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Cardiac rehabilitation: A comprehensive review

February 2001 · Current Controlled Trials in Cardiovascular Medicine 2(5):221-232

DOI:10.1186/cvm-2-5-221
Source · PubMed

Authors:

Andrew P Ignaszewski
Scott A Lear
University of British Columbia - Vancouver

Citations (33) References (98) Figures (6)

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Review
Cardiac rehabilitation: a comprehensive review
Scott A Lear*† and Andrew Ignaszewski*

*Healthy Heart Program, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
†School of Kinesiology, Simon Fraser University, Burnaby, Canada

Correspondence: Scott Lear, [email protected]

Published online: 10 September 2001

Curr Control Trials Cardiovasc Med 2001, 2:221-232
© 2001 BioMed Central Ltd (Print ISSN 1468-6708; Online 1468-6694)

Abstract
Cardiac rehabilitation (CR) is a commonly used treatment for men and women with cardiovascular
disease. To date, no single study has conclusively demonstrated a comprehensive benefit of CR.
Numerous individual studies, however, have demonstrated beneficial effects such as improved risk-
factor profile, slower disease progression, decreased morbidity, and decreased mortality. This paper will
review the evidence for the use of CR and discuss the implications and limitations of these studies. The
safety, relevance to special populations, challenges, and future directions of CR will also be reviewed.

Keywords cardiac rehabilitation, cardiovascular disease, exercise therapy, lifestyle interventions, secondary prevention

Despite a trend towards decreasing mortality, cardiovascular The World Health Organization has defined CR as: “… the
disease (CVD) remains the major cause of death in the western sum of activity required to ensure cardiac patients the best
world [1,2]. Improved management of acute myocardial infarc- possible physical, mental and social conditions so that they
tion (MI), earlier diagnostic procedures, and advanced interven- may, by their own effort, regain as normal a place in the com-
tion techniques have resulted in an increasing number of CVD munity, and lead an active life” [7].
survivors. Early rehabilitation and risk-factor management for
these individuals is essential to regain function and reduce the The goals of CR are restoration of optimal physiological,
risk of a second adverse cardiac event. psychological and vocational status, and reduction of risk of
cardiac morbidity and mortality.
The use of exercise therapy in post-MI survivors began
gaining momentum in the late 1970s when it became clear As CVD is a multifactorial disease, the beneficial outcomes
that immobilization and reduced activity, which was standard from CR are numerous. Possible outcomes include improve-
therapy at that time, resulted in poor long-term prognosis and ment in lifestyle, CVD risk-factors, cost of care, disease pro-
survival [3]. Over the past 30 years, exercise therapy has gression, morbidity, and mortality. To date, no single study
evolved into the multifactorial programs we know today as has conclusively demonstrated a comprehensive benefit of
CR. These programs, which include nutrition counselling, CR. However, such a study is unlikely to ever be conducted,
smoking cessation, weight management, psychosocial coun- as it would be unethical to assign individuals with CVD to a
selling and metabolic risk-factor management, can be found non-CR control group. Instead, the data from various studies,
in many hospitals and communities. The target population for each investigating one or two outcomes, must be compiled to
CR has expanded, and includes men and women of all ages identify the overall benefit of CR.
and those presenting with nonischemic CVD (Table 1).
Several national organizations have published extensive The present review will trace the evidence from studies on
recommendations and guidelines for CR [4–6]. exercise therapy in post-MI survivors to the comprehensive

LHT = The Lifestyle Heart Trial; SCRIP = The Stanford Coronary Risk Intervention Project.
CHF = congestive heart failure; CR = cardiac rehabilitation; CVD = cardiovascular disease; LVEF = left ventricular ejection fraction; MET = meta-
bolic equivalents; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty.

Current Controlled Trials in Cardiovascular Medicine October 2001 Vol 2 No 5 Lear and Ignaszewski

Table 1 Figure 1
 Table 1 Figure 1
Download full-text
TargetPDF Read full-textin cardiac rehabilitation
populations for participation Download citation Copy link
programs

Ischemic heart disease

Post-MI, coronary artery bypass graft, percutaneous
transluminal coronary angioplasty
Stable angina
Other heart conditions
Compensated heart failure
Controlled dysrhythmias
Automatic implanted cardioverter-defibrillate/pacemaker
Post-valve replacement
Cardiomyopathy
Myocardial aneurysm resection
Pre- and post-heart transplant
Congenital heart defects
Other chromic diseases
Stroke
Peripheral vascular disease
High risk of developing CVD

CVD, Cardiovascular disease; MI, myocardial infarction.

