Cardiac Rehabilitation Standard Program for Acute Myocardial Infarction(2013) from the Japanese Association of Cardiac Rehabilitation
 In the Recovery Phase of Myocardial Infarction Japanese Association of Cardiac Rehabilitation
Standard Cardiac Rehabilitation Program Writing Committee
Chairman
Hideo Izawa, Department of Cardiology, Fujita Health University Banbuntane Hotokukai
HospitalVice Chairman
Sumio Yamada, School of Health Sciences, Nagoya University Graduate School of Medicine
Members
Kazuhiko Nishigaki, Department of Cardiology & Respirology, Gifu University Graduate Schoolof Medicine
Yasushi Miyazawa, Department of Clinical Nutrition, Chikamori Hospital
Yuji Kono, Department of Rehabilitation, Fujita Health University Banbuntane Hotokukai
Hospital
Yoshihiro Itou, Department of Cardiology, Fujita Health University School of Medicine
Naohiko Osada, Department of Cardiology, St. Mariannna University School of Medicine
Akihiro Hirashiki, Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya
University School of Medicine
Toshiko Yoshida, Miyagi University School of Nursing
Toshimi Ikegame, Department of Nursing Administration and QI Center, St. Luke’s International
Hospital
Kiyonori Kobayashi, Department of Rehabilitation, Nagoya University Hospital
Tetsuya Takahashi, School of Health Sciences, Tokyo University of Technology
Yuji Morio, Department of Rehabilitation Medicine, St. Marianna University School of Medicine
Hospital
Secretary
Hisao Ikeda, Department of Cardiovascular Internal Medicine, Kurume University Medical
CenterExternal Evaluation Board
Yoichi Goto, Department of Cardiovascular Medicine, National Cerebral and CardiovascularCenterShigeru Makita, Department of Radiation Oncology, Saitama Medical University International
Medical Center

Introduction
There is evidence that appropriate exercise therapy improves exercise tolerance and serves the usefulfunction of secondary prevention in patients with ischemic heart disease. Recent studies indicate that
this therapy may also improve the prognosis of patients with cardiac failure. In western countries,
guidelines recommend that exercise therapy and drug therapy should be provided to patients withcardiovascular disease, and cardiac rehabilitation is widely used. Since percutaneous transluminal
coronary angioplasty has not improved life expectancy in patients with ischemic heart disease,
comprehensive cardiac rehabilitation centered on exercise therapy is an area of growing interest inJapan. However, cardiac rehabilitation in Japan is still relatively new, and increased use of thisapproach requires establishment of a standard cardiac rehabilitation program that is consistent withconditions in Japan.
The standard cardiac rehabilitation program is planned based on two principles: essential aspects ofthe program that should be available in most institutions; and desirable elements that will require
promotion of cardiac rehabilitation and establishment of human resources, education, devices, andfacilities in each institution. Both principles include a guarantee of quality and smooth adoption of the
cardiac rehabilitation program based on current conditions in Japan.
Comprehensive cardiac rehabilitation should be performed as a multidisciplinary and multifaceted
approach to improve exercise capacity and quality of life and to achieve secondary prevention inpatients with cardiovascular disease. The standard cardiac rehabilitation program focuses on acute- torecovery-phase myocardial infarction, which is the most common cardiovascular disease in all
medical institutions. The program consists of essential and desirable elements for operation of the
program, including clinical assessment, assessment of exercise capacity, nutritional management,
guidance on sodium reduction, weight control, blood pressure management, lipid management,
diabetes management, smoking cessation, psychosocial management, instructions on activities ofdaily living, preparation of exercise training programs, and a system for emergency and abnormal
situations.
The standard cardiac rehabilitation program planning committee consists of board members of theJapanese Association of Cardiac Rehabilitation, including multidisciplinary specialists in cardiac
rehabilitation, in order to make the program practical in clinical settings in Japan. The standard
program also adheres to “Guidelines for Rehabilitation in Patients with Cardiovascular Disease (JCS2012)”, which was jointly prepared by the Japanese Circulation Society and other related academic
societies. The program will be updated to correspond with the realities of clinical settings.
The hospital stay in patients with acute myocardial infarction has been shortened, which makes it
more difficult to offer sufficient in-hospital cardiac rehabilitation. However, comprehensive cardiac

rehabilitation for secondary prevention should be continued after discharge and return to society.
Thus, medical institutions should consider their cardiac rehabilitation programs for acute- to recoveryphase myocardial infarction and provide high-quality accessible programs based on the standard
program.

