Comprehensive Cardiac Rehabilitation

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Evolution of Cardiac Rehabilitation

The roots of CR can be traced to the 1950s with the development of hospital-based regimens that were aimed at helping patients recover after a myocardial infarction (MI) event. At that time, prolonged bed rest was thought to help reduce stress and strain as the patient recovers. Eventually in-patient physical activity was found to be safe and helpful for patients recovering from the negative effects of MI as well as prolonged bed rest.

Additional studies in the outpatient CR setting involving patients recovering from a cardiac event showed the benefits of physical activity on functional capacity and quality of life. As more and more evidence was obtained in the 1980s and 1990s about the benefits of lifestyle and medication, CR began to evolve beyond exercise therapy alone as it involved effective lifestyle and medication. Today, CR programs are designed to be centers of secondary CVD prevention, applying evidence-based and guideline-directed medical therapies of known benefit with the help of a multidisciplinary team.

Early models of CR were offered only to patients recovering from MI, but as more evidence accumulated in other patient groups, the scope of the indications for CR expanded. The United States currently has seven patient groups for which CR is recommended in clinical practice guidelines and covered by the Centers for Medicare and Medicaid Services (CMS), as well as commercial insurance providers ( Table 33.1 ). Those indications include: MI, percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), stable angina, heart valve repair/replacement, heart transplantation, and heart failure with reduced ejection fraction (HFrEF). In addition, supervised exercise training is covered by CMS for patients with symptomatic peripheral arterial disease of the lower extremities (claudication).

Elements of Cardiac Rehabilitation Programs

Standards of practice for CR includes the following structural and procedural elements:

Structural Elements

Multidisciplinary Team

The CR care team is comprised of a multidisciplinary team of health care professionals including a physician medical director who oversees the safety and effectiveness of the CR program elements, and a team composed of nurses, exercise physiologists, physical therapists, dietitians, psychologists, social workers, and other professionals. The CR team members have appropriate training, skills, and certification to:

• Administer lifestyle therapies

• Assess and manage the underlying cardiovascular risk of a patient

• Coordinate the cardiovascular care for a patient’s specific cardiovascular condition

• Identify and refer patients for appropriate care of their comorbid conditions

• Prevent and manage medical complications and emergencies that may occur during the course of a patient’s CR program

Facilities, Equipment, and Technology Tools

Center-based CR programs utilize dedicated space, equipment, and technology tools that are appropriate for patient assessments, education and counseling, exercise training, and supervision. ECG telemetry can be used with higher-risk patients for dangerous arrhythmias during CR. Clinical databases serve an important role in documenting patient care activities and outcomes, quality improvement, or research activities.

Process Elements

Referral and Enrollment of Eligible Patients

Current insurance coverage policies for CR in the United States require that eligible patients be referred to a center-based CR program by a physician. A significant portion of patients are not referred to CR, and a significant number of those who are referred to CR do not enroll and participate in CR. These gaps occur for a variety of reasons (patient-, provider-, health-system- and community-based barriers). Systematic approaches to guide patient enrollment will overcome those barriers and promote greater participation of CR ( Fig. 33.1 ). ^,

Patient Assessments

Patients undergo clinical assessments as they begin an outpatient CR program and at key checkpoints during the program. These assessments include a safety evaluation for high-risk cardiovascular conditions (e.g., unstable symptoms), a screening evaluation for comorbid conditions that may require additional evaluation and/or treatment (such as depression, diabetes), and an evaluation of clinical factors (such as functional capacity) that will be used by the CR staff and patients to formulate the individualized treatment plan (ITP), and to measure patient progress and outcomes.

Patient Care Activities

For center-based CR programs, patients ideally attend 36 in-person CR sessions over a period of 12 weeks or more, usually attending three sessions per week. With the help of the CR staff, the patient develops a patient-centered ITP that is followed in the CR center and also at home. The ITP includes patient actions that help the patient implement guideline-directed medical therapy and also appropriate lifestyle therapies, including physical activity and exercise training, nutritional therapy, smoking/tobacco cessation (if indicated), and psychological health management. The CR staff members review the ITP with patients regularly throughout their time in CR and reinforce the patient’s goals with behavioral modification strategies and self-management skills.

Staff members educate patients about management of CVD and related symptoms. The CR staff members help coordinate a patient’s CVD care with members of their health care team to assure that patients are receiving appropriate medications, that their CVD risk factors are under optimal control, and that any comorbid conditions are being addressed.

Quality Improvement Strategies

Quality improvement processes designed to assess adherence to appropriate clinical practice guidelines and performance measures, are an integral part of CR programs, to help meet standards for CR program certification by national organizations and to promote high-quality patient care and outcomes.

Value of Cardiac Rehabilitation

An expanding body of evidence supports the value of CR, showing beneficial clinical, safety, and cost-benefit outcomes related to CR, including the following: