 A study presented at the Canadian Reinvigorate”. Journal of the American College of Cardiology. 65.: 389-395.
15
Thomas, R. J., et al. 2010. AACVPR/ACCF/AHA 2010 Update: performance measures on
Cardiovascular Congress found that CR resulted in a cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services:
endorsed by the American College of Chest Physicians, the American College of Sports
31% reduction in hospital readmissions and a 26% Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac
drop in cardiovascular mortality – for a 7% return on Rehabilitation, the Clinical Exercise Physiology Association, the European Association for
Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National
investment. 24 Another study found that CR can save Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and
the Society of Thoracic Surgeons. J Am Coll Cardiol 56(14): 1159-1167.
patients $640 per quality-adjusted year of life 16
Hillis, LD, et al. 2011 ACCF/AHA guideline for coronary artery bypass
graft surgery: executive summary: a report of the American College of Cardiology
gained.25 Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol,
pp.123-210.
17
Shah, ND, et al. Long-term Medication Adherence After Myocardial Infarction: Experience of
ENROLLMENT IS LIMITED a Community. American Journal of Medicine. Volume 122, Issue 10, Pages 961.e7–961.e13
18
Centers for Medicare and Medicare Services. “Decision Memo for Cardiac Rehabilitation (CR)
The elderly, women, minority populations, and Programs - Chronic Heart Failure.” Accessed on January 27, 2016.
19
Kargarfard, M. et al. Effects of Exercise Rehabilitation on Blood Pressure of Patients after
patients with lower socioeconomic status are less Myocardial Infarction. Int J Prev Med. 2010 Spring; 1(2): 124–130. .
20
likely to be referred to CR, and unfortunately, are Franklin, BA.,et al. 2013. Exercise-based cardiac rehabilitation and improvements in
cardiorespiratory fitness: implications regarding patient benefit. Mayo Clinic Proceedings. Vol.
less likely to take that first critical step to enroll after 88. No. 5. Elsevir.
21
Kotseva, K et al. 2012. Use and effects of cardiac rehabilitation in patients with coronary heart
referral.2 This is of great concern because women disease: results from the EUROASPIRE III survey. European journal of preventive
and minorities are far more likely to die within five cardiology.2047487312449591.
22
Gomadam, P. S., et al. 2015. Degree and Direction of Change of Body Weight in Cardiac
years after a first heart attack as compared to their Rehabilitation and Impact on Exercise Capacity and Cardiac Risk Factors. Am J Cardiol.
l
patients to perform common household tasks. J Cardiopulm Rehabil Prev 31(2): 100-104.
white male patient counterparts.2 23
Johnston, M., et al. 2011. Impact of cardiac rehabilitation on the ability of elderly cardiac
patients to perform common household tasks. J Cardiopulm Rehabil Prev 31(2): 100-104.
24
Pinto, BM., et al. 2013. Psychosocial outcomes of an exercise maintenance intervention after
Phase II cardiac rehabilitation. Journal of cardiopulmonary rehabilitation and prevention 33(2):
THE ASSOCIATION ADVOCATES 91.
25
Williams MA, et al. 2006. Clinical evidence for a health benefit from cardiac rehabilitation: an
The American Heart Association is committed to update. Am Heart J;152(5):835-841.
26
Humen D, et al. 2014. A Cost Analysis of Event Reduction Provided by a Comprehensive
public policies that will reduce the CR treatment gap Cardiac Rehabilitation Program. Canadian Journal of Cardiology; 29.10: S156.
27
Yu, CM., et al. 2004. A short course of cardiac rehabilitation program is highly cost effective
with a specific focus on the most underserved in improving long-term quality of life in patients with recent myocardial infarction or
populations: women, minorities, and low-income percutaneous coronary intervention. Arch Phys Med Rehabil 85(12): 1915-1922.
28
Marzolini, S., et al. 2015. Delays in Referral and Enrolment Are Associated With Mitigated
individuals. These policies include: Benefits of Cardiac Rehabilitation After Coronary Artery Bypass Surgery. Circ Cardiovasc Qual
Outcomes 8(6): 608-620.
29
Johnson, D., et al. 2015. Cardiac rehabilitation in African Americans: Evidence for poorer
• Support legislation that would allow physician outcomes compared with
30
Humen D, et al. 2014. A Cost Analysis of Event Reduction Provided by a Comprehensive
assistants, nurse practitioners and clinical nurse Cardiac Rehabilitation Program. Canadian Journal of Cardiology; 29.10: S156
31
specialists to directly supervise patients in Lavie, CJ, et al. Effects of nonpharmacologic therapy with cardiac rehabilitation and exercise
training in patients with low levels of high-density lipoprotein cholesterol. Am J Cardiol. 1996
cardiac and pulmonary rehabilitation programs Dec 1;78(11):1286-9.
on a day-to-day basis under Medicare.
• Support for the Million Hearts® initiative which 5/2017

aims to prevent 1 million CVD events.10 One