Components of the standard cardiac rehabilitation program1.

Operation of the program

2.

Clinical assessment

3.

Assessment of exercise capacity

4.

Nutritional management

5.

Guidance on sodium reduction

6.

Weight control

7.

Blood pressure management8.

Lipid management

9.

Diabetes management

10. Smoking cessation
11. Psychosocial Management
12. Instructions on activities of daily living
13. Preparation of exercise training programs
14. System for emergency and abnormal situations
Explanation of the elements
Essential Elements
Essential elements of the cardiac rehabilitation program
Desirable Elements
Goals for development of cardiac rehabilitation and establishment of human resources,
education, devices, and facilities in each medical institution

1. Operation of the program
Evaluation
Essential Elements
1.

Establish a patient-centered multidisciplinary cardiac rehabilitation team.

2.

Perform case conferences among multidisciplinary team members routinely.

3.

The program consists of exercise prescription, exercise therapy, patient education, andcounseling.

Desirable Elements
1. Consolidate an intra-hospital ordering system and a clinical pathway of cardiac
rehabilitation to start cardiac rehabilitation program smoothly.
2. Establish a closely collaborated system to other institutions specialized in cardiac
rehabilitation intervention.
Intervention
Essential Elements
1.

Appoint a person in charge of operating the program in the cardiac rehabilitation team.

2.

Check whether the rehabilitation program is patient’s specific intervention or not.

3.

Review the program on a regular basis in terms of continuity and effects ofinterventions.

Desirable Elements
1. Assign an expert physician on exercise test and/or exercise intervention to the cardiac
rehabilitation intervention team.
Goals
Essential Elements
1.

Form a cardiac rehabilitation team with multidisciplinary medical professionals.

2.

Encourage all medical professionals to attend training courses and academic congress
on a regular basis to improve the quality of the cardiac rehabilitation intervention.

Desirable Elements
１. Publish a regular summary of the intervention outcomes.
２. Improve the environment for outpatient cardiac rehabilitation program (facilities suchas a dressing room, scheduling of the program).

2. Clinical assessment
Evaluation
Essential Elements
Evaluate the following items before starting the cardiac rehabilitation program to clarify thegoals, objectives and risk factors when the program is in place.
1.

Obtain information on medical history from patients.
a) Identify present illness and history of diagnosis and treatment of cardiovasculardiseases and results of heart function tests.
b) Identify complications (peripheral arterial disease, cerebrovascular disease, lungdisease, renal disease, diabetes, orthopedic diseases, psychiatric/nervous systemdisease).
c) Identify cardiac symptoms: precordial symptoms, palpitation, shortness of breath,dyspea, NYHA classification.
d) Identify the drugs being used (including type, dosage, frequency, and medication
status compliance). In particular, check the medication status of antiplatelet agents
such as aspirin and clopidogrel, anticoagulant agents such as warfarin, β blockers,
antihyperlipidemic agents, and angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs).
e) Identify coronary risk factors: hypertension, dyslipidemia, diabetes, smoking,obesity, physical inactivity, family history.

2.

Examination of physical findings.
a) Examine circulation/respiratory status: pulse, blood pressure, heart sound/cardiac
murmur, respiratory sound, respiratory status, palpation of lower limbs andpretibial edema, extremity/carotid pulse extremity.
b) Killip classification

3.

Analyze laboratory test findings.
a) Resting 12-lead electrocardiograms: presence of Q wave and arrhythmiab) Chest X-ray images: CTR, pulmonary congestionc) Blood biochemistry: peak CK (CK-MB), BNP or NT-ProBNP, liver/renal function
tests, coronary risk factors (diabetes, dyslipidemia)d) Echocardiography: left ventricular ejection fraction (LVEF), left ventricular enddiastolic diameter (LVEDD), left ventricular wall motion.
e) Exercise tolerance test: Perform a 200-300 m walking test before starting machine
exercise in the cardiac rehabilitation room and a submaximal or symptom limited
exercise tolerance test after the patient is accustomed to the exercise.
f) Coronary angiography or coronary CT angiography: check for residual
stenosis/occlusion

4.

Review the treatment policy.

a) Schedule of future revascularization for treatment of residual stenosis/occlusionb) Schedule of future device treatment such as ICD and CRT
Desirable Elements
Check the following test results (if available).
1.

Radioisotope examination: exercise tolerance or pharmacologic stress testing withmyocardial perfusion imaging

2.

Cardiopulmonary exercise

3.