Diagrammatic outline of the modern cardiac rehabilitation program.
programs we know today. Excellent reviews of dietary and ECG, Electrocardiography.
smoking interventions have been written, and the reader is
directed to these [8,9]. At the end of this review, evidence in
other populations will be discussed, as well as the challenges of exercise therapy and CR. These studies were mainly
facing CR programs today and areas requiring further study. restricted to middle-aged men who had experienced a prior
MI. Interventions lasted from 6 weeks to 3 years and con-
The modern CR program sisted of mainly exercise therapy, while a few included other
Figure 1 outlines the multidisciplinary nature of the modern lifestyle strategies (dietary, smoking cessation and psycho-
CR program. CR comprises three distinct phases: inpatient, social counselling). The results of these studies have varied.
outpatient, and in the community/home. Participation in these Some have reported nonsignificant changes in mortality
programs is determined by appropriate risk stratification to [13–17], while others have demonstrated significant reduc-
maximize health care resources and benefits. The inpatient tions in mortality [18–21]. Sample sizes in these studies
program consists of low-level activities that gradually varied from 167 to 651 participants, much smaller than other
progress throughout the hospital stay to prevent recondition- mortality trials, which may account for some of the nonsignifi-
ing. Education and counselling also begin at this time. The cant findings. Differences in the intervention method, the
outpatient program is the most common CR model in use and duration, and the follow-up period also confound compar-
may last from 2 to 4 months. These programs combine physi- isons between studies.
cian-supervised exercise sessions with cardiovascular risk
reduction, commonly using a case management model. A full Much of the evidence to support reduced mortality from CR is
risk-factor and lifestyle assessment is conducted both at the provided by two meta-analyses that have been conducted to
beginning and end of the program. On completion of the out- combine the results of the earlier exercise therapy and CR
patient program, patients can then continue in a local commu- studies [13–18]. These investigations were restricted to studies
nity center CR program. Patients who are at low risk may of men and women post-MI. Oldridge et al included data from
appropriately continue their program in a home-based setting. 20 studies totalling 4347 patients (2202, intervention; 2145,
control) [22], while O’Connor et al included 22 studies totalling
Evidence for the benefits of CR 4554 patients (2310, intervention; 2244, control) [23]. All-
Mortality trials cause and cardiovascular mortality in the exercise therapy group
The benefits of physical activity and exercise have been rec- were significantly reduced compared with the control group
ognized for centuries. Numerous epidemiological studies (Table 2). No significant difference in nonfatal MI was reported
have associated physical activity participation with reduced in either analysis; in fact, slightly more occurrences were noted
CVD risk and mortality [10–12]. Based on this association, in the intervention group. The authors speculated that those par-
early investigations set out to determine the survival benefits ticipants in the exercise therapy group were more likely to

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Table 2 Since these two meta-analyses were completed, four other

studies have been published reporting outcomes from 2 to
Summary of major findings from two meta-analyses of
19 years of follow-up (summarized in Table 3) [20,21,25,26].
randomized exercise therapy and cardiac rehabilitation trials
Three of these studies reported results of earlier follow-up
Oldridge O’Connor periods that were incorporated into the previous meta-analy-
et al [22] et al [23] ses [14,18,27], while the fourth had not been previously
reported [20].
All-cause mortality 0.76 (0.63–0.92)* 0.80 (0.66–0.96)‡
 All-cause mortality 0.76 (0.63–0.92)* 0.80 (0.66–0.96)‡
Cardiovascular
Download full-text PDF mortality Read0.75 (0.62–0.93)†
full-text 0.78 (0.63–0.96)‡
Download citationFirst, the PRECOR
Copygroup
link randomized men to either a 6-week
Sudden death Not reported 0.92 (0.69–1.23) CR, a counselling program, or control (usual care, no inter-
Nonfatal myocardial infarction 1.15 (0.93–1.42) 1.09 (0.88–1.34) vention) [20]. No difference in all-cause mortality was
observed between the three groups after 2 years follow-up
Data presented as odds ratio (95% confidence intervals). Values but, when the counselling program and control groups were
below 1.00 favor cardiac rehabilitation intervention. * P = 0.004,
† P = 0.006; ‡ significantly lower than comparison group, no P values
combined and compared with the CR group, a significant dif-
reported. ference did exist in favor of CR.

In the second study, Hedback and Perk found no difference in

survive a repeat MI than those in the control group. The similar all-cause or cardiovascular mortality after 5 years of follow-up
finding between these two meta-analyses is not surprising since between the non-randomized CR and reference groups [27].
16 of the studies analyzed were common to both; the results At 10 years, significant reductions were observed in these out-
should therefore not be considered independent of one another. comes as well as in sudden death and nonfatal MI [21].
Because women accounted for less than 3% of the patients,
gender-related outcomes were not analyzed. The relative reduc- Hamalainen et al randomized 375 participants to either a multi-
tion of all-cause and cardiovascular mortality (approximately factorial CR intervention or control (usual care, no intervention
20–25%) is similar to the reduction in mortality observed in for 10 years [19]. The authors reported significant reductions in
lipid-lowering trials [24]. sudden death and cardiovascular mortality, with no difference

