New Concepts in Cardiac Rehabilitation and Secondary Prevention After Myocardial Infarction

Introduction

Evidence-based treatments for patients with myocardial infarction (MI) have improved outcomes, with substantive reductions in mortality rates ( Chapter 2 ). Nevertheless, patients who survive an acute MI remain at increased risk for recurrent MI and death and also suffer from clinical symptoms and loss of physical, psychological, or social functioning after discharge that can lead to impaired health-related quality of life. The effectiveness and accessibility of cardiac rehabilitation and secondary prevention services after MI have therefore never been more important. Current international clinical guidelines, including those of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology, endorse rehabilitation and secondary prevention as key elements of standard post-MI management.

Our approach to post-MI rehabilitation has changed radically in the last 80 or so years. In the 1930s, restriction of physical activity and prolonged bed rest were standard of care for patients suffering from an MI. Subsequent evolution of practices such as chair therapy (1940s), brief daily walks of 3 to 5 minutes (1950s), and structured inpatient cardiac rehabilitation programs for early ambulation after MI (1960s) led to the development of today’s multidisciplinary, comprehensive cardiac rehabilitation and secondary prevention programs for a broad group of patients with atherosclerotic cardiovascular disease.

The following definition from the Agency for Health Care Policy and Research encompasses these contemporary concepts:

Cardiac rehabilitation [and secondary prevention] services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counselling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients. ^6a

Although exercise training remains a cornerstone of intervention, current practice guidelines consistently recommend “comprehensive rehabilitation” programs that should contain the necessary core components to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle.

Cardiac rehabilitation and secondary prevention services should begin in the inpatient setting for patients who have survived an acute MI and continue into the early-outpatient and late-outpatient phases of follow-up ( Figure 34-1 ). Although in many countries this inpatient and early-outpatient care is covered by health care providers and insurers, the costs of late-outpatient or “maintenance” programs often need to be met by the patients themselves.

FIGURE 34-1, The trajectory of cardiac rehabilitation and secondary prevention after acute coronary syndrome.

This chapter presents the evidence for cardiac rehabilitation and secondary prevention after MI, focusing on the findings of systematic reviews and meta-analyses; details the components of cardiac rehabilitation and secondary prevention delivery using current high-profile international practice and policy statements; and finally, considers current and future key challenges facing rehabilitation and secondary prevention services.

Evidence for Cardiac Rehabilitation and Secondary Prevention

The first systematic reviews and meta-analyses of cardiac rehabilitation were published more than 20 years ago and reported a 20% to 25% reduction in all-cause and cardiovascular mortality in pooled data from 22 randomized controlled trials (RCTs) in more than 4300 post-MI patients, comparing exercise-based cardiac rehabilitation with a no-exercise rehabilitation approach in the control group. A number of updated versions of this systematic review/meta-analysis of cardiac rehabilitation and secondary prevention have since been published.

The 2016 Cochrane systematic review and meta-analysis “Exercise-based cardiac rehabilitation for coronary heart disease” provides a useful summary of the available evidence. The inclusion and exclusion criteria for the 2016 Cochrane review are summarized in Table 34-1 . Bibliographic databases of Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Science Citation Index Expanded were searched to July 2014. The study authors identified a total of 63 RCTs ( Table 34-e1 ). Although this update included a total of 14,486 patients, most trials were relatively small in size (median number of patients, 126; range, 28 to 2304). Greater than 80% of the trial populations were post-MI patients, with the remainder consisting of patients who had undergone coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI); in more than one half of the patients in these cohorts, previous MI was the exclusive diagnosis. The median follow-up period was 12 months. Programs typically were conducted in a supervised outpatient hospital/center-based setting, either exclusively or in combination with some maintenance home exercise sessions. Although it was noted that the quality of reporting had improved in more recently published RCTs, overall, the authors judged the various individual categories of study risk of bias as either high or unclear.

TABLE 34-1

Inclusion and Exclusion Criteria for 2016 Cochrane Review

From Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.

Inclusion

Study design : RCTs of exercise-based CR with a follow-up period of at least 6 months post randomisation
Population : Patients of all gender or ages who have had an MI, or who have undergone revascularization (coronary artery bypass grafting [CABG], percutaneous coronary intervention [PCI]) or who have angina pectoris or coronary heart disease defined by angiography
Intervention : Exercise-based CR, defined as a supervised or unsupervised inpatient, outpatient, or community- or home-based intervention that includes some form of exercise training, either alone or in addition to psychosocial and/or educational interventions
Control : Standard medical care, such as drug therapy, but without any form of structured exercise training program
Outcomes : One or more of the following outcomes: death (total and cardiovascular-related); MI (fatal and nonfatal); revascularizations (CABG and PCI); hospitalizations; health-related quality of life assessed using validated instruments (e.g., Short-Form-36, EQ-5D); or costs and cost-effectiveness

Exclusion

Studies exclusively recruiting patients with heart failure, with atrial fibrillation, after heart valve surgery, with heart transplants, or implanted with cardiac resynchronization device or with implantable cardioverter-defibrillator; or patients who completed a cardiac rehabilitation program before randomization

CR, Cardiac rehabilitation; MI, myocardial infarction; RCTs, randomized controlled trials.