Intracardiac pressure measurement/ hemodynamics: pulmonary artery wedge
pressure, cardiac output, pulmonary arterial pressure, right atrial pressure

Intervention
Essential Elements
1.

Prepare a clinical assessment to be given to the patient or kept in the medical record.

Desirable Elements
None
Goals
Essential Elements
1.

Summarize short-term treatment goals and strategy.

Desirable Elements
1.

Prepare a discharge plan containing a summary of long-term treatment goals andstrategy that can be given to the patient or kept in the medical record.

3. Assessment of exercise capacity
Evaluation
Essential Elements
1.

Interview patients on amount of physical activity currently and before hospitalization.

2.

Evaluate appropriate activity level.

3.

Obtain information on prescribed medications.

Desirable Elements
None
Intervention
Essential Elements
1.

In recovery phase (Phase 2), a symptom-limited exercise test using a bicycle
ergometer or treadmill should be performed to evaluate heart rate, blood pressure, 12lead electrocardiograms and Borg scale during exercise.

2.

Evaluate the 6-minute walk test in patients who cannot perform a symptom-limited
exercise test due to low physical or cardiac function.

3.

Evaluate the lower extremity muscle strength in patients with very low functional
reserve.

Desirable Elements
1.

Evaluate exercise capacity in detail based on the results of cardiopulmonary exercise
testing (respiratory gas analysis).

2.

Evaluate exercise related factors including respiratory function, depression andanxiety.

Goals
Essential Elements
1.

Reassess exercise capacity regularly and revise the exercise program and acceptablephysical activity level.

2.

Evaluate exercise capacity and clinical status at the same time.

3.

Include exercise capacity data in explanation of clinical condition to patients.

Desirable Elements
1.

Use the exercise capacity data for establishment of other treatment plans, such as
medications.

4. Nutritional management
Evaluation
Essential Elements
1.

Obtain information on eating habits before hospitalization (meal times, foodpreferences, unbalanced diet, frequency of eating out).

2.

Check who cooks meals at home.

3.

Obtain information on history of alcohol intake and current alcohol consumption.

4.

Check for obesity, hypertension, diabetes, and dyslipidemia.

Desirable Elements
1.

Assessment of intake energy and nutrient balance by a registered dietitian before
hospitalization.

2.

Evaluation of food intake at home for 3 to 5 days after discharge.

Intervention
Essential Elements
1.

Instruction by a registered dietitian if there are problems with nutritional status and/or
eating habits.

2.

Explain the importance of nutrient balance and the adverse influence of excessive foodintake and alcohol consumption.

Desirable Elements
1.

Provide instructions on diet and nutrition on a regular basis to family members (inparticular, to persons in charge of cooking).

2.

Provide advice on use of a food-composition table.

3.

Evaluate food intake on a regular basis after discharge to promote improvement of
eating behavior.

Goals
Essential Elements
1.

Establish an appropriate dietary habit to correct coronary risk factors of obesity,
hypertension, diabetes, and dyslipidemia.

Desirable Elements
None5. Guidance on sodium reduction
Evaluation
Essential Elements
1.

Perform an interview to obtain information on dietary habits and food preferences
before hospitalization, and evaluate behaviors related to sodium intake.

Desirable Elements
1.

Evaluate intension of spouses or housemates regarding sodium reduction.

2.

Evaluate sodium intake before hospitalization in an interview, using a list of sodium
contents of food.

3.

Assessment of sodium intake using a simple sodium intake measurement device orother approaches.

Intervention
Essential Elements
1.

Explain the importance of sodium reduction to prevent recurrence of coronary arterydisease.

2.

Promote self-control to reduce sodium intake using a list of sodium contents of food.

3.

Set goals of gradual sodium reduction at 1-2g per 3 months to achieve 8g/day sodium
intake.

Desirable Elements
1.

Establish a specific diet plan to achieve sodium intake of 6g/day or less.

2.

Explain the importance of sodium reduction and caution regarding cooking with lesssodium to patients and family members (mainly spouses and persons in charge of
cooking), and construct a social support for sodium reduction.

Goals
Essential Elements
1.

Understand the importance of sodium reduction to prevent onset or recurrence ofcoronary artery disease.

Desirable Elements
1.

Establish conditions that maintain the sodium reduction behavior after discharge.

2.

Establish conditions that maintain the prescribed diet behavior and sodium intake.

6. Weight control
Evaluation
Essential Elements
1.

Measure body weight, abdominal circumference, and body mass index (BMI).