Table 3

Summary of recent randomized exercise therapy and cardiac rehabilitation (CR) trials investigating the effects on long-term
mortality

Follow-up
Cohort Intervention Comparison group (years) Relative risk reduction*

Hedback 305 men and women, Multifactorial, 2 x per week Non-randomized reference 10 27% all-cause mortality
et al [21] post-MI, < 65 years exercise sessions, 3 months with no CR (P < 0.01)

24% cardiovascular mortality

(P < 0.001)

33% nonfatal MI (

PRECOR 182 men post-MI, Multifactorial, 3 x per week Control (usual care, 2 7% absolute reduction in
Group [20] < 65 years exercise sessions; or no intervention) all-cause mortality
counselling only, 6 weeks

Hamalainen 375 men and women, Multifactorial, exercise Randomized control group 15 4% all-cause mortality
et al [25] post-MI, < 65 years sessions, 3 years (not significant)

18% cardiovascular mortality

P = 0.04)

43% sudden death

(P = 0.006)

NEHDP [26] 651 men, post-MI, Exercise only, 2 years Control (usual care, 19 No reported benefits
< 65 years no intervention)

MI, Myocardial infarction; NEHDP, The National Exercise and Heart Disease Project. * Relative risk reduction in favor of intervention. †
occurred in CR intervention. results are based on comparison of CR intervention with counselling intervention and control (usual care, no
intervention) combined.

Current Controlled Trials in Cardiovascular Medicine October 2001 Vol 2 No 5 Lear and Ignaszewski

Table 4

Summary of comprehensive cardiac rehabilitation trials that used coronary atherosclerotic disease progression as the primary
outcome

Results

Study Follow-up duration Control Intervention

Schuler et al [29]† 1 year (n = 36) 33% progression, 28% progression,

61% no change, 33% no change,
6% regression 39% regression
Niebauer et al [30]† 5 years (n = 25) 75% progression, 38% progression,
13% no change, 38% no change,
13% regression 25% regression

Schuler et al [31]† 1 year (n = 113) 48% progression, 23% progression,

 Schuler et al [31]† 1 year (n = 113) 48% progression, 23% progression,
35% no change, 45% no change,
Download full-text PDF Read full-text 17%
Download regression
citation 33% regression
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Niebauer et al [33]† 6 years 74% progression, 59% progression,
26% no change, 22% no change,
0% regression 19% regression
The Lifestyle Heart Trial [34,35]‡ 1 year (n = 41) 2.28 (–3.00 to 4.86) (n = 15) –1.75 (–4.08 to 0.58) (n = 18)
(53% progression, 18% progression,
5% no change, (0% no change,
42% regression) 82% regression)
5 years (n = 35) 11.77 (3.40–20.14) (n = 15) –3.07 (–5.91 to –0.24) (n = 20)
SCRIP [36]§ 4 years (n = 246) –0.045 ± 0.073 –0.024 ± 0.067
(50% progression, (50% progression,
20% no change, 18% no change,
10% regression, 20% regression,
21% mixed changes) 12% mixed changes)

* Between-group comparisons; ns, not significant. † Progression, ≥ 10% decrease; no change, ≤ 10% change; regression, ≥ 10% increase in
percent minimal diameter. Patient assigned an average score when multiple stenoses analyzed. ‡ Average percent diameter stenosis change from
baseline; 186 lesions analyzed (77 control, 109 intervention) by quantitative coronary angiography. Results reported from participants completing a
5-year follow-up. § Absolute change in minimal diameter stenosis (mm) per year as assessed by quantitative coronary angiography.

in all-cause mortality or nonfatal MI. After 15 years of follow-up, Comprehensive disease regression trials
these reductions in the intervention group persisted for sudden
death and cardiovascular mortality [25]. More recent CR trials have focused on other clinical out-
comes such as atherosclerotic progression (summarized in
Finally, the National Exercise and Heart Disease Project had Table 4). This is due to the high correlation between
the longest follow-up period to date (19 years), yet failed to disease progression and cardiac events [28]. The use of
demonstrate any reduction comparing exercise therapy with disease progression as an outcome allows for a smaller
control (usual care, no intervention), in all-cause or cardiovas- sample size and follow-up period than required by a mortal-
cular mortality, with no report on nonfatal MI [26]. This result ity trial.
was consistent during the five follow-up periods from 3 to
19 years. It is possible that the duration of the exercise-only Schuler at al studied a group of 36 men with stable angina
intervention, 8 weeks, was not long enough to produce and coronary artery stenosis, and assigned them to either
lasting benefits and therefore not as effective as the interven- CR (dietary counselling, twice-weekly exercise sessions, and
tions of the other studies. a home exercise program) intervention or to control (usual
care, no intervention) for 12 months based on proximity to
Despite the lack of a consistent reduction in mortality and the the study site [29]. Participants were asked not to use lipid-
myriad of differences in these studies, there is a trend lowering medications for the duration of the study. When
towards reduced all-cause and cardiovascular mortality. participants were grouped according to progression — no
Owing to the study populations being overwhelmingly limited change or regression of stenosis — the intervention group
to men younger than 65 years post-MI, investigation of underwent significantly less progression than the control
gender-related results was not possible. The possible benefit group. The authors also noted significantly improved myocar-
of CR in older adults and in those who have CVD but have dial perfusion during maximal stress testing and decreased
not experienced a previous MI is also unclear. total cholesterol in the intervention group.

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This cohort was again followed-up 4 years later, at which time consisted of an initial 1-week retreat, a low-fat vegetarian diet,
the significant differences in disease progression between twice-weekly group support meetings, stress management,
groups no longer existed [30]. An increase in weight and total and monitored weekly exercise.
cholesterol between years 1 and 5, possibly the result of
decreased dietary adherence, may have attenuated the differ- Adherence to the intervention was reported to be high. After
ences in disease progression between groups. 1 year, significant reductions in weight and lipid values were
noted in the intervention group. All detectable lesions were
Limitations of the previous study (small sample size, group included in the final analysis. With respect to percent diame-
assignment of convenience) led the authors to conduct a ter stenosis, disease regression occurred in the intervention
second study in 113 men with coronary artery stenosis [31]. group while the control group experienced disease progres-
The intervention was identical to the previous study but par- sion. This difference was significant, even when lesions less
ticipants were randomly assigned to either intervention or than 50% stenosed were excluded. The authors also noted a
control (usual care, no intervention). Participants in the inter- dose-dependent relationship between program adherence
vention group underwent significantly greater reductions in and change in percent diameter stenosis.
dietary fat and total cholesterol, and a significantly greater
increase in maximal oxygen consumption, compared with the After 5 years, adherence to the program decreased modestly
control group. This resulted in a more favorable lipid profile, for the intervention participants [35]. There was also a
and reduced weight, compared with control. Significantly modest deterioration of lipid values between years 1 and 5 in
fewer participants in the intervention group experienced the intervention group and participants gained back one-half
disease progression compared with the control group at of the weight lost in the first year. Despite this, participants in
 1 year (23% versus 48%, respectively; P < 0.05). Further the intervention group continued to undergo further disease
investigation
Download full-text PDF of this cohort
Readdidfull-text
not determine any difference citationregression (7.9%
Download in relative
Copy link regression) while the control group
coronary collateral formation between groups [32]. underwent disease progression (27.7% relative progression).
The authors again noted a dose-dependent relationship
Five years later, there was still a significant difference between program adherence and change in percent diameter
between the intervention and control groups with respect to stenosis. Participants in the control group experienced nearly
disease progression (59% versus 74%, respectively; double the amount of cumulative combined cardiovascular
P < 0.05) [33]. This difference was significant for ‘per lesion’ events than in the intervention group (2.25 versus 0.89
and ‘per patient’ comparisons. No significant differences events per patient).
existed in clinical events, and the significant differences in
lipid profile and weight that occurred at 12 months were no This study identified the importance of lifestyle modification
longer evident at 6 years. The authors reported a significant for the treatment of CVD and demonstrated its feasibility in a
correlation between exercise capacity and relative stenosis self-selected population. However, incorporation of this
diameter (r = 0.319, P < 0.01). In contrast to the previous program into daily practice may prove difficult because it
study, the exercise capacity of the intervention participants requires a great deal of resources per patient and highly moti-
continued to improve between years 1 and 6. vated individuals; over 50% of those participants randomized
to the intervention program refused participation and were
Two controlled studies that demonstrated the benefits of not followed on an intent to treat basis.
comprehensive CR are (Table 4) the Lifestyle Heart Trial
(LHT) [34,35] and the Stanford Coronary Risk Intervention SCRIP
Project (SCRIP) [36]. Both of these studies included men The SCRIP continues to be one of the largest, randomized,
and women with documented coronary artery disease, and long-term multifactorial CR studies to date [36]. The interven-
used disease progression (assessed by quantitative coronary tion used in this study is markedly different from that of previ-
angiography) as the outcome. ous studies; participants randomized to the intervention
underwent counselling sessions by a nurse and a dietician
The LHT every 2–3 months only, and no on-site exercise sessions
The unique approach of the LHT was to demonstrate the were conducted. During the counselling sessions, partici-
effectiveness of aggressive lifestyle management, with no pants were prescribed a home exercise program, prescribed
lipid-lowering medications, to induce disease regression. Eli- lipid-lowering medications, and underwent a smoking cessa-
gible men and women were identified from their hospital tion program as required. Unlike previous studies, the SCRIP
charts and randomly assigned either to the intervention or did not include an on-site exercise program; however, exer-
control (usual care, no intervention) without prior consent. cise capacity increased significantly in the intervention group
These individuals were then contacted by the study co- compared with in the control (usual care, no intervention)
ordinator, informed of their group assignment and asked to group (1.7 ± 2.4 versus 0.7 ± 2.1 metabolic equivalents
provide informed consent. Of the 93 individuals contacted, [METs] above baseline values, respectively; P =
only 48 (five women) agreed to participate. The intervention inclusion of lipid-lowering medications is also a departure

