Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by a multidisciplinary, private-sector comprising health care professionals and consumer representatives sponsored by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung, and Blood Institute (NHLBI). Panel members were:

• Nanette Kass Wenger, MD (Co-Chair)
• Erika Sivarajan Froelicher, RN, PhD (Co-Chair)
• L. Kent Smith, MD, MPH (Project Director)
• Philip A. Ades, MD
• Kathy Berra, BSN
• James A. Blumenthal, PhD
• Catherine M. E. Certo, ScD, PT
• Anne M. Dattilo, PhD, RD
• Dwight Davis, MD
• Robert F. DeBusk, MD
• Joseph P. Drozda, Jr., MD
• Barbara J. Fletcher, RN, MN
• Barry A. Franklin, PhD
• Helen Gaston
• Philip Greenland, MD
• Patrick E. McBride, MD, MPH
• Christopher G. A. McGregor, MB, FRCS
• Neil B. Oldridge, PhD
• Joseph C. Piscatella
• Felix J. Rogers, DO

An explicit, science-based methodology was employed together with expert clinical judgment to develop specific statements on comprehensive, long-term cardiac rehabilitation involving medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice.

This Quick Reference Guide for Clinicians presents summary points from the Clinical Practice Guideline. The latter provides a description of the guideline development process, thorough analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, more complete information for health care decisionmaking, consideration for patients with special needs, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners based on available resources and circumstances presented by the individual patient.

AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to:

• Director, Office of the Forum for Quality and Effectiveness in Health Care
• AHCPR
• Willco Building, Suite 310
• 6000 Executive Boulevard
• Rockville, MD 20852

Abstract

This Quick Reference Guide for Clinicians highlights the conclusions and recommendations from Cardiac Rehabilitation, Clinical Practice Guideline No. 17, which was formulated by a panel representing the major health care disciplines involved in cardiac rehabilitation. The conclusions and recommendations were derived from an extensive and critical review of the scientific literature pertaining to cardiac rehabilitation, as well as from the expert opinion of the panel. This guide addresses the role of cardiac rehabilitation and the potential benefits to be derived in the comprehensive care of the 13.5 million patients with coronary heart disease in the United States, as well as the 4.7 million patients with heart failure and the several thousand patients undergoing heart transplantation. This Quick Reference Guide for Clinicians highlights the major effects of multifactorial cardiac rehabilitation services: medical evaluation, prescribed exercise, cardiac risk factor modification, and education, counseling, and behavioral interventions. The outcomes of and recommendations for cardiac rehabilitation services are categorized as to their effects on exercise tolerance, strength training, exercise habits, symptoms, smoking, lipids, body weight, blood pressure, psychological well-being, social adjustment and functioning, return to work, morbidity and safety issues, mortality and safety issues, and pathophysiologic measures. Patients with heart failure and after cardiac transplantation, as well as elderly patients, are specifically addressed. Alternate approaches to the delivery of cardiac rehabilitation services are presented.

Suggested Citation

This document is in the public domain and may be used and reprinted without special permission. AHCPR and NHLBI appreciate citation as to source, and the suggested format is provided below:

Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation as Secondary Prevention. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. AHCPR Pub. No. 96-0673. October 1995.

Purpose and Scope

Cardiovascular disease is the leading cause of morbidity and mortality in the United States, accounting for almost 50 percent of all deaths. Coronary heart disease (CHD) with its clinical manifestations of stable angina pectoris, unstable angina, acute myocardial infarction, and sudden death affects 13.5 million Americans. Nearly 1.5 million Americans sustain myocardial infarction each year, of which almost 500,000 episodes are fatal. Myocardial infarction can occur at young age: 5 percent occur in people younger than age 40, and 45 percent occur in people under age 65.

The almost 1 million survivors of myocardial infarction each year and the more than 7 million patients with stable angina pectoris are candidates for cardiac rehabilitation, as are patients following revascularization with coronary artery bypass graft surgery (CABG) (309,000 patients in 1993, 45 percent under age 65) or percutaneous transluminal coronary angioplasty (PTCA) and other transcatheter interventional procedures (362,000 in 1993, 54 percent under age 65). Although several million patients with CHD are candidates for cardiac rehabilitation services, only 11 20 percent have participated in cardiac rehabilitation programs. More recently, among patients with acute myocardial infarction enrolled in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) Trial, 38 percent of U.S. patients and 32 percent of Canadian patients were subsequent participants in cardiac rehabilitation programs.

Heart failure is the most common discharge diagnosis for hospitalized Medicare patients and the fourth most common discharge diagnosis for all hospitalized patients in the United States. Application of cardiac rehabilitation services to patients with heart failure and after cardiac transplantation has gained increasing recognition and acceptance as its benefits and safety are documented. An estimated 4.7 million patients with heart failure may be candidates for cardiac rehabilitation.

Cardiac rehabilitation is characterized by comprehensive long- term services involving medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. This multifactorial process is designed to limit the adverse physiologic and psychological effects of cardiac illness, reduce the risk of sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the patient's psychosocial and vocational status. Provision of these services is physician-directed and implemented by a variety of health care professionals.

This guide is designed for use by health practitioners who provide care to patients with cardiovascular disease. These clinicians include physicians (primary care, cardiologists, and cardiovascular surgeons), nurses, exercise physiologists, dietitians, behavioral medicine specialists, psychologists, and physical and occupational therapists. The information can guide clinical decisionmaking regarding referral and followup of patients for cardiac rehabilitation services, as well as administrative decisions regarding the availability of and access to cardiac rehabilitation.

Figure 1 [parts 1 and 2] presents the decision tree for cardiac rehabilitation services. This figure describes patient categories addressed by the guide as well as the patient assessment and treatment strategies involved in the delivery of cardiac rehabilitation services. Tables 1 and 2 summarize the scientific evidence on which Cardiac Rehabilitation, Clinical Practice Guideline No. 17, is based. The evidence summaries (Tables 1 and 2) display the outcomes pertaining to the two major components of cardiac rehabilitation services: (1) exercise training and (2) education, counseling, and behavioral interventions. Cardiac Rehabilitation, Clinical Practice Guideline No. 17, the highlights of which are provided here, offers a more comprehensive presentation of the scientific basis for cardiac rehabilitation services and their outcomes.

Figure 1

Table

Table 1. Summary of evidence for cardiac rehabilitation outcomes: Effects of exercise training.

Table

Table 2. Summary of evidence for cardiac rehabilitation outcomes: Effects of education, counseling, and behavioral interventions.

The components of cardiac rehabilitation services include exercise training; education, counseling, and behavioral interventions; and organizational issues, including consideration of alternate approaches to the delivery of cardiac rehabilitative care. The physiologic parameters targeted included improvement in exercise tolerance and exercise habits; optimization of risk factor status including improvement in blood lipid and lipoprotein profiles, body weight, blood glucose and blood pressure levels, and cessation of smoking. Emotional responses to living with heart disease must be addressed, including reduction of stress and anxiety and lessening of depression. Functional independence of patients, particularly at elderly age, is an essential goal. Return to appropriate and satisfactory occupation could benefit both patients and society. Throughout, the panel highlighted the added effectiveness of multifactorial cardiac rehabilitation services, integrated in a comprehensive approach.

More than 400 scientific reports were critically reviewed, with 334 included as references in the Clinical Practice Guideline. The review process focused on the components of cardiac rehabilitation as specific interventions, with benefits and harms rigorously examined, and attention devoted to the generalizability of published results. When appropriate and necessary, expert opinion was formally derived from the panel to supplement conclusions derived from the comprehensive review of the scientific literature.

The results of cardiac rehabilitation services, based on reports in the scientific literature, are summarized in this Quick Reference Guide for Clinicians. The most substantial benefits include:

• Improvement in exercise tolerance.
• Improvement in symptoms.
• Improvement in blood lipid levels.
• Reduction in cigarette smoking.
• Improvement in psychosocial well-being and reduction of stress.
• Reduction in mortality.

The outcomes of application of cardiac rehabilitation services are addressed on the following pages.

Exercise Tolerance

Cardiac rehabilitation exercise training consistently improves objective measures of exercise tolerance, without significant cardiovascular complications or other adverse outcomes. Appropriately prescribed and conducted exercise training is recommended as an integral component of cardiac rehabilitation services, particularly for patients with decreased exercise tolerance. Continued exercise training is required to sustain improved exercise tolerance.

The beneficial effect of cardiac rehabilitation exercise training on exercise tolerance is one of the most clearly established favorable outcomes for coronary patients with angina pectoris, myocardial infarction, CABG, and PTCA and for patients with compensated heart failure or a decreased ventricular ejection fraction or following cardiac transplantation. This approach is particularly beneficial for patients with decreased functional capacity. The large number of studies that reported a favorable outcome allowed the panel to ascertain the characteristics of exercise training that resulted in improved exercise tolerance. The most consistent benefit appeared to occur with exercise training at least three times weekly for 12 or more weeks' duration. The duration of aerobic exercise training sessions varied from 20 to 40 minutes, at an intensity approximating 70 85 percent of the baseline exercise test heart rate.

No increase in cardiovascular complications or other serious adverse outcomes were reported in any randomized controlled trial that evaluated exercise training in patients with CHD. These trials involved patients with various manifestations of CHD including 3,932 patients following myocardial infarction, 745 patients with catheterization-documented CHD, 215 patients following CABG, and 139 patients following PTCA. No deterioration in measures of exercise tolerance was reported in any patient undergoing exercise training, nor did any controlled study document significantly greater improvement in exercise tolerance in control patient groups compared with exercise patient groups.

Limited data fail to demonstrate the efficacy of education, counseling, and behavioral interventions as sole interventions, independent of cardiac rehabilitation exercise training, in improving exercise tolerance. Education and behavioral interventions may improve morale, self-esteem, and adherence to exercise.

Strength Training

Strength training improves skeletal muscle strength and endurance in clinically stable coronary patients. Training measures designed to increase skeletal muscle strength can safely be included in the exercise-based rehabilitation of clinically stable coronary patients, when appropriate instruction and surveillance are provided.