TABLE 34-e1

Cochrane 2016 Review Summary of Study and Patient Characteristics

Adapted from Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 67:1-12, 2016.

Category	No. of Studies (%) or Median ^∗ (Range)
Study Characteristics
Publication year
1970-1979	2 (3)
1980-1989	12 (19)
1990-1999	20 (32)
2000-2009	21 (33)
2010 onward	8 (13)
Study location
Europe	37 (59)
North America	12 (19)
Asia	6 (10)
Australasia	5 (8)
Other	2 (3)
Not reported	1 (2)
Single center	45 (71)
Sample size	126 (28-2304)
Duration of follow-up	12 months (6-120)
Population Characteristics
Gender
Males only	18 (29)
Females only	1 (2)
Both males and females	41 (65)
Not reported	3 (5)
Age (years)	56.0 (49.3-71.0)
Diagnosis
Post–myocardial infarction only	31 (49)
Revascularization only	2 (3)
Angina only	5 (8)
Mixed-CHD population	25 (40)
Intervention Characteristics
Intervention type
Exercise-only programs	25 ^† (38)
Comprehensive programs	39 ^† (60)
Duration of intervention (months)	6 (1-48)
Dose of intervention
Duration	6 months (1-48)
Frequency	1-7 sessions/week
Length	20-90 minutes/session
Intensity	50%-85% of maximal heart rate 50%-95% of maximal oxygen uptake (VO ₂ max) Borg rating of 11-15
Setting
Center-based only	33 (52)
Combination of center- and home-based	13 (21)
Home-based only	15 (24)
Not reported	2 (3)

CHD, Coronary heart disease.

∗ Median of study means.

† One study includes both exercise-only and comprehensive cardiac rehabilitation (CR) arms.

Meta-analyses showed that cardiac rehabilitation had no effect on total mortality compared with that for the control group but led to a reduction in cardiovascular mortality (relative risk, 0.74; 95% CI, 0.64 to 0.86) ( Table 34-2 and Figure 34-2 ). Exercise-based rehabilitation reduced the risk of hospital admissions (relative risk, 0.82; 95% CI, 0.70 to 0.96) ( Figure 34-e1 ). No significant impact on either the risk of recurrent MI or revascularization was noted. In view of the variation in health-related quality of life outcome measures across trials, meta-analysis for this aspect of outcomes was not possible. Of 20 studies that reported quality of life, however, a majority (13 trials, 65%) showed higher outcome levels in one or more quality of life domains after rehabilitation compared with those for control groups. With data from multiple RCTs and meta-analyses of RCTs, the efficacy of cardiac rehabilitation fulfills grade A/level I evidence.

TABLE 34-2

Summary of Meta-analysis of Effects of Exercise-Based Cardiac Rehabilitation on Clinical Event Outcomes

Adapted from Anderson L, Thompson DR, Oldridge N, et al: Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev (1):CD001800, 2016.

Outcome	No. of Participants (with No. of Studies)	No. of Events/ Participants		Relative Risk (with 95% CI)	Statistical Heterogeneity I statistic Chi-Square Test (with P value)	GRADE/Quality of Evidence
Outcome	No. of Participants (with No. of Studies)	Intervention	Comparator	Relative Risk (with 95% CI)		GRADE/Quality of Evidence
All-cause mortality (all studies)	12,455 (47)	838/6424	865/6031	0.94 (0.87-1.02)	0% (0.58)	+ + + − Moderate ^∗
CV mortality (all studies)	7469 (27)	292/3850	375/3619	0.74 (0.64-0.85)	0% (0.70)	+ + + − Moderate ^∗
Fatal and/or nonfatal MI (all studies)	971 (36)	356/4951	387/4766	0.89 ( 0.78-1.02)	0% (0.48)	+ + − − Low ^∗†
CABG (all studies)	5891 (29)	208/3021	212/2870	0.94 ( 0.78-1.12)	0% (0.86)	+ + + − Moderate ^∗
PCI (all studies)	4012 (16)	171/2013	197/1999	0.86 (0.71-1.04)	0% (0.59)	+ + + − Moderate ^∗
Hospital admissions (all studies)	3030 (15)	407/1556	453/1474	0.86 (0.77-0.95)	34.5% (0.10)	+ + − − Low ^∗†

CABG, Coronary artery bypass grafting; CV, cardiovascular; GRADE, Grades of Recommendation, Assessment, Development and Evaluation [with plus or minus assigned for each of the four grading categories]; MI, myocardial infarction; PCI, percutaneous coronary intervention.

† Funnel plots and/or Egger test suggest evidence of asymmetry.

Grade Working Group Quality of Evidence

High quality : Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality : Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality : Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality : We are very uncertain about the estimate.

∗ Random sequence generation, allocation concealment, and blinding of outcome assessors were poorly described in greater than 50% of included studies; bias likely.

FIGURE 34-2, Meta-analysis of cardiovascular mortality.

In addition to efficacy, two key additional key evidence considerations for rehabilitation and secondary prevention are safety and cost-effectiveness. Exercise-based rehabilitation appears to be very safe. An observational study of more than 25,000 patients in a French registry of rehabilitation-related complications reported one cardiac event for 50,000 hours of exercise training—equivalent to 1.3 cardiac arrests per 1 million patient-hours. An earlier American study reported only one case of ventricular fibrillation per 111,996 patient-hours of exercise and one MI per 294,118 patient-hours. A systematic review of economic evaluations of cardiac rehabilitation and secondary prevention reported a cost per life-year gained ranging from US$2193 to US$28,193. In 2007, the National Institute of Health and Care Excellence (NICE) in the United Kingdom estimated the incremental cost-effectiveness ratio for rehabilitation after MI at approximately £7860 and £8360 per quality-adjusted life-year (QALY) gained for men and women, respectively. NICE’s current funding threshold is £20,000/QALY, indicating the provision of cardiac rehabilitation and secondary prevention to be cost-effective.

Components of Cardiac Rehabilitation and Secondary Prevention

Systematic Referral

All eligible patients with acute MI and all patients in the immediate postoperative period after CABG or PCI should be referred to a comprehensive outpatient rehabilitation and secondary prevention program either before hospital discharge or during the first immediate follow-up visit. The services should be instituted as soon as possible after hospital admission. Cardiac rehabilitation and secondary prevention generally are considered most beneficial when delivered soon after the index hospitalization. In certain situations, however, clinical, social, and logistic reasons can delay enrollment in a structured program. To ensure effective access to rehabilitation and preventive services, referral should be considered by all health care practitioners with responsibility for the care of post-MI patients in the 12 months after their acute event or cardiac surgery.

Despite the substantive evidence for the benefits of such services, implementation of and patient enrollment in cardiac rehabilitation and secondary prevention programs remain below desired levels. Studies in Europe, North America, and Australia have reported participation rates of 20% to 50%. The gap in delivery is especially large in older patients, women, and members of ethnic minorities. Reasons behind these gaps in participation are generally classified into three categories: (1) patient-based, especially lack of sufficient financial resources and/or health care insurance coverage to participate or lack of interest in participating in the program; (2) provider-based, especially lack of physician referral of patients; and (3) system-based barriers, especially lack of resources to fund rehabilitation/preventive services or lack of services within close proximity to a patient’s home. A Cochrane systematic review assessed the efficacy of interventions to improve uptake of and adherence to cardiac rehabilitation and secondary prevention. However, this review found only weak evidence (11 RCTs) supporting specific interventions to increase uptake. Systematic referral procedures and interventions targeting patient-identified barriers may increase the likelihood of success. At referral, clinicians need to be aware of potential patient barriers ( Table 34-3 ). Some particular approaches to overcoming these barriers are presented later under Innovative and Models of Rehabilitation and Prevention (in the section on maintaining long-term behavioral changes).

TABLE 34-3

Barriers to Participation in Cardiac Rehabilitation and Secondary Prevention

Patient-Related Barriers	Provider- and System-Related Barriers
Older age, female sex Smoking Depression Social isolation Family obligations Limited finances Lack of transportation Patient refusal	Lack of services Distance to services Lack of systematic referral Lack of physician endorsement

FIGURE 34-e1, Meta-analysis of hospital admission.

Patient Risk Assessment and Tailored Planning

Formulation of an individually tailored, patient-specific plan for cardiac rehabilitation and secondary prevention should be based on a careful risk assessment at discharge or as soon as possible after hospital admission and before initiation of the program. This risk assessment should systematically collect and document the clinical information as listed in Table 34-4 .

TABLE 34-4

Patient Risk Assessment and Clinical Data Collection

Adapted from Balady GJ, Williams MA, Ades PA, et al: Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 115:2675-2682, 2007; and Piepoli MF, Corra U, Adamopoulos S, et al: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664-681, 2014.

Assessment Component	Description
Clinical history	Screening for cardiovascular risk factors, comorbid conditions and disabilities, psychological stress, vocational situation
Symptoms	Cardiovascular disease—NYHA functional class for dyspnea and Canadian Cardiovascular Society (CCS) class for symptoms of angina
Medication	Including dose, frequency, side effects
Adherence	To medical regimen and self-monitoring (weight, BP, symptoms)
Physical examination	General health status, body mass index (BMI), waist circumference, heart failure signs, cardiac and carotid murmurs, pulse, BP control, extremities for presence of arterial pulses and orthopedic pathology, neurological abnormalities
ECG	Heart rate and rhythm, repolarization
Cardiac imaging	2D and Doppler echocardiography when appropriate—in particular, ventricular function, valvular heart disease, presence of effusion
Blood testing	For routine biochemical assay: including full blood count, electrolytes, renal and liver function, fasting blood glucose (HbA _1C if fasting blood glucose is elevated or with known diabetes), total cholesterol, LDL-C, HDL-C, triglycerides
Physical activity level by history	Domestic, occupational, and recreational needs; activities relevant to age, gender, and daily life; readiness to change behavior; self-confidence; barriers to increased physical activity; and social support in making positive changes
Peak exercise capacity	Symptom-limited exercise testing, either on bicycle ergometer or on treadmill. If this is not feasible (e.g., because of recent surgery), submaximal exercise evaluation and/or six-minute walk test should be considered.
Education	Clear, comprehensible information on the basic purpose of the CR program and the role of each component (including optimal medical therapy compliance) Education on self-monitoring protocols (weight, blood pressure, warning symptoms and signs of instability, e.g., angina, dyspnea) and self-management

BP, Blood pressure; CR, cardiac rehabilitation; 2D, two-dimensional; ECG, electrocardiogram; HbA _{1C ,} , A _1C hemoglobin (glycosylated); HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NYHA, New York Heart Association.

Exercise Testing and Training

Symptom-limited exercise testing before participation in an exercise-based cardiac rehabilitation program is strongly recommended (see also Chapter 30 ). Exercise test parameters should include assessment of heart rate and rhythm, signs and symptoms, ST-segment changes, hemodynamics, perceived exertion, and exercise capacity. On the basis of this exercise test, patients can then be risk-stratified to select the appropriate level of supervision and monitoring required during their exercise-based rehabilitation program. Exercise training should incorporate an individualized exercise prescription for aerobic training that should be regularly reviewed by the program team and modified if necessary. Current recommendations for exercise prescription are as follows:

Frequency: 3 to 5 sessions per week
Intensity: 50% to 80% of maximal exercise capacity
Duration: 20 to 60 minutes per session
Modality: walking, treadmill, cycling, rowing, stair climbing, arm/leg ergometry, and other modalities, using continuous or interval training as appropriate

Exercise-based rehabilitation programs also can include resistance exercise.

Education

A Cochrane review identified 13 RCTs examining patient education interventions among 68,556 subjects with coronary heart disease, with a follow-up period of 6 to 60 months. The meta-analysis from this review showed weak evidence of an effect of education compared with usual care on all-cause mortality (relative risk [RR], 0.79; 95% CI, 0.55 to 1.13) and cardiac morbidity (recurrent MI: RR, 0.63; 95% CI, 0.26 to 1.48; revascularization: RR, 0.58; 95% CI, 0.19 to 1.71; and hospitalization: RR, 0.83; 95% CI, 0.65 to 1.07). After education, some evidence indicates that quality of life scores were higher than those in control groups. These findings generally are supportive of cardiac rehabilitation and secondary prevention, including some form of education, either in groups or as individual consultations. Further research into different models of education is needed, however, to inform future more specific recommendations on the nature and content of this education delivery.

Current guidelines for education include its role in providing a positive impact on healthy behavior ( Table 34-5 ), risk factor modification ( Table 34-6 ) and improving adherence to cardioprotective medications ( Table 34-7 ), as well as psychosocial support including vocational guidance and sexual functioning ( Table 34-8 ).

TABLE 34-5

Assessment, Clinical Interventions, and Expected Outcomes for Behavioral Interventions after Acute Myocardial Infarction

Adapted from Smith SC Jr, Benjamin EJ, Bonow RO, et al: AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 124:2458-2473, 2011; Balady GJ, Williams MA, Ades PA, et al: Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 115:2675-2682, 2007; and Piepoli MF, Corra U, Adamopoulos S, et al: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664-681, 2014.

Area of Interest, with Treatment Goals ^∗	Evaluation/Assessment	Intervention	Expected Outcomes
Physical activity counseling E : Moderate aerobic activity, minimum 2.5 hours/week, in multiple bouts each lasting ≥10 minutes U : Moderate aerobic activity, 30 minutes/day, 5-7 days/week U : Complementary resistance training, 2 days/week	Assess current physical activity level and determine domestic, occupational, and recreational needs. Assess readiness to change behavior, self-confidence, and barriers.	Recommend gradual increases in daily lifestyle activities over time, and how to incorporate it into daily routine and evenly spread throughout the week, i.e., minimum 5 days a week. Emphasize sedentary lifestyle as risk factor and the benefits of physical activity: Any increase in activity has a positive health benefit. Advise : Individualize physical activity according to patient’s age, past habits, comorbid conditions, preferences, and goals. Reassure regarding the safety of the recommended protocol. Encourage involvement in leisure activities that are enjoyable. Forewarn : Inform patients on the risk of relapses; education should underline how benefits may be achieved and the need for lifelong continuation. If physical activity interruption has occurred, physical, social, and psychological barriers should be explored, and alternative approaches suggested.	Increased participation physical activities. Improved psychosocial well-being Prevention of disability Improved aerobic fitness and body composition
Smoking cessation Nonsmoker status	Smoking status and use of other tobacco products Amount of smoking (per day) (number of years) Determine readiness to change; if ready, choose a date for quitting.	All smokers should be encouraged professionally to stop smoking all forms of tobacco permanently. Follow-up : Referral to special programs and/or pharmacotherapy (including nicotine replacement) are recommended, as is a stepwise strategy for smoking cessation. Provide structured follow-up. Offer behavioral advice and group or individual counseling. Consider nicotine replacement therapy, combined with bupropion or varenicline if not contraindicated.	Long-term abstinence from smoking
Nutritional counseling Heart-healthy diet	Daily caloric intake and dietary content of fat, saturated fat, sodium, and other nutrients Assess eating habits.	Education regarding dietary goals and how to attain them Healthy food choices: Wide variety of foods; low-salt foods Mediterranean diet: fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy products Replace saturated fat with the above foods and with monounsaturated and polyunsaturated fats from vegetable (oleic acid as in olive oil and rapeseed oil) and marine sources to reduce total fat to <30% of energy, of which less than 1/3 is saturated Avoid : beverages and foods with added sugars and salty food Integrate behavior-change models and compliance strategies into counseling sessions.	Patient understands basic principles of dietary content. Patient adheres to prescribed diet.
Weight control management Body mass index (BMI) : 18.5-24.9 kg/m ² Waist circumference : 80 cm in women, 94 cm in men	Measure weight, height, and waist circumference. Calculate BMI.	BMI : It is useful to consistently encourage weight control through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated. Waist circumference : It is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.	To lose 5%-10% of body weight in 6 months. Consider referring patient to specialist obesity clinic if goal not reached.

∗ E, Europe ; U, United States of America.

TABLE 34-6

Assessment, Clinical Interventions, and Expected Outcomes with Risk Factor Control after Acute Myocardial Infarction

Area of Interest, with Treatment Goal	Evaluation and Assessment	Intervention	Expected Outcomes
Blood pressure management For hypertensive patients : ≤140/≤90 mm Hg For patients with diabetes, heart failure, or chronic kidney disease : ≤130/≤80 mm Hg	Measure seated resting blood pressure on at least two visits. Measure blood pressure in both arms at program entry. To rule out orthostatic hypotension, measure lying, seated, and standing blood pressure at program entry and after adjustments in antihypertensive drug therapy. Assess current treatment and compliance. Assess use of nonprescription drugs that may adversely affect blood pressure.	Provide and/or monitor drug therapy in concert with primary HCP as follows: For blood pressure 120-139 mm Hg systolic or 80-89 mm Hg diastolic : Provide counseling on lifestyle modifications, including regular physical activity/exercise; weight management; moderate sodium restriction and increased consumption of fresh fruits, vegetables, and low-fat dairy products; alcohol moderation; and smoking cessation. Provide drug therapy for patients with chronic kidney disease, heart failure, or diabetes if blood pressure is >130/>80 mm Hg after lifestyle modification. For blood pressure >140/>90 mm Hg : Provide counseling on lifestyle modifications and drug therapy according to current guidelines on hypertension.	Short-term : Continue to assess and modify intervention until normalization of blood pressure in prehypertensive patients. Long-term : Maintain blood pressure at goal levels.
Lipid management	Obtain fasting measures of total cholesterol, HDL-C, LDL-C, and triglycerides. In patients with abnormalities, obtain a detailed history to determine whether diet, drug, and/or other conditions that may affect lipid levels can be altered. Assess current treatment and compliance.	Nutritional counseling : Provide guidance consistent with the Therapeutic Lifestyle Change diet, such as the recommendation to add plant stanol/sterols and viscous fiber and the encouragement to consume more omega-3 fatty acids, as well as weight management counseling, as needed, in all patients. Add or intensify drug treatment in those with LDL-C <100 mg/dL; consider adding drug treatment in those with LDL-C <70 mg/dL. Provide interventions directed toward management of triglycerides to attain non–HDL-C <130 mg/dL. These include nutritional counseling; guidance and support in weight management, exercise, smoking cessation, and alcohol moderation; and drug therapy. Monitor treatment in collaboration with primary health care provider. Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months after initiation or change in lipid-lowering medications. Assess creatine kinase levels and liver function in patients taking lipid-lowering medications as recommended by drug manufacturer.	Short-term : Continue to assess and modify intervention until LDL-C is <100 mg/dL (further reduction to a goal of <70 mg/dL is considered reasonable) and non–HDL-C is <130 mg/dL (further reduction to a goal of <100 mg/dL is considered reasonable). Long-term : LDL-C <100 mg/dL is recommended goal (further reduction to <70 mg/dL is considered reasonable). Non–HDL-C <130 mg/dL is recommended goal (further reduction to <100 mg/dL is considered reasonable).

Area of Interest, with
Treatment Goal

Evaluation and Assessment

Intervention

Expected Outcomes

Blood pressure management

For hypertensive patients : ≤140/≤90 mm Hg
For patients with diabetes, heart failure, or chronic kidney disease : ≤130/≤80 mm Hg

Measure seated resting blood pressure on at least two visits.
Measure blood pressure in both arms at program entry.
To rule out orthostatic hypotension, measure lying, seated, and standing blood pressure at program entry and after adjustments in antihypertensive drug therapy.
Assess current treatment and compliance.
Assess use of nonprescription drugs that may adversely affect blood pressure.

Provide and/or monitor drug therapy in concert with primary HCP as follows:
For blood pressure 120-139 mm Hg systolic or 80-89 mm Hg diastolic :
Provide counseling on lifestyle modifications, including regular physical activity/exercise; weight management; moderate sodium restriction and increased consumption of fresh fruits, vegetables, and low-fat dairy products; alcohol moderation; and smoking cessation.
Provide drug therapy for patients with chronic kidney disease, heart failure, or diabetes if blood pressure is >130/>80 mm Hg after lifestyle modification.
For blood pressure >140/>90 mm Hg :
Provide counseling on lifestyle modifications and drug therapy according to current guidelines on hypertension.

Short-term : Continue to assess and modify intervention until normalization of blood pressure in prehypertensive patients.
Long-term : Maintain blood pressure at goal levels.

Lipid management

Obtain fasting measures of total cholesterol, HDL-C, LDL-C, and triglycerides.
In patients with abnormalities, obtain a detailed history to determine whether diet, drug, and/or other conditions that may affect lipid levels can be altered.
Assess current treatment and compliance.

Nutritional counseling : Provide guidance consistent with the Therapeutic Lifestyle Change diet, such as the recommendation to add plant stanol/sterols and viscous fiber and the encouragement to consume more omega-3 fatty acids, as well as weight management counseling, as needed, in all patients.
Add or intensify drug treatment in those with LDL-C
<100 mg/dL; consider adding drug treatment in those with LDL-C <70 mg/dL.
Provide interventions directed toward management of triglycerides to attain non–HDL-C <130 mg/dL. These include nutritional counseling; guidance and support in weight management, exercise, smoking cessation, and alcohol moderation; and drug therapy.
Monitor treatment in collaboration with primary health care provider.
Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months after initiation or change in lipid-lowering medications.
Assess creatine kinase levels and liver function in patients taking lipid-lowering medications as recommended by drug manufacturer.

Short-term : Continue to assess and modify intervention until LDL-C is <100 mg/dL (further reduction to a goal of <70 mg/dL is considered reasonable) and non–HDL-C is <130 mg/dL (further reduction to a goal of <100 mg/dL is considered reasonable).
Long-term : LDL-C <100 mg/dL is recommended goal (further reduction to <70 mg/dL is considered reasonable).
Non–HDL-C <130 mg/dL is recommended goal (further reduction to <100 mg/dL is considered reasonable).

HCP, Health care provider; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.

TABLE 34-7

Recommendations for Cardioprotective Medication after Acute Myocardial Infarction