Current Controlled Trials in Cardiovascular Medicine October 2001 Vol 2 No 5 Lear and Ignaszewski

from the other studies, but this reflects changes in clinical resulting in reduced disease progression and clinical events.
practice and the use of all clinical tools at the disposal of the Table 5 summarizes the strength of evidence for the use of
CR program. CR for CVD risk-factor modification and quality of life
improvements.
After 4 years, lipids, systolic blood pressure, body composi-
tion, and fasting glucose all significantly improved in the inter- The case management model
vention group compared with the control group. There was With the growing number of CVD survivors, traditional exer-
no change in the proportion of smokers after 4 years. Partici- cise-based CR programs will not have the resources to meet
pants in the intervention group underwent significantly less the demand for their services. Exercise-based programs may
absolute change in the minimal, and mean, diameter of dis- not be necessary for patients at low and moderate risk. The
eased vessels compared with the control group. This was SCRIP demonstrated that CR could be effective without a
significant for both ‘per patient’ and ‘per vessel’ analyses, and supervised exercise component. The SCRIP and other
remained significant after adjusting for age and baseline studies have led to the development of the nurse case man-
segment diameter. agement system.

Although not an a priori endpoint, the intervention group The Multi-Fit model is a physician-supervised, nurse-managed
experienced significantly fewer cardiac events compared to intervention. DeBusk et al studied this model in 585 patients
participants in the control group (n = 44 versus n = 25, (20% women) who were recruited while recovering in hospi-
respectively; P = 0.05). This finding is similar to that of the tal from a recent MI [39]. Participants were randomized to
LHT. The majority of the events experienced by the interven- either an intervention or a control group. The intervention was
tion group occurred during the study’s first year, which were based on social learning theory, which consisted of goal
mostly percutaneous transluminal coronary angioplasty setting for lifestyle behaviours based on the participants'
(PTCA) procedures. The authors speculated that the motivation to change, identification of possible barriers to
increased contact with the intervention staff might have change and relapse prevention strategies. The intervention
uncovered the need for these patients to undergo the proce- began with lifestyle counselling during the hospital stay. Fol-
dure at an earlier stage. lowing discharge, contact with intervention participants was

restricted to telephone and mail, with a maximum of four visits

 restricted to telephone and mail, with a maximum of four visits
This study is unique in that it used a physician-supervised, with the nurse during the 12-month intervention. The interven-
Download full-text PDF
nurse-managed Read afull-text
intervention, method that is easilyDownload citationtion focused onCopy
replicable link cessation, diet, exercise, and lipid-
smoking
in other clinics and does not require on-site exercise ses- lowering therapy (limited to bile acid resins and niacin).
sions. However, the SCRIP intervention used risk-factor
targets to guide treatment strategies, which were considered Exercise capacity was greater at 6 months in the intervention
to be aggressive at the time and beyond current guidelines. group than in the control (usual care, no intervention) group
This may have resulted in a bias towards success for the (9.3 and 8.4 METs, respectively). No report on exercise
intervention group. capacity was provided at 12 months. At the end of
12 months, smoking cessation rates (70% versus 53%,
These studies have demonstrated that CR with or without P = 0.03), total cholesterol (–0.64 mmol/l versus
lipid-lowering medication use is effective at reducing disease –0.09 mmol/l, P < 0.001) and low-density lipoprotein choles-
progression. The reduction of progression observed in the terol (–0.65 mmol/l versus –0.14 mmol/l, P < 0.001) reduc-
SCRIP is equivalent or superior to a number of trials investi- tions were significantly greater in the intervention group than
gating the effects of lipid-lowering only [28,37,38], and in the control group.
reflects the benefit of multifactorial CR interventions utilizing
all clinical tools. The mean regression demonstrated in the This novel intervention strategy demonstrates effective risk-
LHT by lifestyle changes alone has not been realized in most factor management without requiring numerous patient visits.
pharmacological interventions. In spite of the small sample The use of telephone and mail contact greatly reduced the
size and self-selected population in the LHT, these results are nurse intervention time (average 9 hours per patient), and
impressive. The reduction in events reported in the LHT and allowed for a greater number of participants (nearly double) in
the SCRIP attests to the benefit of disease regression by CR. the intervention than any other study.

Risk-factor modification As the study was only conducted for 1 year, it does not
CR studies investigating clinically relevant endpoints have provide additional information on clinical outcomes. However,
been limited to those previously discussed. As with other the 24% relative reduction of low-density lipoprotein choles-
CVD interventions, CR is aimed at modifying various CVD terol is similar to that observed in long-term lipid-lowering
risk-factors based on the evidence that risk-factor reduction trials that demonstrated significant reductions in mortality
will reduce morbidity and mortality. The SCRIP demonstrated [40]. The authors of this intervention have already reported on
that CR is effective at comprehensive risk-factor modification, the benefits of its use in clinical practice [41].

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Table 5 In one study, 73 men were randomized to an intervention of

daily-prescribed home exercise or to control (usual care, no
Strength of evidence ratings for modification of various
outcomes and cardiovascular disease risk-factors as a result of
intervention) [50]. After 6 months, the intervention group had
cardiac rehabilitation participation significant improvement in exercise capacity, New York Heart
Association functional class, maximal ventilation, mean total
Strength of Highlighted peripheral resistance, and stroke volume. Left ventricular
Outcome evidence* references
ejection fraction (LVEF) improved from 30 ± 8% at baseline
Smoking cessation, relapse prevention B [39,79] to 35 ± 9% at 6 months.
Improved lipid profile A [31,36]
The second study randomized 99 men and women with CHF
Decreased blood pressure B [19] to a supervised intervention of twice-weekly exercise
Improved blood sugar control B [80] sessions or to control (usual care, no intervention) for
14 months [51]. Exercise capacity increased from baseline to
Increased exercise capacity A [81,82]
14 months to a greater extent in the intervention group
Increased physical activity B [83]
(15.7 ± 2 ml/kg/min to 19.9 ± 1 ml/kg/min) compared with
Decreased body weight B [36] the control group (15.2 ± 2 ml/kg/min to 16 ±
Improved psychosocial well-being A [84,85] P < 0.001). Much of the increase in exercise capacity in the
intervention group occurred during the initial 2
Improved social functioning B [86]
Quality of life also increased significantly in the intervention
* A, Evidence provided by well-designed, controlled trials with group as measured by the Minnesota Living with Heart
statistically significant results consistent across trials; B, evidence Failure Questionnaire. However, no changes were reported in
provided by observational studies or controlled trials with less the control group. In contrast to the previous study, LVEF did
consistent results; C, opinion of expert consensus due to a lack of
controlled trials and/or consistent results. not change significantly in the intervention group. Despite
this, a significant difference in combined cardiac events (17
versus 37, P = 0.006), CHF readmission (5 versus 14,
Safety of CR P = 0.02), and cardiac mortality (9 versus 20, P
The use of exercise therapy for patients with CVD has proven observed between groups at 14 months. These studies
effective, but also carries a burden of risk. Physical exertion provide definite support for the inclusion of CHF patients in
has been reported to be a trigger of MI and sudden cardiac CR programs.
death in individuals both without known CVD [42,43] and
with CVD [44–46]. Previous documentation of CVD did not Efficacy in other populations
appear to increase the risk of MI during exercise [44,45]. The majority of CR studies to date have been restricted to
Mittleman et al reported an increased risk of 5.9 times for MI middle-aged men who suffered a recent MI, yet patients

during physical exertion in 1228 men and women. When enrolled in CR programs comprise a much broader popula-
 during physical exertion in 1228 men and women. When enrolled in CR programs comprise a much broader popula-
stratified
Download full-text PDF by activity levels,
Readthis risk was reducedDownload
full-text to 2.4 for
citationtion. Only recently
Copyhave
link these populations been included in
individuals who were ‘active’ more than five times per week, CR studies and, as a result, outcome data is limited.
and increased to a remarkable 107 for sedentary individuals
[44]. Other studies have similarly reported a reduced risk of Several of the more recent studies have included women, but
MI during exercise in the habitually active compared with these numbers have been too small to separately determine
sedentary individuals [43,45]. The issue of complications morbidity and mortality rates. Women have traditionally had
during CR has been reported in several studies [36,47–49]. lower rates of CVD than men but it is anticipated that this dis-
These studies report complication rates from 1.23 to 2.88 crepancy will decrease in the future [2]. The limited number
and fatalities from 0.13 to 0.86 per 100,000 patient-hours. of CR studies investigating women has found significant risk-
There is a trend towards less frequent events reported in the factor modification, similar to that observed in men [52,53].
more recent studies, suggesting that current CR programs
may be safer than the earlier ones. Electrocardiographic Individuals older than 65 years are also often excluded from
telemetry is widely used in CR programs as a safety precau- studies. When compared with younger adults, elderly individ-
tion; however, its use has not been demonstrated to be uals demonstrate similar benefits to CVD risk-factors, and
superior to traditional CR supervision [47,48]. exercise capacity [53–55].

