# Cardiac rehabilitation

Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) 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". CR is a comprehensive model of care delivering established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life and reducing the risk of future heart problems.
CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.
Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology and the European Society of Cardiology, among other associations. Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator).

## Cardiac rehabilitation setting

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. Hybrid programs are also increasingly being offered.

## Cardiac rehabilitation phases
### Inpatient program (phase I)

Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.
Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises.

### Outpatient program (phase II)

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery. This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues. Shorter time to start is associated with better outcomes.
Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program.
Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.
The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered, and it is well-established that the more the better.
After CR is finished, there are long-term maintenance programs (phase III) available to interested patients, as benefits are optimized with long-term adherence. Unfortunately however, patients generally have to pay out-of-pocket for these services.

## Under-use of cardiac rehabilitation

CR is significantly under-used globally. Rates vary widely.
Under-use is caused by multi-level factors. At the health system level, this includes lack of available programs. At the provider level, low referral rates are a major barrier. At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible, but most can be mitigated. Women, ethnocultural minorities, older patients, those of lower socio-economic status, with comorbidities, and living in rural areas are less likely to access CR, despite the fact that these patients often need it most.
Strategies are now established on how we can mitigate these barriers to CR use. It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html). It is also key for healthcare providers to promote CR to patients at the bedside. The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.
Training more healthcare professionals to deliver CR can also help. CR programs can also join a registry to assess and improve their utilization—among other quality indicators. Offering programs tailored to under-served groups such as women may also facilitate program participation.

## Benefits

Participation in CR may be associated with many benefits. For acute coronary syndrome patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%. The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence.
CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity, and is cost-effective. In low and middle-income countries, there is some evidence that CR is effective in improving functional capacity, risk factors and quality of life as well.
There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same. Home-based CR is generally safe. Home-based programs with technology are similarly shown to be effective.
There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues, atrial fibrillation, heart transplant recipients, and heart failure.

## Cardiac rehabilitation societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR. The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, ICCPR seeks to promote CR in low-resource settings, among other aims outlined in their Charter. CR societies offer registries, clinician certification, and program certification, among other resources.