Clinical Guideline Number 17

AHCPR Publication No. 96-0672:

October 1995

Link to the National Guideline Clearinghouse

The Agency for Health Care Policy and Research (AHCPR) was established in December 1989 under Public Law 101-239 (Omnibus Budget Reconciliation Act of 1989) to enhance the quality, appropriateness, and effectiveness of health care services and access to these services. AHCPR carries out its mission by conducting and supporting general health services research, including medical effectiveness research, facilitating development of clinical practice guidelines, and disseminating research findings and guidelines to health care providers, policymakers, and the public.

The legislation also established within AHCPR the Office of the Forum for Quality and Effectiveness in Health Care (the Forum). The Forum has primary responsibility for facilitating the periodic review, and updating of clinical practice guidelines. The guidelines will assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.

The National Heart, Lung, and Blood Institute (NHLBI) supports biomedical research and patient and professional education on health care. NHLBI has coordinated development of several professionally oriented clinical guidelines, including ones on high blood pressure and high blood cholesterol, and collaborated with AHCPR in supporting a clinical practice guideline on unstable angina. Recognizing the importance of cardiac rehabilitation, NHLBI has again collaborated with AHCPR as a partner in the development of this clinical practice guideline.

Guidelines are available in formats suitable for health care practitioners, the scientific community, educators, and consumers. 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.

Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. This guideline was developed by a private-sector panel convened by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung, and Blood Institute (NHLBI). The panel, assembled by the American Association of Cardiovascular and Pulmonary Rehabilitation, employed an explicit science-based methodology and expert clinical judgment to develop specific statements on management of cardiac rehabilitation.

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 reliability and utility of the guideline in clinical practice. The panel's recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants.

The guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done.

We believe that this AHCPR and NHLBI-assisted clinical practice guideline will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in the guideline. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner based on available resources and circumstances presented by individual patients.

Clifton R. Gaus, ScD

Administrator

Agency for Health Care Policy and Research

Claude Lenfant, MD

Director

National Heart, Lung and Blood Institute

Publication of this guideline does not necessarily represent endorsement by the U.S. Department of Health and Human Services.

Cardiovascular disease is the leading cause of morbidity and mortality in the United States, responsible for almost 50 percent of all deaths. Coronary disease, the major category of cardiovascular disease, is clinically manifest as stable angina pectoris, unstable angina pectoris, myocardial infarction, silent myocardial ischemia, and sudden death. More than 13.5 million Americans have a history of myocardial infarction or experience angina pectoris. Nearly 1.5 million Americans sustain myocardial infarction each year, of which almost 500,000 are fatal. Five percent of myocardial infarctions occur in people younger than age 40, and about 45 percent occur in people under age 65. About 55 percent of all acute myocardial infarctions occur in the Medicare age group.

The almost 1 million survivors of myocardial infarction are potential candidates for cardiac rehabilitation services, as are the more than 7 million patients with stable angina pectoris and patients following revascularization with coronary artery bypass surgery (309,000 patients in 1993, 45 percent under age 65), and percutaneous transluminal coronary angioplasty and other transcatheter interventional procedures (362,000 in 1993, 54 percent under age 65). Of these several million patients with coronary disease who are candidates for cardiac rehabilitation services, only 11-38 percent of patients typically participate in cardiac rehabilitation programs.

Another major cardiac problem -- heart failure -- is the most common discharge diagnosis for hospitalized Medicare patients and the fourth most common discharge diagnosis for all patients hospitalized in the United States. The prevalence of heart failure has increased steadily with aging of the U.S. population and with the improved rate of survival resulting from the use of newer therapies for cardiovascular diseases. Many patients with end-stage heart failure are candidates for cardiac transplantation surgery. As benefits and safety are documented, cardiac rehabilitation services for patients with heart failure and after cardiac transplantation have gained increasing acceptance.

This Clinical Practice Guideline was developed under a contract from Agency for Health Care Policy and Research with the support of the National Heart, Lung, and Blood Institute. The contract was awarded to the American Association of Cardiovascular and Pulmonary Rehabilitation, which convened a private-sector multidisciplinary panel of experts that included physicians (cardiologists, internists, family physicians, and cardiac surgeons), registered nurses, a clinical health psychologist, a registered dietitian, exercise physiologists, a physical therapist, and two consumer-patient members -- collectively referred to in this document as "the panel." The panel principally based the conclusions and recommendations in this guideline on scientific evidence from an extensive review of original research published in peer-reviewed medical and health sciences journals. This guideline addresses the role of cardiac rehabilitation services for adult patients with coronary disease, with heart failure, and after cardiac transplantation.

This guideline is designed to assist health care practitioners and consumers in making more informed decisions about their choices and to inform them of the cost-effectiveness of cardiac rehabilitation services. Needs for additional research are also highlighted.

Coronary heart disease, heart failure, and cardiac transplantation are common cardiac problems of patients throughout the United States. The impact of these chronic conditions on patients, their families, and their communities represents both a major challenge and a major opportunity for providing optimal comprehensive management. Cardiac rehabilitation is defined by the World Health Organization as "the sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community." This guideline uses the U.S. Public Health Service definition of cardiac rehabilitation, namely "cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients." This guideline is designed for health professionals who provide care for cardiac patients, as well as for consumers, and is intended to optimize the quality, safety, effectiveness, and access to cardiac rehabilitation services.

The panel further defines cardiac rehabilitation as a multifactorial intervention process that follows a well-defined program structure. The process begins with assessments regarding all relevant aspects of the patient's status: medical, nutritional, psychosocial, educational, and vocational. The implementation of cardiac rehabilitation, based on these initial assessments, is designed to address the individual patient's needs as he or she works toward achieving optimal outcomes. This guideline addresses the relationship between identified patient needs and the provision of multifactorial services throughout the cardiac rehabilitation process to ensure optimal attention to these needs.

This guideline provides broad recommendations based on evaluation of the scientific evidence pertaining to the various components of cardiac rehabilitation. The key components of cardiac rehabilitation -- exercise, education, counseling (about cardiac risk factor modification, development of psychosocial and motivational skills), and behavioral interventions -- are each addressed.

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted, for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR appreciates citation as to source, and the suggested format is provided below: Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute. AHCPR Publication No. 96-0672. October 1995.

Nanette Kass Wenger, MD

Panel Co-Chair

Professor of Medicine (Cardiology)

Emory University School of Medicine

Consultant, Emory Heart Center

Atlanta, Georgia

Cardiologist

Erika Sivarajan Froelicher, RN, PhD

Panel Co-Chair

Professor

Department of Physiological Nursing

School of Nursing and Adjunct Professor

Department of Epidemiology and Biostatistics

School of Medicine

University of California, San Francisco

San Francisco, California

Cardiovascular Nurse

Philip A. Ades, MD

Director, Cardiac Rehabilitation Associate Professor

University of Vermont College of Medicine

Burlington, Vermont

Cardiologist

Kathy Berra, BSN (Subcommittee Chair)

Clinical Trials Director

Stanford Center for Research in Disease Prevention

Palo Alto, California

Cardiovascular Nurse

James A. Blumenthal, PhD (Subcommittee Chair)

Director, Behavioral Medicine Program

Center for Living

Duke University Medical Center

Durham, North Carolina

Clinical Psychologist

Catherine M. E. Certo, ScD, PT

Associate Professor

Boston University

Sargent College of Allied Health Professions

Boston, Massachusetts

Physical Therapist/Exercise Physiologist

Anne M. Dattilo, PhD, RD

Assistant Professor

Department of Nutrition

University of Georgia

Athens, Georgia

Dietitian

Dwight Davis, MD

Director, Cardiac Rehabilitation Program

Professor of Medicine

University Hospital

The Milton S. Hershey Medical Center

Hershey, Pennsylvania

Cardiologist

Robert F. DeBusk, MD (Subcommittee Chair)

Professor of Medicine

Stanford University School of Medicine

Palo Alto, California

Cardiologist

Joseph P. Drozda, Jr., MD

Chief of Cardiology and Medical Director of the Cardiac Rehabilitation Program

DePaul Health Center

St. Louis, Missouri

Cardiologist

Barbara J. Fletcher, RN, MN

Director of Research

Emory Health Enhancement Program

Emory University

Atlanta, Georgia

Cardiovascular Nurse

Barry A. Franklin, PhD (Subcommittee Chair)

Director, Cardiac Rehabilitation and Exercise Laboratories

William Beaumont Hospital

Royal Oak, Michigan

Exercise Physiologist

Helen Gaston (deceased)

Tempe, Arizona

Consumer Representative

Primary Care, Community Health

Philip Greenland, MD (Subcommittee Chair)

Harry W. Dingman Professor of Cardiology

Chair, Department of Preventive Medicine

Northwestern University Medical School

Chicago, Illinois

Cardiologist

Patrick E. McBride, MD, MPH

Associate Professor

Department of Family Medicine and Medicine-Cardiology

University of Wisconsin-Madison

Madison, Wisconsin

Family Physician

Christopher G. A. McGregor, MB, FRCS

Mayo Clinic

Rochester, Minnesota

Cardiothoracic Surgeon

Neil B. Oldridge, PhD (Subcommittee Chair)

Professor of Health Sciences

University of Wisconsin-Milwaukee

Milwaukee, Wisconsin

Exercise Physiologist

Joseph C. Piscatella

President

Institute for Fitness and Health, Inc.

Tacoma, Washington

Consumer Representative

Felix J. Rogers, DO

Downriver Cardiology Consultants

Trenton, Michigan

Cardiologist

William Johnson, PhD

Professor of Health Economics

School of Health Administration and Policy

Arizona State University

Tempe, Arizona

Health Policy Analyst

Jennie J. Kronenfeld, PhD

Professor

School of Health Administration and Policy

Arizona State University

Tempe, Arizona

Health Policy Analyst

Steven H. Woolf, MD, MPH

Assistant Clinical Professor

Department of Family Practice

Medical College of Virginia

Fairfax, Virginia

Methodologist

L. Kent Smith, MD, MPH

Director, Cardiac Rehabilitation

Arizona Heart Institute

Phoenix, Arizona

Project Director

Dorothy B. Seidman

Project Headquarters

Phoenix, Arizona

Project Manager

Mariette Chagnon, MS

Project Headquarters

Phoenix, Arizona

Literature Assistant

Pat Comoss, RN, BS

Chair

AACVPR Project Oversight Committee

Harrisburg, Pennsylvania

Nurse Consultant, Cardiac Rehabilitation

Julie Piech

Project Headquarters

Phoenix, Arizona

Project Assistant

This guideline is dedicated to our wonderful panel member, the late Helen Gaston. Helen was a special person, and her loss is inestimable. As a participant in cardiac rehabilitation services, Helen was a believer in the value of cardiac rehabilitation. She served as an inspiration to hundreds of patients involved in cardiac rehabilitation.

Helen provided culturally sensitive insight as both an educator and a consumer of cardiac rehabilitation services. Her contributions to the development of this Clinical Practice Guideline, although tragically cut short, were of unique and invaluable benefit.

This Clinical Practice Guideline is the culmination of commitment, expertise, and concern on the part of many individuals.

The panel appreciates the steadfast support and guidance provided by Carole Hudgings, PhD, RN, the AHCPR project officer for most of the guideline development, and by Ernestine W. Murray, RN, MAS, the subsequent project officer.

George Sopko, MD, of the National Heart, Lung, and Blood Institute, provided invaluable clinical and administrative expertise, encouragement, and support to the panel throughout the deliberation and decisionmaking process.

The methodologist for this guideline, Steven H. Woolf, MD, MPH, educated the panel in the essentials of guideline development. His knowledge was essential in establishing the guideline process during the project's first year.

The panel also acknowledges the understanding and support of Pat Comoss, RN, who served as liaison on behalf of the American Association of Cardiovascular and Pulmonary Rehabilitation. She carried out her demanding responsibilities with exceptional patience, grace, and understanding.

The invaluable role of the peer reviewers is also acknowledged. Their clear and detailed critical review of the guideline document, on two separate occasions, greatly enhanced the final product.

The panel is particularly grateful to the untiring dedication of the project office staff: Dorothy B. Seidman, Julie Piech, and Mariette Chagnon, MS.