CR for congestive heart failure A growing population of CR participants has undergone a

Coincident with the increased number of survivors of CVD is prior revascularization procedure without experiencing a pre-
the increase in individuals suffering from congestive heart vious MI. Evidence suggests that patients who have under-
failure (CHF). It is predicted that CHF will become the cardio- gone PTCA have different perceptions of their own health
vascular epidemic of the future [1]. Two randomized studies and their need for risk-factor reduction [56,57]. However,
have demonstrated the benefits of exercise therapy [50,51]. these patients can benefit from CR participation [58].
 Download full-text PDF Read full-text Download citation Copy link

Citations (33) References (98)

... Data published by the Amercican College of Sports Medicine in 2010 (10) found one major event per 81670 training
hours. Lear et al. (11) found in their review, between 1,23 and 2,88 major events and between 0,13 and 0,88 lethal
incidents per 100 000 training hours during cardiac rehabilitation. They also showed that the more recent the registries,
the lesser the number of events. ...
... Reduced exercise capacity is one of the most powerful predictors of mortality [10]. Indeed, studies demonstrated that
a low cardiorespiratory fitness has a much worse impact on morbidity and mortality than smoking or obesity [2, 11] .
Thus, despite the fact that obesity is a risk factor for NCDs per se, moderately fit obese persons have about half the
mortality risk than normal-weighted unfit persons [11]. ...
... Indeed, studies demonstrated that a low cardiorespiratory fitness has a much worse impact on morbidity and
mortality than smoking or obesity [2,11]. Thus, despite the fact that obesity is a risk factor for NCDs per se, moderately
fit obese persons have about half the mortality risk than normal-weighted unfit persons [11] . In patients with
cardiovascular diseases (e.g. ...

Recommendations for the neuropsychological assessment supporting the diagnosis of dementia in the Luxembourgish
context (NP-DiaDem)
Article Full-text available
Jan 2016
Anne-Marie Schuller · V. Matuszewski · P. Santos · Jean-Paul Steinmetz

View Show abstract

... CR is the process of restoring desirable levels of physical, social and psychological functioning after the onset of
cardiovascular illness with aims to optimize patients functioning, enhance quality of life, and minimize the risk of
recurrent cardiac events [3, 4] . Comprehensive CR programs are multi-component interventions, which include elements
of exercise training, relaxation and stress management, secondary prevention, and pay attention to patient's
psychological adjustment. ...
... Achieving a good exercise capacity is a key goal in cardiac rehabilitation, as this is a key determinant of current
quality of life and future morbidity and mortality [3, 4] . Beneficial effects of yoga on functional capacity have been
reported in healthy adults, albeit of lesser magnitude to those observed with aerobic exercise [14] in those with chronic
heart failure, an improvement in maximal oxygen consumption and concurrent changes in levels of inflammatory
markers of CRP and IL-6 were also identified [15]. ...
... Acute phase cardiac rehabilitation is given to patient in the early period after ACS (during index hospitalization), while
recovery phase or maintenance phases cardiac rehabilitation is provided for patients who are recovering from ACS.
Exercise therapy is expected to have various effects such as improving post-AMI heart failure and survival. It has been
reported that AMI patient who participate in cardiac rehabilitation have a similar mean survival time to person without
 AMI [4] and that cardiac rehabilitation is at least as effective as PCI in reducing major adverse cardiac events in patient
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with stablePDF
CAD [21]. ... Read full-text Download citation Copy link

Joga i rehabilitacja kardiologiczna (Yoga-CaRe) u osób po przebyciu ostrego epizodu wieńcowego

Article Full-text available
Apr 2017
Santosh Kumar Sinha · Vinay Krishna · Vikas Mishra · Chandra Mohan Varma

View Show abstract

... Cardiac rehabilitation programs (CRP) are known to improve outcomes of patients with cardiovascular disease. 1
Utilizing exercise, pharmacological therapy, risk factor modification, as well as behaviour and dietary modification, CRP
has been shown to decrease mortality and the likelihood of readmission. [1][2][3][4][5] Most research involving CRP has
been done in Caucasian populations with little data available on other ethnicities such as the South Asian population. ...
... Cardiac rehabilitation programs (CRP) are known to improve outcomes of patients with cardiovascular disease. 1
Utilizing exercise, pharmacological therapy, risk factor modification, as well as behaviour and dietary modification, CRP
has been shown to decrease mortality and the likelihood of readmission. [1] [2][3][4][5] Most research involving CRP has
been done in Caucasian populations with little data available on other ethnicities such as the South Asian population.
Moreover, CRP was originally designed for the typical Caucasian exercise habit as well as the typical Caucasian diet. ...