Scientific data demonstrate the effectiveness of resistance exercise training in selected patients with CHD. The absence of signs or symptoms of myocardial ischemia, abnormal hemodynamic changes, and cardiovascular complications in these studies suggests that resistance exercise training is safe for selected coronary patients who have previously participated in rehabilitative aerobic exercise training. Improvement in muscle strength can benefit patients' performance of activities of daily living. The absence of cardiovascular and orthopedic complications in the 3-year followup of strength training was largely attributed to strict preliminary screening and careful supervision. Most studies involved small numbers of low-risk male patients, 70 years or younger, with minimal functional aerobic impairment and with normal or near- normal left ventricular function. The extent to which the safety and effectiveness demonstrated by these studies can be extrapolated to other populations of coronary or cardiac patients (e.g., women, older patients of both genders with low aerobic fitness, patients at moderate-to-high cardiovascular risk) requires study.

Exercise Habits

Cardiac rehabilitation exercise training promotes increased participation in exercise by patients after myocardial infarction and CABG. This effect does not persist long-term after completion of exercise rehabilitation. Long-term cardiac rehabilitation exercise training is recommended to provide the benefit of enhanced exercise tolerance and exercise habits.

There is suggestive evidence that exercise training enhances subsequent exercise habits. A limitation of the scientific data relating to continued exercise habits as a result of rehabilitative exercise training is the self-report nature of the information, which was typically based on questionnaire or physical activity diary data. Despite limited information in the cardiac rehabilitation literature, extensive studies and position statements in populations without apparent heart disease document that regular exercise, including a wide scope of physical activities with a broad range of intensity and duration, has beneficial effects on overall health, morbidity, and mortality. Patients should be encouraged to undertake exercise activities following cardiac exercise rehabilitation that are personally enjoyable and that can be sustained long-term. The panel highlighted the need to encourage women, particularly older women, to participate in cardiac rehabilitation designed to enhance exercise capacity and physical activity.

The panel endorses the position statement of the American Heart Association regarding physical activity, that "regular aerobic physical activity increases exercise capacity and plays a role in both primary and secondary prevention of cardiovascular disease."

Symptoms

Exercise rehabilitation decreases angina pectoris in patients with CHD and decreases symptoms of heart failure in patients with left ventricular systolic dysfunction. Exercise training is recommended as an integral component of the symptomatic management of these patients. Symptoms of angina pectoris are also reduced by cardiac rehabilitation education, counseling, and behavioral interventions alone or as a component of multifactorial cardiac rehabilitation.

Improvement in cardiovascular symptomatic status, both angina pectoris and heart failure symptoms, occurs as a result of cardiac rehabilitation exercise training. Symptomatic outcomes in the scientific studies were confounded by inadequate information regarding changes in medication status, by differing levels of exercise or physical activity, as well as by nonrehabilitation exercise activities of control patients. Change in symptomatic status of cardiac patients often results in changes in medication regimens.

Education and behavioral interventions, either alone or as components of multifactorial cardiac rehabilitation, are associated with reduction in angina pectoris. Behavioral interventions are generally effective in reducing anginal pain.

Smoking

A combined approach of cardiac rehabilitation education, counseling, and behavioral interventions results in smoking cessation and relapse prevention. Smoking cessation and relapse prevention programs should be offered to patients who are smokers to reduce their risk of subsequent coronary events. Smoking cessation is achieved by specific smoking cessation strategies.

Well-designed education, counseling, and behavioral interventions (relapse prevention) reduce cigarette smoking. Between 17 and 26 percent of patients can be expected to stop smoking, in addition to the spontaneously high smoking cessation rates in most populations soon after myocardial infarction. One effective model includes nurse-managed smoking cessation behavioral intervention with biochemical verification of smoking status. Whether biochemical verification should be recommended for clinical practice is unclear. Scientific evidence, consensus papers, and other scientific reviews in nonrehabilitation settings, including the Surgeon General's messages since 1965, lend strong support that education, counseling, and behavioral interventions are beneficial for smoking cessation. Given the documented benefit of smoking cessation in decreasing coronary risk, specific techniques of proven value in effecting smoking cessation should be incorporated in multifactorial cardiac rehabilitation.

There is little or no evidence of beneficial outcome in smoking cessation resulting from exercise training as a sole intervention.

Lipids

Intensive nutrition education, counseling, and behavioral interventions improve dietary fat and cholesterol intake. Education, counseling, and behavioral interventions about nutrition, with and without pharmacologic lipid-lowering therapy, result in significant improvement in blood lipid levels and are recommended as a component of cardiac rehabilitation. Optimal lipid management requires specifically directed dietary and, as medically indicated, pharmacologic management, in addition to cardiac rehabilitation exercise training.

Efficacy is documented in non-cardiac-rehabilitation settings of intensive nutrition education, counseling, and behavioral interventions on dietary fat intake and blood lipid levels. Results from a meta-analysis of 70 studies indicate that weight reduction through dietary modification can help normalize plasma lipid and lipoprotein levels in overweight individuals. The Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) (NCEP II) recommended a low-density lipoprotein (LDL) cholesterol goal of less than 100 mg/dL for coronary patients. This requires high- intensity intervention that includes education, counseling, behavioral intervention, and adherence and motivational strategies as well as pharmacologic therapy for appropriate patients. Thus, independent effects of education and counseling may be impossible to ascertain.

Improvement in lipid profiles resulting from multifactorial cardiac rehabilitation is well established by review of the scientific literature. Most randomized controlled trials reported beneficial effects on total cholesterol, LDL cholesterol, high- density lipoprotein (HDL) cholesterol, and triglyceride levels in rehabilitation compared with control patients. Well-designed nonrandomized controlled trials reported similar beneficial outcomes. The rehabilitation studies that reported the most favorable impact on lipid levels were multifactorial, that is, providing exercise training, dietary education and counseling, and, in some studies, pharmacologic treatment, psychological support, and behavioral training. These favorable effects on lipid profiles involved patients who were both younger and older than 65 years of age. Cardiac rehabilitation exercise training as a sole intervention has inconsistent effects on lipid and lipoprotein levels.

The panel concurs with the recommendation of the NCEP II regarding the role of physical activity for lipid control, namely "the appropriate use of physical activity is considered an essential element in the nonpharmacologic therapy of elevated serum cholesterol." The panel also noted the results of a major randomized placebo-controlled trial of cholesterol lowering in coronary patients, most with prior myocardial infarction. Patients treated with a cholesterol-altering medication and a Step I diet showed a significant reduction in total mortality, coronary death, and major coronary events compared with diet-plus placebo-treated patients. Favorable results occurred in both men and women patients younger and older than 60 years of age. The panel agreed with the trial conclusions that patients with CHD and diet-resistant cholesterol levels above 210 mg/dL should be considered for treatment with lipid-altering medication.

Body Weight

Multifactorial cardiac rehabilitation that combines dietary education, counseling, and behavioral interventions designed to reduce body weight can help patients lose weight. Education as a sole intervention is unlikely to achieve and maintain weight loss. Cardiac rehabilitation exercise training as a sole intervention also has an inconsistent effect on controlling overweight and is not recommended as an isolated approach for weight loss. The optimal management recommended for overweight patients to promote maintenance of weight loss requires multifactorial rehabilitation including nutrition education, counseling, and behavioral modification, in addition to exercise training.

Education is a necessary component of a successful weight- reduction intervention but is not sufficient as a sole intervention to effect sustained weight loss. Nutrition education combined with behavioral interventions and prescribed exercise training can achieve modest and sustained weight loss. Results of meta-analysis of 70 studies indicate that weight reduction through dieting can also help normalize plasma lipid and lipoprotein levels in overweight individuals. The panel noted a review of the behavioral therapy literature involving obese patients; state-of-the-art weight loss programs that have been shown to be successful in nonrehabilitation settings are also likely to be successful in a cardiac rehabilitation setting. Expert opinion agrees that multifactorial interventions, with intensive education, counseling, and behavioral intervention, are effective to reduce weight.

Rehabilitative exercise training, as a component of multifactorial intervention, appears beneficial in improving body weight, excess body mass, or percentage of body fat. Exercise training as a sole intervention has no consistent effect, but no exercise-training study specifically targeted overweight coronary patients, and the definition of "overweight" varied among studies.

Blood Pressure

Expert opinion supports a multifactorial education, counseling, behavioral, and pharmacologic approach as the recommended strategy for the management of hypertension. This approach is documented to be effective in nonrehabilitation populations. Neither education, counseling, and behavioral interventions nor rehabilitative exercise training as sole interventions have been shown to control elevated blood pressure levels.

Scientific evidence suggests that cardiac rehabilitation education alone fails to significantly decrease blood pressure. One of the most serious flaws in study designs includes the mixed sample of normotensive patients and a small proportion of hypertensive patients. The panel recommends the application of The Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V) educational and behavioral recommendations as an important component of a multifactorial approach to reduce hypertension for the cardiac rehabilitation population. The JNC V recommendations, which were based on the opinion of recognized experts on hypertension, stated that "lifestyle modifications such as weight reduction, physical activity and moderation of dietary sodium are recommended as definitive or adjunctive therapy for hypertension." The JNC V also concluded that the scientific literature does not support use of stress management as a sole intervention for hypertension control and reiterated that relaxation and biofeedback techniques have little effect on hypertension control.

Review of the scientific evidence suggests that exercise-based cardiac rehabilitation has only modest effects in reducing blood pressure levels, but confounding variables include the effects of antihypertensive medications and medication changes. No study was specifically designed to address hypertension control in patients with elevated blood pressures participating in exercise-based cardiac rehabilitation. It is unlikely that hypertensive patients with CHD would be provided solely exercise training without other appropriate therapies such as weight reduction, sodium restriction, moderation or abstinence from alcohol, or pharmacologic therapy, although these components may have been directed by the patient's treating physician.

Comprehensive educational programs should include information about weight management, exercise, and nutrition; they should provide information about the purpose of medications, their potential side effects, and strategies to improve medication adherence.

Psychological Well-Being

Education, counseling, and/or psychosocial interventions, either alone or as a component of multifactorial cardiac rehabilitation, result in improved psychological well-being and are recommended to complement the psychosocial benefits of exercise training.

Cardiac rehabilitation exercise training, with and without other cardiac rehabilitation services, results in improvement in measures of psychological status and functioning and is recommended to enhance psychological functioning, particularly as a component of multifactorial cardiac rehabilitation. Exercise training as a sole intervention does not consistently improve measures of anxiety and depression.

The scientific literature provides evidence of psychological improvement following education, counseling, and/or interventions. Training in behavioral modification, stress management, and relaxation techniques is effective in lowering levels of self-reported emotional stress and in modifying Type-A behavior.

Cardiac rehabilitation exercise training, either alone or as a component of multifactorial rehabilitation, often results in improvement in various measures of psychological status and functioning. This evidence from the scientific literature is consistent with the widespread belief among cardiac rehabilitation professionals that cardiac rehabilitation exercise training improves the sense of well-being among participants, particularly among individuals with high levels of distress at entry into the study. Patients tend to perceive themselves as improving in a number of psychosocial domains, although these perceptions may not be objectively documented. More sensitive tests may have to be developed to better ascertain changes in cardiac patients without specific psychiatric illness.

Studies of exercise rehabilitation as a sole intervention are confounded by the consequences of group interaction, formation of social support networks, peer and professional support, counseling, and guidance, all of which may affect depression, anxiety, and self-confidence.

Social Adjustment and Functioning

Cardiac rehabilitation exercise training improves social adjustment and functioning and is recommended to improve social outcomes.

The scientific literature addressed various measures of social adjustment and functioning in patients following cardiac rehabilitation exercise training including the Sickness Impact Profile scores, leisure and social questionnaire scores, social activity scores, and scores of satisfaction with work and social satisfaction. Randomized controlled trials established that social benefits result from participation in exercise and in multifactorial cardiac rehabilitation. Only two reports involved patients over age 65; social outcomes for this age group may differ from those in the majority of patients studied, younger than 60-65 years.

Return to Work

Cardiac rehabilitation exercise training exerts less of an influence on the rates of return to work than many nonexercise variables including employer attitudes, prior employment status, economic incentives, and the like. Exercise training as a sole intervention is not recommended to facilitate return to work, nor have education, counseling, and behavioral interventions resulted in improvement in rates of return to work. Many patients return to work without formal interventions. However, in selected patients, formal cardiac rehabilitation vocational counseling may improve rates of return to work.

Assessment of return to work as a result of exercise training must be considered within the context of social and political variables that are typically not addressed in the studies of cardiac rehabilitation; these include the political system and social policies of the country in which cardiac rehabilitation occurs. Additional factors include employment statistics for the years of the study, economic incentives or disincentives for patients to return to work, non-patient-related factors such as employer attitudes, and the preillness employment status of the patient, among others. Return to work as a measure of outcome of exercise-based cardiac rehabilitation may not be appropriate unless formal vocational rehabilitation services are provided to patients as part of the rehabilitative process.

Although multifactorial cardiac rehabilitation has not been shown to alter the rates of return to work, education and counseling may improve a patient's potential for return to work. Better understanding (via education) of capabilities and limitations regarding work may influence a patient's self-efficacy for returning to previous employment or for seeking job retraining. A randomized controlled trial in a nonrehabilitation setting of the effects of occupational work evaluation on return to work, involving patients after myocardial infarction, documented a marked reduction in duration of convalescence.

Morbidity and Safety Issues

The safety of exercise rehabilitation is well established; the rates of myocardial infarction and cardiovascular complications during exercise training are very low.

Cardiac rehabilitation exercise training does not change the rates of nonfatal reinfarction.

Education, counseling, and behavioral interventions as components of multifactorial cardiac rehabilitation may decrease progression of coronary atherosclerosis and lower recurrent coronary event rates.

Appropriately designed and conducted exercise-based cardiac rehabilitation can safely be undertaken in appropriately selected patients undergoing individualized initial assessment and surveillance.

The randomized controlled trials reported in the scientific literature show no evidence for reduction in cardiac morbidity, specifically nonfatal reinfarction, as a result of exercise rehabilitation. No study documented an increase in morbidity comparing rehabilitation patients with control patients among 4,578 patients in the controlled trials reviewed.

A large survey of adverse experiences during rehabilitative exercise training in 142 U.S. cardiac rehabilitation programs (1980-84) reported a very low rate of nonfatal reinfarction of 1 per 294,000 patient-hours. These 1980-84 survey data may not be applicable to contemporary treatment of coronary patients, including the widespread use of risk stratification procedures following myocardial infarction, the more aggressive management techniques including thrombolytic therapy and myocardial revascularization, as well as current pharmacologic therapies for postinfarction patients (e.g., beta blockers, angiotensin- converting enzyme [ACE] inhibitors) that may further reduce reinfarction and morbidity in coronary patients. The current low nonfatal reinfarction rates may not be amenable to further reduction by exercise training as a sole intervention.

Based on the scientific literature, education, counseling, and behavioral interventions alone may have limited beneficial effect on cardiovascular event rates. Education, counseling, and behavioral interventions designed to encourage patients to adhere to therapies, as a component of multifactorial cardiac rehabilitation, have been associated with reduction in recurrent cardiovascular event rates, as well as with regression of atherosclerosis.

Mortality and Safety Issues

Based on meta-analyses, total and cardiovascular mortality are reduced in patients following myocardial infarction who participate in cardiac rehabilitation exercise training, especially as a component of multifactorial rehabilitation. Education, counseling, and behavioral interventions reduce cardiac and overall mortality rates and are recommended in the multifactorial rehabilitation of patients with CHD.

A survival benefit among patients participating in exercise training as a component of multifactorial cardiac rehabilitation is suggested from review of the scientific data, but this benefit cannot be attributed solely to exercise training because many studies involved multifactorial rehabilitation. Because of the small number of patients in most randomized controlled trials, the panel used results of meta-analyses to gain additional information about mortality outcomes. Two meta-analyses of 21 randomized controlled trials of cardiac rehabilitation that included more than 4,000 patients with CHD established significant mortality reduction, approximating 25 percent at 3 years, in rehabilitation patients compared with control patients. This mortality reduction is similar to that with other interventions for patients with CHD (e.g., trials of beta-blocker drug therapy following myocardial infarction; ACE inhibitor therapy for left ventricular systolic dysfunction and heart failure). The beneficial mortality outcome was greater in the 15 trials that used multifactorial cardiac rehabilitation compared with the 7 trials that used exercise training as the sole intervention.

The randomized controlled trials in the panel's database that reported mortality rates included a total of 7,063 patients. In no trial was the rate of fatal events greater in the intervention group than in the control group.

Most studies involved principally male patients younger than age 65 years following myocardial infarction and excluded high-risk complex patients, limiting the generalizability of the data. The percentage of females, when enrolled, was 20 percent or less. Furthermore, subsequent to the research studies cited as scientific evidence, mortality has been further reduced by nonrehabilitation interventions such as myocardial revascularization procedures and newer pharmacologic agents that have far more powerful effects on survival.

Information obtained from two large surveys of cardiac rehabilitation program responses to questionnaires provided retrospective safety data regarding exercise training. Few fatal cardiac events occurred during or immediately following exercise training: 1 per 116,400 patient-hours of participation in supervised exercise training in the 1978 report and 1 per 784,000 patient-hours in the 1986 report. The data from both survey reports antedate the use of contemporary risk stratification procedures and contemporary medical and surgical therapies for CHD and heart failure. No mortality data were reported by gender or patient age, nor was definitive information available regarding the effect of levels of supervision and electrocardiographic (ECG) monitoring of exercise training.

A variety of education, counseling, and behavioral interventions are associated with reductions in total and cardiac mortality rates. The panel noted the consistency with which decreased mortality rates were reported in the randomized controlled trials of multifactorial cardiac rehabilitation involving education, counseling, and behavioral interventions. The panel recognizes the potential for reducing mortality rates by education, counseling, and behavioral interventions that are designed to reduce cardiac risk, as components of multifactorial cardiac rehabilitation.

Pathophysiologic Measures

Patients With Heart Failure and Cardiac Transplantation

Rehabilitative exercise training in patients with heart failure and moderate-to-severe left ventricular systolic dysfunction improves functional capacity and symptoms, without changes in left ventricular function. Cardiac rehabilitation exercise training is recommended to attain functional and symptomatic improvement.

Rehabilitative exercise training in patients following cardiac transplantation improves measures of exercise tolerance and is recommended for this purpose.

In the early years of exercise rehabilitation, cardiac enlargement, decreased left ventricular ejection fraction, and overt cardiac failure were considered relative or absolute contraindications to exercise training. Only in recent years has exercise training been undertaken in these patients; even these recent trials reflect only limited concomitant use of contemporary vasodilator drug therapies, particularly ACE inhibitors, which are now considered the standard of care for heart failure. The panel concurs with the recommendation of the AHCPR publication Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction, Clinical Practice Guideline No. 11, that "patients with heart failure due to left-ventricular systolic dysfunction should be given a trial of ACE inhibitors unless specific contra-indications exist."

Most studies of exercise training of patients with heart failure and moderate-to-severe left ventricular dysfunction do not demonstrate deterioration in left ventricular function. Peripheral (skeletal muscle) adaptations appear to mediate the improvement in exercise tolerance. Exercise training augments the symptomatic and functional benefits of ACE inhibitor therapy. Low- to moderate- intensity exercise and home exercise regimens provide benefit, but adverse events may occur in this high-risk patient group.

In summary, although the studies of exercise training have been limited by small numbers and young populations consisting predominantly of men, and had CHD as the major etiology of heart failure, exercise training in patients heart failure and decreased ventricular systolic function resulted in documented improvement in functional capacity. Data reinforce that the favorable training effects in these patients are due predominantly to adaptations in the peripheral circulation and skeletal musculature rather than adaptations in the cardiac musculature.

Cardiac transplantation, too, is a relatively recent surgical intervention; even more recent for cardiac transplantation patients is the frequent application of exercise training. The few studies reported demonstrate improvement in exercise capacity in these medically complex patients, who are often markedly deconditioned prior to cardiac transplantation. Pretransplantation rehabilitative strength training may enhance preoperative status and operative recovery; effects of strength training after cardiac transplantation require study.

Elderly Patients

Elderly coronary patients have exercise trainability comparable to younger patients participating in similar exercise rehabilitation. Elderly female and male patients show comparable improvement. Referral to and participation in exercise rehabilitation is less frequent at elderly age, especially for elderly females. No complications or adverse outcomes of exercise training at elderly age were described in any study. Elderly patients of both genders should be strongly encouraged to participate in exercise-based cardiac rehabilitation.

Elderly patients constitute a high percentage of those with myocardial infarction, CABG, and PTCA. Elderly patients are also at high risk of disability following a coronary event.

Although few studies and no randomized controlled trials addressed the efficacy and safety of exercise training and multifactorial rehabilitation at elderly age, the available studies provide important new information of beneficial functional improvement from exercise training for current clinical practice.

Special effort is recommended to overcome the obstacles to entry and participation in cardiac rehabilitation services for elderly patients.

Alternate Approaches to the Delivery of Cardiac Rehabilitation Services

Alternate approaches to the delivery of cardiac rehabilitation services, other than traditional supervised group interventions, can be implemented effectively and safely for carefully selected clinically stable patients. Transtelephonic and other means of monitoring and surveillance of patients can extend cardiac rehabilitation services beyond the setting of supervised, structured, group-based rehabilitation. These alternate approaches have the potential to provide cardiac rehabilitation services to low- and moderate-risk patients, who comprise the majority of patients with stable CHD, most of whom do not currently participate in structured supervised rehabilitation.

Recent studies have explored new approaches to deliver cardiac rehabilitation services, with the goals of increasing availability and decreasing costs, while preserving efficacy and safety. Case management approaches to exercise training, smoking cessation, diet drug management of hyperlipidemia, and providing emotional support and guidance to patients as needed that rely on telephone contact can be provided to appropriately selected patients with CHD.

The generalizability of these case management systems to other treatment settings including university centers, public and community hospitals, and clinics will depend largely on formulas for reimbursement for services and the extent of physician support for this approach, as well as State regulations regarding medical and health care practices. Within each of these settings, managed care programs seeking optimal methods for coronary risk factor reduction and exercise rehabilitation may favor case management systems that provide convenient, individualized health care at low cost.

The feasibility, safety, efficacy, and economic impact of these alternate approaches have to be assessed in more diverse populations of patients with stable CHD, particularly elderly patients, those with ventricular dysfunction, and other patients of higher risk status.

Adherence

Adherence to cardiac rehabilitation services may improve patient outcomes. Adherence to cardiac rehabilitation services may be enhanced by clear communication; emotional support; understanding the patient's (and family's) values, viewpoints, and preferences; and integration of the intervention into the patient's lifestyle.

Cost

Limited data suggest that multifactorial cardiac rehabilitation is a cost-effective use of medical care resources.

A limited number of economic evaluations of rehabilitation in patients after coronary events demonstrated favorable economic outcomes. Although none of these studies provided comprehensive economic analyses, the costs of cardiac rehabilitation have to be considered in the perspective of benefits of such rehabilitation. At relatively low cost, clinical benefits are attained, as are favorable economic outcomes. Nonetheless, application of longer term multifactorial cardiac rehabilitation services may entail increased costs.

Availability of Guidelines

For each clinical practice guideline developed under the sponsorship of the Agency for Health Care Policy and Research (AHCPR), several versions are produced to meet different needs.

The Clinical Practice Guideline presents recommendations for health care providers with brief supporting information, tables and figures, and pertinent references.

The Quick Reference Guide for Clinicians is a distilled version of the Clinical Practice Guideline, with summary points for ready reference on a day-to-day basis.

The Consumer Version, available in English and Spanish, is an information booklet for the general public to increase patient knowledge and involvement in health care decisionmaking.

To order single copies of guideline products or to obtain further information on their availability, call the AHCPR Publications Clearinghouse toll-free at 800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Single copies of the Clinical Practice Guideline are available for sale from the Government Printing Office, Superintendent of Documents, Washington, DC 20402, with a 25- percent discount given for bulk orders of 100 copies or more. The Quick Reference Guide for Clinicians and the Consumer Version in English are also available for sale in bulk quantities only. Call (202) 512-1800 for price and ordering information.

The Guideline Technical Report contains complete supporting materials for the Clinical Practice Guideline, including background information, methodology, literature review, scientific evidence tables, recommendations for research, and a comprehensive bibliography. It is available from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Call (703) 487-4650 for price and ordering information.

The full text of guideline documents for online retrieval may be accessed through a free electronic service from the National Library of Medicine called HSTAT (Health Services/Technology Assessment Text). Guideline information is also available through some of the computer-based information systems of the National Technical Information Service, professional associations, nonprofit organizations, and commercial enterprises.

A fact sheet describing Online Access for Clinical Practice Guidelines (AHCPR Publication No. 94-0075) and copies of the Quick Reference Guide for Clinicians and the Consumer Version of each guideline are available through AHCPR's InstantFAX, a fax-on-demand service that operates 24 hours a day, 7 days a week. AHCPR's InstantFAX is accessible to anyone using a facsimile machine equipped with a touchtone telephone handset: Dial (301) 594-2800, push "1", and then press the facsimile machine's start button for instructions and a list of currently available publications.

U. S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Executive Center, Suite 501, 2101 East Jefferson Street, Rockville, MD 20852. AHCPR Publication No. 96-0673, October 1995.

Selected Bibliography

1. Ades PA, Waldmann ML, Gillespie C A controlled trial of exercise training in older coronary patients J Gerontol 199550A:M7–11. [PubMed: 7814791]
2. Agency for Health Care Policy and Research. Cardiac rehabilitation programs. Health technology assessment reports, 1991, no. 3. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. DHHS publication no. AHCPR 92-0015. Dec 1991.
3. American Heart Association. Cardiac rehabilitation programs: a statement for health care professionals from the American Heart Association [position statement] Circulation. 1994;90:1602–10. [PubMed: 8087975]
4. DeBusk RF, Houston Miller N, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE 3d, Heller RS, Rompf J, Gee D, et al A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721–9. [PubMed: 8147544]
5. Feigenbaum E, Carter E Cardiac rehabilitation services. Health technology assessment report, 1987, no 6, Rockville, , MD: . U.S. Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Care Technology Assessment. DHHS publication no. PHS 88-3427 Aug. 1988.
6. Giannuzzi P, Tavazzi L, Temporelli PL, Corra U, Imparato A, Gattone M, Giordano A, Sala L, Schweiger C, Malinverni C. Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. J Am Coll Cardiol. 1993;22:1821–9. [PubMed: 8245335]
7. Hambrecht R, Niebauer J, Marburger C, Grunze M, Kalberer B, Hauer K, Schlierf G, Kubler W, Schuler G. Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. J Am Coll Cardiol. 1993;22:468–77. [PubMed: 8335816]
8. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, Williams PT, Johnstone IM, Champagne ME, Krauss RM, et al Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease: The Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994;89:975–90. [PubMed: 8124838]
9. Konstam M, Dracup K, Baker D, Bottorff MB, Brooks, NH, Dacey RA, Dunbar SB, Jackson AB, Jessup M, et al Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction Clinical practice guideline no. 11, Rockville, , MD: . U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR publication no. 94-0612 June 1994.
10. Lavie CJ, Milani RV, Littman AB. Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly. J Am Coll Cardiol. 1993;22:678–83. [PubMed: 8354798]
11. National Cholesterol Education Program. The second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). NIH publication no. 93-3095. Bethesda (MD): National Institutes of Health, National Heart, Lung, and Blood Institute. Sep. 1993.
12. National High Blood Pressure Education Program. The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure NIH publication no. 93-1088, Bethesda , (MD):. National Institutes of Health, National Heart, Lung, and Blood Institute Jan. 1993.
13. O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr, Hennekens CH An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234–44. [PubMed: 2665973]
14. Oldridge NB, Guyatt G, Jones N, Crowe J, Singer J, Feeny D, McKelvie R, Runions J, Streiner D, Torrance G Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. Am J Cardiol. 1991;67:1084–9. [PubMed: 2024598]
15. Schuler G, Hambrecht R, Schlierf G, Niebauer J, Hauer K, Neumann J, Hoberg E, Drinkmann A, Bacher F, Grunze M. Regular physical exercise and low-fat diet: effects of progression of coronary artery disease. Circulation. 1992;86:1–11. [PubMed: 1617762]
16. Stevenson LW, Steimle AE, Fonarow G, Kermani M, Kermani D, Hamilton MA, Moriguchi JD, Walden J, Tillisch JH, Drinkwater DC, et al. Improvement in exercise capacity of candidates awaiting heart transplantation. J Am Coll Cardiol. 1995;25:163–70. [PubMed: 7798496]
17. Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA. 1986;256:1160–3. [PubMed: 3735650]
18. Wenger NK, Balady GJ, Cohen LH, Hartley LH, King SB 3d, Miller HS Jr, Weiner DA (the Ad Hoc Task Force on Cardiac Rehabilitation). Cardiac rehabilitation services following PTCA and valvular surgery: guidelines for use. Cardiology. 1990;19:4–5.
19. Wenger NK, Haskell WL, Kanter K, Squires RW, Yusuf S (the Ad Hoc Task Force on Cardiac Rehabilitation). Cardiac rehabilitation services after cardiac transplantation: guidelines for use. Cardiology. 1991;20:4–5.
20. Worcester MC, Hare DL, Oliver RG, Reid MA, Goble AJ. Early programmes of high and low intensity exercise and quality of life after acute myocardial infarction. Br Med J. 1993;307:1244–7. [PMC free article: PMC1679381] [PubMed: 8281056]
21. World Health Organization Expert Committee. Rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Technical report series no. 831. Geneva: World Health Organization. 1993. [PubMed: 8351937]

AHCPR Publication No. 96-0673.