Drug Category	Recommendations
Antiplatelet agents/anticoagulants	See Chapter 35 .
Renin-angiotensin-aldosterone system blockers
ACE inhibitors	ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction ≤40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. It is reasonable to use ACE inhibitors in all other patients.
ARBs	The use of ARBs is recommended in patients who have heart failure or who have had a myocardial infarction with left ventricular ejection fraction ≤40% and who are ACE inhibitor–intolerant. It is reasonable to use ARBs in other patients who are ACE inhibitor–intolerant. The use of ARBs in combination with an ACE inhibitor is not well established in patients with systolic heart failure.
Aldosterone-blocking agents	Use of aldosterone blockade in post–myocardial infarction patients without significant renal dysfunction (creatinine clearance >30 mL/min) or hyperkalemia (potassium should be <5.0 mEq/L) is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and a β-blocker, who have a left ventricular ejection fraction of 40% or less, and who have either diabetes or heart failure.
β-Adrenergic blockers (β-blockers)	1. β-Blocker therapy should be used in all patients with previous myocardial infarction or with left ventricular systolic dysfunction (as indicated by ejection fraction of 40% or less) unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol.) 2. β-Blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function who have had a myocardial infarction or an ACS. 3. It is reasonable to continue β-blockers beyond 3 years as chronic therapy in all patients with normal left ventricular function who have had a myocardial infarction or an ACS. 4. It is reasonable to use β-blocker therapy in patients with left ventricular systolic dysfunction (as indicated by ejection fraction of 40% or less) without heart failure or previous myocardial infarction.
Influenza vaccine	Patients should have an annual influenza vaccination.

ACE, Angiotensin-converting enzyme; ACS, Acute cardiac syndrome; ARBs, angiotensin receptor blockers.

TABLE 34-8

Assessment, Clinical Interventions, and Expected Outcomes for Psychosocial Management and Vocational Advice after Myocardial Infarction

Adapted from Smith SC Jr, Benjamin EJ, Bonow RO, et al: AHA/ACCF Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 124:2458-2473, 2011; Balady GJ, Williams MA, Ades PA, et al: Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 115:2675-2682, 2007; and Piepoli MF, Corra U, Adamopoulos S, et al: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664-681, 2014.

Area of Interest, with Treatment Goal	Evaluation and Assessment	Intervention	Expected Outcomes
Psychosocial management Absence of clinically significant depression and psychosocial problems	Screen for psychological distress using interview and/or other standardized measurement tools. Screen for substance abuse of alcohol and/or other psychotropic agents.	Offer individual and/or small group education and counseling on adjustment to heart disease, stress management, and health-related lifestyle change (e.g., profession, car driving, sexual activities), relaxation techniques. Whenever possible, offer spouses and other family members, domestic partners, and/or significant others access to information sessions. Teach and support self-help strategies and ways of obtaining effective social support. Provide vocational counseling in case of work-related stress. Treatment of depression in collaboration with mental health specialist and primary care provider	Emotional well-being Absence of clinically significant psychosocial problems and acquisition of stress management skills Improved health-related quality of life
Vocational advice Return to previous activities unless contraindications	Before discharge, return to previous activities must be discussed with the patients and their partners and return to previous activities must be promoted, unless there is a medical contraindication. The presence of any barriers to return to work (RTW) after illness should be assessed.	All procedures to help patients to overcome barriers to RTW and thereby remain in, return to, or gain access to employment; e.g., retraining and capacity building, reasonable adjustments and control measures, disability awareness, condition management, and medical treatment	Return to previous activities
Sexual functioning Return to previous activities unless contraindicated		Offer individual and/or small group education and counseling on sexual functioning and sexual activities.	Return to previous activities unless contraindicated.

Area of Interest, with
Treatment Goal

Evaluation and Assessment

Intervention

Expected Outcomes

Psychosocial management

Absence of clinically significant depression and psychosocial problems

Screen for psychological distress using interview and/or other standardized measurement tools.
Screen for substance abuse of alcohol and/or other psychotropic agents.

Offer individual and/or small group education and counseling on adjustment to heart disease, stress management, and health-related lifestyle change (e.g., profession, car driving, sexual activities), relaxation techniques.
Whenever possible, offer spouses and other family members, domestic partners, and/or significant others access to information sessions. Teach and support self-help strategies and ways of obtaining effective social support.
Provide vocational counseling in case of work-related stress.
Treatment of depression in collaboration with mental health specialist and primary care provider

Emotional well-being
Absence of clinically significant psychosocial problems and acquisition of stress management skills
Improved health-related quality of life

Vocational advice

Return to previous activities unless contraindications

Before discharge, return to previous activities must be discussed with the patients and their partners and return to previous activities must be promoted, unless there is a medical contraindication.
The presence of any barriers to return to work (RTW) after illness should be assessed.

All procedures to help patients to overcome barriers to RTW and thereby remain in, return to, or gain access to employment; e.g., retraining and capacity building, reasonable adjustments and control measures, disability awareness, condition management, and medical treatment

Return to previous activities

Sexual functioning

Return to previous activities unless contraindicated

Offer individual and/or small group education and counseling on sexual functioning and sexual activities.

Return to previous activities unless contraindicated.