Differences in Clinical Measures and Outcomes in South Asians versus Caucasians attending Cardiac Rehabilitation
Article Full-text available
Apr 2021
Gami L Nanayakkara · Tracey Rai · Lena Kirincic · Manohara Senaratne

View Show abstract

... Therefore, it is necessary for health professionals, family members and laypersons to know and have training in these
actions that must follow an out-of-hospital "Survival Chain" sequence presented in the Figure 1. Considering the
increased risk for re-occurrence of CA, secondary prevention and cardiac rehabilitation programs are necessary for
those who survived CA [88] . The main components of a subsequent cardiac rehabilitation program are presented in
Figure 2. The BLS is a set of measures that aim to maintain blood flow to vital organs. ...
... Components of a cardiac rehabilitation program. Such a program includes interventions on behavior, exercise,
nutrition, smoking cessation, education, and medicines [88] . With the arrival of AED, immediately stop what you are
doing and according to standard procedures, position it on the victim. ...

Prevention of Sudden Death Related to Sport: The Science of Basic Life Support-from Theory to Practice
Article Full-text available
Apr 2019
Rodrigo Vancini · Pantelis Theo Nikolaidis · Claudio Andre Barbosa de Lira · Beat Knechtle

View Show abstract

... These programs were thereafter expanded over the following decades to allow more patients to benefit from CR. 3
The initial traditional format was presented to patients in the form of a short-term program in a hospital or medical
center. 4 Since then, however, delivery formats have gradually evolved, so that home-based programs, remote and rural
services for specific groups, hybrid CR programs, Internetbased delivery, telephone health services, exercise-based
telehealth interventions, and telephone-focused interventions have been introduced. 3, 5-9 In each delivery format,
tailored to the needs and preferences of the recipients, the patients participate in a specific number of exercise
sessions and training classes for the management of risk factors. ...

Updated Outpatient Cardiac Rehabilitation Delivery Formats Tailored to the Iranian Population: A reminder for the update
delivery of CRs
Article Full-text available
Jun 2020
Saeid Komasi · Angelo Compare · Delaram Bagheri Rad

View Show abstract

... In the late 1970s, the concept of prescribing exercise therapy for post-MI patients began to gain momentum as it
became increasingly clear that immobilisation and reduced activity results in poor long-term prognosis and survival
(Lear & Ignaszewski, 2001) . The establishment of the benefits of exercise therapy on patients' prognosis led to a surge
of interest in the effects of exercise therapy on morbidity and mortality rates which then revealed undeniable
improvements. ...

Overview of Cardiac Rehabilitation Evidence, Benefits and Utilisation

Article Full-text available
Dec 2017 · Glob J Health Sci
Abdulrahman Al Quait · Patrick Doherty

View Show abstract

Download
... full-text PDF dos programasRead
os objectivos full-text físico nos indivíduos
de exercício Download citation de síndrome coronário
com sequelas Copy linkagudo são os
de melhorar a eficácia da resposta ao exercício e potenciar os diferentes mecanismos de adaptação a nível
cardiovascular, muscular e respiratório (12, 17,, 18, 23) . assume-se que o exercício físico praticado regularmente
desenvolve a capacidade muscular de extracção de oxigénio, a força muscular, a resistência e a massa muscular
esquelética (9, 12, 19) . para além disso, estudos recentes sugerem também que o exercício pode aumentar o número e
diferenciação das células precursoras endoteliais, permitindo assim uma mais eficaz regeneração do endotélio e uma
melhor perfusão do miocárdio via neo-angiogenese e arteriogenese (11,18,21,24) . ...

Efeitos de um programa prolongado de exercício na tolerância ao esforço de indivíduos com antecedentes de síndrome
coronário agudo
Article Full-text available
Jan 2010
Andreia Noites · Madalena Teixeira · Vasco Gama Ribeiro · José Alberto Duarte

View

Why do we keep asking, do we still need cardiac rehabilitation?

Article
Feb 2020
Scott A Lear · Susie Cartledge

View

ЕКОНОМІЧНА ЕФЕКТИВНІСТЬ ТА ОРГАНІЗАЦІЙНІ АСПЕКТИ РЕАЛІЗАЦІЇ ПРОГРАМ КАРДІОРЕАБІЛІТАЦІЇ ЗГІДНО З

МІЖНАРОДНИМ ДОСВІДОМ, ПЕРСПЕКТИВИ РОЗВИТКУ В УКРАЇНІ
Article Full-text available
Jan 2019
P. F. Kolisnyk · Olena Dolynna · Serhii Petrovych Kolisnyk · I.V. Baranova

View Show abstract

Cardiac rehabilitation
Chapter
Jan 2004
Piotr Dylewicz · Sławomira Borowicz-Bieńkowska · Ewa Deskur-Śmielecka · Izabela Przywarska

View Show abstract

Show more
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