Desirable Elements
1.

Measure percent body fat (body composition).

Intervention
Essential Elements
Indication: patients with BMI ≥ 25kg/m2 or waist circumference ≥ 85 cm in males and ≥ 90
cm in females (Japanese waist circumference criteria of Metabolic Syndrome)
1.

Explanation to patient that obesity is a risk factor for recurrence of coronary arterydisease.

2.

Establishment of a habit to measure body weight during hospitalization through giving
an example, such as a measurement time after urination in the morning.

3.

Prescribe lifestyle behavior to manage weight loss including dietary habit or exercise(physical activity), and set an appropriate goal by identification of modifiable factors.

4.

Target BMI < 25 kg/m2 and waist circumference < 85 cm in male and < 90 cm in female.

5.

Set a desired value as a first target level especially in patients with anxiety or depression
and perform a step-by-step approach. DO NOT set strict goals at first.

Desirable Elements
1.

Set a daily calorie intake and prescribe the dietary behavior and exercise program toachieve the goal.

2.

Explain the importance of calorie balance of protein, lipid and carbohydrate to elderly
patients, in order to avoid loss of muscle mass due to excessive weight loss.

Goals
Essential Elements
1.

Maintain and improve the lifestyle of patients in terms of body weight control by dietand exercise.

2.

Decrease body weight, waist circumference and BMI, and maintain after discharge.

Desirable Elements
1.

Improve body composition, including a decrease in body fat mass and an increase inskeletal muscle mass.

7. Blood pressure management
Evaluation
Essential Elements
1.

Measure blood pressure twice or more in a sitting position at rest for more than 5
minutes, if possible.

2.

Measure blood pressure in both arms at the initial measurement.

3.

Measure blood pressure lying, sitting, and standing immediately after stopping bed rest,
in order to exclude orthostatic hypotension.

Desirable Elements
1.

Check whether the blood pressure measurement is performed at home after discharge.

Intervention
Essential Elements
Start drug therapy to follow-up blood pressure, if meeting the following criteria.
1.

For patients with systolic blood pressure (SBP) 120-139 mmHg or diastolic bloodpressure (DBP) 80-89 mmHg, give instructions on improvement of lifestyle, including
daily physical activities, exercise, and weight control; sodium intake and intake of fresh
fruit, vegetables, and low-fat food; appropriate alcohol consumption; and smoking
cessation.

2.

For patients with chronic kidney disease, cardiac failure, and/or diabetes with SBP ≥130
mmHg and DBP > 80 mmHg, start drug therapy and give instructions on improvementof lifestyle.

3.

For patients with SBP ≥ 140 mmHg or DBP ≥ 90 mmHg, start drug therapy andimprovement of lifestyle.

Desirable Elements
1.

Patients with hypertension complicated with myocardial infarction should receive a β
blocker, ACE inhibitor (ACEi), or ARB as first line therapy. However, a definite andsufficient antihypertensive effect should be obtained, with possible concurrent use of adiuretic and/or Ca antagonist.

2.

For elderly patients (diuretic, ACEi, ARB, Ca antagonist) or those who develop cardiac
failure (diuretic, β blocker, ACEi, ARB), metabolic syndrome (ACEi, ARB), diabetes(ACEi, ARB), atrial fibrillation (ACEi, ARB, β blocker), or renal failure (ACEi, ARB,
loop diuretic) regardless of age, select each drug based on guidelines such as the
Guidelines for Management of Hypertension.

Goals
Essential Elements
1.

Provide appropriate interventions for patients with prehypertension until blood pressure
returns to normal; for hypertension patients until blood pressure decreases to < 130/85

mmHg; for elderly hypertension patients until blood pressure decreases to < 140/90
mmHg; and for patients with diabetes, cardiac failure, and/or chronic renal disease until
blood pressure decreases to < 130/80 mmHg.
2.

Maintain the target blood pressure for as long as possible.

Desirable Elements
1.

Control risk factors other than blood pressure to prevent recurrence of cardiovasculardiseases.

8. Lipid management
Evaluation
Essential Elements
1.

Measure fasting LDL cholesterol, HDL cholesterol, and triglyceride.

2.

Perform an interview on the history of drug or diet therapy to determine possible effects
on blood lipids.

3.

Perform an interview on drug compliance.

4.

Reevaluate the lipid profile within 8 weeks after starting lipid-lowering treatment.

5.

Determine creatine kinase (CK) and hepatic function on a regular basis to evaluate
adverse reactions to lipid-lowering drug therapy.