Several principles of behavior change and validated educational theories are helpful in improving the patient’s motivation as well as individual ability to comprehend and digest a broad array of information. None of these principles (i.e., stages of change, self-efficacy concepts, outcome models, biofeedback) should be regarded as mutually exclusive, often the principles are combined, depending on patients’ needs and staff competences. Table 34-9 lists “ten strategic steps” to enhance counseling on behavioral change.

TABLE 34-9

Ten Strategic Steps to Enhance Counseling on Behavioral Change

From Perk J, De Backer G, Gohlke H, et al: European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 33:1635-1701, 2012.

1.
Develop a therapeutic alliance.
2.
Provide counseling for all patients at risk for or with manifest cardiovascular disease.
3.
Assist patients to understand the relationship between their behavior and health.
4.
Help patients assess the barriers to behavior change.
5.
Gain commitments from patients to own their behavior change.
6.
Involve patients in identifying and selecting the risk factors to change.
7.
Use a combination of strategies including reinforcement of the person’s capacity for change.
8.
Design a lifestyle modification plan.
9.
Involve other health care staff whenever possible.
10.
Monitor progress through follow-up contact.

Psychosocial Support

The relationship between psychosocial and cardiac health is complex, and both direct (e.g., psychological effects on immunologic function) and indirect (e.g., behaviorally mediated) mechanisms are thought to play a role. Consequently, patients may be offered a wide variety of psychological therapies to treat depression, anxiety, stress, or maladaptive behaviors, and these treatments aim to improve both psychological and cardiac health. Underpinning all psychosocial therapies for cardiac patients is some combination of the following four hypotheses: (1) that coronary heart disease and associated medical or surgical treatments may cause psychological distress; (2) that psychological symptoms may cause or exacerbate cardiac disease; (3) that unhealthy behaviors may be increased when people experience psychological distress; and (4) that psychological techniques may be useful in modifying risky behaviors.

Major depressive disorder is present in approximately 20% of patients with ischemic heart disease, which makes depression the most important psychosocial target in the clinical practice of cardiology. Depression and ischemic heart disease have a bidirectional relationship—that is, ischemic heart disease can cause depression, and depression is an independent risk factor for ischemic heart disease and its complications. Depression among people with established ischemic heart disease is clinically important in that it is associated with worse medical outcomes including poorer health-related quality of life, greater morbidity (odds ratio [OR], 2.0) and mortality (OR, 1.8 to 2.6), and greater use of routine and unscheduled health care.

The impact of psychological interventions for patients with a coronary heart disease has been the subject of a Cochrane review. The review included 24 RCTs comparing psychological interventions with usual care in 9296 participants who were predominantly at low risk for adverse outcomes after an MI or PCI procedure. The evidence showed of a trend toward a reduction in all-cause mortality (RR, 0.89; 95% CI, 0.75 to 1.05) and fewer cardiac deaths with psychological intervention (RR, 0.80; 95% CI, 0.64 to 1.00). No significant effects were observed in terms of the risk of revascularization (RR, 0.95; 95% CI, 0.80 to 1.13) and nonfatal reinfarction (RR, 0.87; 95% CI, 0.67 to 1.13). One of seven trials reported superiority in health-related quality of life after a psychological intervention compared with that in the control group.

A possible explanation for the fact that this analysis does not provide more unequivocal evidence for support of psychological interventions in terms of reductions in mortality and morbidity is that a majority of trials included all cardiac patients, regardless of their psychological symptoms. A plausible theory is that patient psychological screening after an acute event and then targeting interventions to those meeting a clinical threshold for psychological symptoms, depression or anxiety may be important to discerning efficacy of these interventions. The clinical value and cost-effectiveness of a strategy of targeting psychological interventions after an MI in those patients with diagnosed depression are being addressed in an ongoing RCT (CADENCE, ISRCTN 34701576). Under the umbrella of psychosocial support, current guidelines also advocate the integration of vocational advice on return to work and advice on resuming normal sexual functioning (see Table 34-8 ).

Comprehensive Risk Factor Management

As summarized in Table 34-6 , risk factor management is a pivotal part of comprehensive cardiac rehabilitation and secondary prevention.

Physical Activity Counseling

Participation in an exercise training program as part of cardiac rehabilitation and secondary prevention, as described previously, is considered an important tool to increase long-term physical activity level in post-MI patients. Regular physical activity is associated with a reduced risk of fatal and nonfatal coronary events in healthy people, persons with coronary risk factors, and cardiac patients over a wide age range. A sedentary lifestyle is one of the major risk factors for cardiovascular diseases. Engaging in regular physical activity is therefore suggested by guidelines as a very important nonpharmacologic component of risk factor control in primary as well as secondary prevention (see Table 34-5 ).

After an acute MI, a regimen of 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activity to improve cardiorespiratory fitness, should be encouraged. The basic goal in this context is to move patients out of the least-fit, least-active high-risk cohort.

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