Desirable Elements
1.

Evaluate the lipid profile every 4-6 weeks after starting lipid-lowering treatment.

Intervention
Essential Elements
Encourage consultation on the following items with a registered dietitian.
1.

Advice on appropriate total amount of energy (standard body weight  25-30 kcal) anda balanced diet (carbohydrate:protein:lipid = 60:15-20:20-25%).

2.

For patients with high LDL cholesterol, advice on maintenance of a strict fat-restricteddiet (fat energy ratio: ≤ 20%) and a cholesterol-restricted diet.

3.

For patients with a high triglyceride level, advice on restriction of alcohol consumption,
intake of energy from carbohydrates, body weight control, and exercise counseling.

4.

For patients with low HDL cholesterol, advice on exercise counseling and smoking
cessation.

5.

Start drug therapy if sufficient improvement is not obtained by lifestyle guidance.

Desirable Elements
1.

Patients with high LDL cholesterol should consume food containing high amounts of
unsaturated fatty acids (abundant in oil extracted from sardines and mackerel, vegetableoil). The intake ratio of saturated:monounsaturated:polyunsaturated fatty acids should
be maintained at about 3:4:3.

Goals
Essential Elements
1.

Patients should understand and take more interest in the significance of lipid
management in coronary artery disease.

Desirable Elements
1.

The levels of LDL cholesterol, HDL cholesterol, and triglyceride should quickly reach≤ 100 mg/dl, ≥ 40 mg/dl, and ≤ 150 mg/dl, so that atherosclerotic plaque will be reduced
and cardiovascular events will decrease.

9. Diabetes management
Evaluation
Essential Elements
1.

Determine if diabetes is present in all patients and describe the results in the medical
record.

2.

Describe the history of complications of cardiovascular disease and systemic
complications in the medical record.

3.

Check the history of and compliance with diet therapy for hyperglycemia andhypoglycemic episodes at the initial counseling.

4.

Check recent fasting blood glucose levels and HbA1c before starting exercise.

Desirable Elements
None
Intervention
Essential Elements
1.

Instruct patients and medical staff on appropriate examinations and treatment inaccordance with warnings and guidelines when hyperglycemia or hypoglycemia occurs.

2.

For patients with diabetes who are receiving treatment with insulin injection or insulin
secretagoguesa) Always pay attention to onset of hypoglycemia.
b) Encourage the patient to take a sufficient amount of water to avoid an increase inblood glucose.
c) Monitor closely if plasma glucose levels continuously decrease within 24-48 hours
after exercise.

Desirable Elements
1.

For patients with diabetes who have recently had hypoglycemic episodes, evaluate blood
glucose levels before and after exercise and until the level stabilizes. Patients whodevelop hypoglycemia should take 15 g of carbohydrate before exercise. Patients whodevelop hyperglycemia should drink an appropriate amount of water if they have nosubjective symptoms. The doctor or medical staff in charge should be asked whether
treatment is needed, as required.

2.

Instruct patients to take responsibility for self-care during exercise without supervision.

3.

Patients should receive nutritional advice as therapy from a diabetes dietician.

4.

Discuss acquisition of knowledge and measures against diabetes, patient compliance,and referral to a diabetologist.

Goals
Essential Elements
1.

The patient should be able to understand the signs and symptoms of impaired glucose

tolerance and should communicate with medical staff.
2.

Establish that the patient can undertake self-care, including self-measurement of blood
glucose levels and self-judgment of activity levels.

Desirable Elements
1.

Control the blood glucose level at 90-130 mg/dL or HbA1c < 6.9 (NGSP).

2.

Decrease the incidence of systemic complications and maintain prevention of
hyperglycemia or hypoglycemia at rest and during exercise.

10. Smoking cessation
Evaluation
Essential Elements
1.

Check smoking habits (including snuff, etc.) and smoking history to identify nonsmokers, former smokers, and current smokers.

2.

Evaluate the past smoking status of former smokers and current smokers, anddependency if there is a history of smoking cessation. Check the risk of passive smoking
at home or in the workplace.

3.

Ask smokers about their intention to start smoking cessation.

4.

Obtain information on the smoking cessation status of former smokers and smokers
before and after introduction of cardiac rehabilitation to check physical andpsychosocial changes associated with smoking cessation.

Desirable Elements
1.

Ask smokers and former smokers about their current status and intention to continue
smoking cessation, and determine physical and psychosocial changes caused bysmoking cessation.

2.

Continue to evaluate behavior modification phases of smoking cessation in smokers andformer smokers (precontemplation, contemplation, preparation, action, maintenance).

3.

Determine cigarette dependence and nicotine addiction of smokers. If smokers are stillsmoking, reevaluate this information.

Intervention
Essential Elements
Perform the following procedures in the 5A approach (Ask, Advice, Assess, Assist, Arrange).
1.

Ask smokers about their current intention to stop smoking (at introduction of cardiac
rehabilitation).

2.

Communicate with smokers clearly and individually about the significance of smoking
cessation.

3.

Hold an education session to promote understanding of the significance of smoking
cessation (including passive smoking). Teach smokers using the 5R’s (Relevance, Risks,
Rewards, Roadblocks, Repetition). Explain the relevance and risks of health problems
and the effects of smoking cessation; ask about individual factors that interfere withsmoking cessation; and hold sessions to repeat the conversation, in order to motivate
smoking cessation.

4.

Instruct nonsmokers and former smokers about the effects of smoking and how to avoid
passive smoking.

5.

Conduct an interview for quitters about their physical and psychosocial status (bodyweight gain, stress, sleep deficit, etc.) to predict increased risks for smoking and theenvironment and behaviors that promote smoking, and give advice on how to handle orsolve these problems.
6.

Support family members of patients to obtain assistance with smoking cessation. Informfamily members who are smokers about the significance of smoking cessation.

Desirable Elements
Add “Assist and Arrange” to the Essential Elements in the 5A approach and enhance support.
1.

Encourage patients to make a plan for smoking cessation: for example, establishing astarting day for smoking cessation.

2.

Provide educational materials for smoking cessation and establish continuing
opportunities to promote understanding of smoking cessation (including avoidance of
passive smoking). Provide continuing personal counseling or group guidance using the
5R’s (Relevance, Risks, Rewards, Roadblocks, Repetition) to smokers and former
smokers who started smoking cessation within the previous 6 months.

3.

Explain drug therapy to smokers and consider using this therapy when necessary.

4.

Introduce a smoking cessation clinic that patients may attend if they wish.

5.

Conduct an interview for former smokers and quitters about their physical andpsychosocial status (body weight gain, stress, sleep deficit, etc.) to predict increased
risks for smoking and the environment and behaviors that promote smoking, give advice
on how to handle or solve these problems, and continue to provide advice after theinterview.

6.

Support patients in obtaining social support for smoking cessation and avoidance of
passive smoking, such as cooperation in the workplace.

Goals
Essential Elements
1.

Encourage patients and their family members to understand the ill effects of smoking,including passive smoking, and the significance of smoking cessation.

2.

Encourage smokers to be motivated to start smoking cessation. Instruct former smokers
on continuation of smoking cessation.

3.

Avoid physical and psychological damage to smokers that may be associated withsmoking cessation.

Desirable Elements
1.

Encourage smokers to continue smoking cessation for 1 year or more. DO NOT allow
a restart of smoking in former smokers.

2.

Improve the physical and mental status of smokers due to smoking cessation.

3.

Obtain social support at home and in the workplace to avoid the ill effects of passive
smoking.

11. Psychosocial Management
Evaluation
Essential Elements

1.

Identify an interview to obtain psychological information.
a) Anxiety and concernsb) Motivation and adherence for cardiac rehabilitationc) Presence and degree of drug/alcohol used) History of psychiatric disordere) Use of drugs that may have psychological effects (e.g., β blocker, antidepressant,hypnotic, psychotropic drugs)

2. Identify an interview to obtain social information.
a)Social support (marital status, family, partner, key person)b)

Use of social resources (certification of required care insurance/long-term careservice, care manager)c)

Economic situation (e.g., insurance, pension, public assistance)d)Availability of a primary care doctor after discharge (for follow-up)e)Concrete method for continuation of cardiac rehabilitation (e.g., distance, time,commuting)2.

Identify an interview on lifestyle (e.g., exercise, diet, sleep, work, how to spend theirspare time).

3.

Build rapport between patients and medical staff and consider patients concerns whenidentifying an interview on psychological and social information, life style.

Desirable Elements
1.

Evaluate anxiety, depression, and social isolation using a reliable and validated method*1

2.

Evaluate QOL (quality of life) using a reliable and validated method *2.

3.

Evaluate cognitive functions using a reliable and validated method *3.

4.

Identify an interview on stress in spouse and family members.

5.

Obtain information on sexual dysfunction/ adjustment.

Intervention
Essential Elements1.

Ask and talk about psychosocial problems with patients, family members, domestic
partners, and/or significant others.

2.

Provide information on cardiac diseases and psychiatric symptoms.

3.

Hold patient education sessions and conferences hosted by a multidisciplinary team.

4.

Enhance social support.

5.

Use the social support system inside or outside the hospital. (e.g., maximum copayment
for high medical care costs, assistance by public medical expenses for disease/treatment,
sickness and injury allowance/disability pension, long-term care insurance system).

Desirable Elements
1.

Encourage family members, partners, and key persons to participate in patient education

sessions.
2.

Provide stress management and relaxation methods.

3.

Provide professional counseling and treatment.

4.

Use clinical pathways for acute-phase diseases

5.

Use region clinical pathways.

Goals
Essential Elements
1.

Patients can solve or reduce psychosocial problems.
a) Attempt to correct lifestyle for health maintenance.
b) Obtain suitable social support and resources.
c) Obtain further treatment/control if there are serious psychological problems

Desirable Elements
1.

The QOL of the patient is improved.

2.

Patients continue to participate in the cardiac rehabilitation program.

3.

Depression and anxiety symptoms of patients are reduced.

4.

Allow patients and family members to acquire relaxation and stress management skills.

5.

Patients can avoid excessive alcohol consumption.

6.

Patients can achieve smoking cessation.

*1e.g., Hospital Anxiety and Depression Scale*2e.g., SF-36*3e.g., Mini mental state examination (MMSE)

12. Instructions on activities of daily living
Evaluation
Essential Elements
1.

Perform an interview on household duties, work, and recreation before hospitalization.

2.

Evaluate current physical activity levels using a questionnaire.

3.

Quantitatively evaluate physical activities in daily living based on the results of various
tests, such as an exercise tolerance test.

Desirable Elements
1.

Evaluate behavior modification, inhibition of increase of physical activities, and social
support.

Intervention
Essential Elements
1.

Provide advice, support, and counseling for physical activities.

2.

Establish an exercise program necessary for individual daily living.

3.

Plan routines to increase physical activities based on current routines.

4.

Advise elderly patients on low intensity aerobic activity to minimize musculoskeletal
injury.

5.

Provide advice on slowly increasing physical activities if a patient wants to do this.

6.

Suggest a method of enhancing physical activities in daily living (e.g., commuting,leisure activities)

7.

Advise the patient to avoid performing unaccustomed vigorous physical activity.

Desirable Elements
1.

Encourage moderate intensity exercise for 20-60 minutes per day for 5 or more days per
week.

2.

Provide educational materials as part of advice, support, and counseling.

3.

Reevaluate activities of patients who participate in the exercise training program.

Goals
Essential Elements
1.

Greater participation in household duties, work, and recreation activities.

2.

Improved psychosocial health and reduced stress.

3.

Support opportunities for functional independence to prevent disability.

4.

Increase opportunities for independence to achieve recommended goals.

Desirable Elements
1.

Improve aerobic exercise performance and body composition to reduce the risk ofcoronary artery diseases.

2.

Introduce regular physical activities into lifestyle.

13. Preparation of exercise training programs
Evaluation
Essential Elements
1.

Obtain a medical history for the patient to determine items that may affect exercise
training.
a) Orthopedic disease, peripheral arterial disease, cerebrovascular disease, lungdisease, renal disease, psychiatric disorder, nervous system disease, etc.

2.

Observe abnormal reactions during an exercise tolerance test or exercise training.
a) Perform a symptom-limited exercise tolerance test using a cycle ergometer ortreadmill in the recovery phase to evaluate heart rate, blood pressure, 12-leadelectrocardiograms, and the rating of perceived exertion (RPE) scale during the test.
b) Reevaluate the above items on a regular basis.

Desirable Elements
1.

Perform cardiopulmonary exercise to evaluate the maximal oxygen uptake andanaerobic threshold.

2.

Observe abnormalities in heart rate and ventilation responses in cardiopulmonary
exercise.

3.

Determine muscle strength such as grip strength and knee extension muscle strength.

4.

Check full body flexibility.

5.

Check balance ability.

6.

Monitor mental/psychological characteristics such as depression and anxiety.

7.

Evaluate health related QOL.

Intervention
Essential Elements
1.

Confirm approval of an indication for exercise training by a primary care physician andrehabilitation physician.

2.

Explain the objectives, individual goals, and contents of the exercise training program
to patients and obtain their informed consent.

3.

Make an individual program of aerobic exercise and resistance training and provide thisto patients.

4.

Perform warm-up before starting each exercise session, and cool-down and stretching
movements after each session.

5.

Perform continuous ECG monitoring during training sessions at least in early phase after
starting the program (if the exercise training session is performed at the outpatient
department, necessity of continuous ECG monitoring depends on the risk severity).

6.

Measure blood pressure before and after exercise. Measure blood pressure during sometraining sessions immediately after starting.

7.

Provide advice to patients on the risk of onset of serious symptoms and on safetymanagement during the exercise training sessions.
8.

Modify the exercise prescription according to the condition of each patient.

Desirable Elements
1.

Define the frequency, intensity, duration, and mode of aerobic exercise.
a) Frequency: 3-7 days/week, every day if possibleb) Intensity: 40-60% of maximal oxygen uptake, 55-69% of maximal heart rate, 4060% of heart rate reserve (Karvonen: k = 0.4-0.6), heart rate of the anaerobic
threshold or intensity 1 minute before the anaerobic thresholdc) Duration: 20-60 minutesd) Mode: Walking, aerobics, cycling, jogging, light swimming, etc.

2.

Define the frequency, intensity, duration, and mode of resistance training.
a) Frequency: 2-3 times/weakb) Intensity: Upper limb exercise: 30-40% of 1RM, lower limb exercise: 50-60% of
1RM, 1 set consists of 10 to 15 times
Repeatable load, moderate fatigue, Borg Scale: 11-13, Upper limit is set at “a little

hard”c) Duration: 1 to 3 sets of 8-10 kinds of exercises involving upper and lower limbsd) Mode: rubber band, weights on ankles and wrists, dumbbell, free weights, pulley,weight machine, etc.
3.

Start the exercise program during hospitalization, and participate in the program at theoutpatient department for approximately 3 months (2 to 5 months) after discharge.

4.

Receive supervised exercise training for 30 to 90 days after onset according to the degreeof risk, and subsequently receive non-supervised exercise therapy. Finally, patients will
be able to manage the exercise program by themselves.

Goals
Essential Elements
1.

Patients should understand safe and effective ways to do exercise training.

2.

Maintain and improve exercise tolerance (maximal oxygen uptake, anaerobic
threshold), flexibility, muscle endurance, and muscle strength.

3.

Decrease ventilation, heart rate, cardiac work (rate-pressure product) at the same levelof exertion, and increase the myocardial ischemia threshold and alleviate cardiac failure.

4.

Remove anxiety about exercise and improve activity.

5.

Decrease coronary risk factors.

6.

Improve health-related QOL and obtain mental and psychological effects.

Desirable Elements
1.

Inhibit progression of coronary stenosis.

2.

Decrease the incidence of coronary events.

3.

Decrease hospitalization caused by exacerbation of cardiac failure.

4.

Improve life expectancy (reduce risk of all-cause mortality, decrease cardiac death).

14. System for emergency and abnormal situations

Evaluation
Essential Elements
1.

Place oxyecoia supply equipment, cardioverter (manual defibrillator or AED), a cardiac
monitor, sphygmomanometer, and a crash cart in a training room for functional
exercises.

2.

Train medical staff who are responsible for cardiac rehabilitation to perform basic life
support (BLS) while waiting for doctors who can provide advanced cardiovascular life
support (ACLS), in case of sudden changes in a patient's condition.

Desirable Elements
1.

Provide necessary tests and procedures, such as ECG, biochemical tests,
echocardiography, and radiography.

2.

Provide emergency internal/surgical therapy for onset of complications or recurrence,and have the potential to transfer patients to a partner hospital rapidly if they needemergency surgery.

3.

Arrange for availability of cardiac rehabilitation specialists certified by the Japanese
Association of Cardiac Rehabilitation.

Intervention
Essential Elements
1.

Perform simulation of measures to be taken in emergency/abnormal cases on a regularbasis.

2.

Inspect drugs and equipment for use in emergencies (e.g., a cardioverter) in a crash cart
every day.

Desirable Elements
1.

Simulate a response to an emergency/abnormal case at least once each year and involve
all staff in charge of cardiac rehabilitation. The simulation should consist ofmeasurement of timing from onset to procedures, a check of skills for BLS, anddiscussion of problems after the simulation.

Goals
Essential Elements
1.

Provide prompt life support through establishment of equipment and systems for an
emergency.

Desirable Elements
1.

Improve the lifesaving rate in emergency/abnormal cases.