Clinical Practice Guidelines

AHCPR releases cardiac rehabilitation guideline

Cardiac rehabilitation services—medically supervised interventions aimed at limiting physical and other damage from heart disease that reduce the risk of death and help patients resume a normal life—are widely under-used in spite of their proven benefits, according to a newly released Agency for Health Care Policy and Research-supported clinical practice guideline. Indeed, less than a third of heart patients participate in cardiac rehabilitation programs even though potentially all of them could benefit from the services, notes Douglas B. Kamerow, M.D., M.P.H., AHCPR's director of Clinical Practice Guideline Development.

The clinical practice guideline recommends a comprehensive approach to cardiac rehabilitation that includes exercise training to improve exercise tolerance and stamina and education, counseling, and behavioral interventions to assist patients in achieving and maintaining optimal health. The guideline also recommends considering home-based cardiac rehabilitation, guided by a health care professional, as an alternate approach for low- or moderate-risk patients who cannot participate in traditional, structured group cardiac rehabilitation, which is generally conducted in hospitals or other health or community facilities.

An estimated 13.5 million Americans have coronary heart disease, including almost 1 million who survive heart attacks each year, more than 600,000 annually who undergo coronary artery bypass surgery or balloon angioplasty—an invasive procedure used to open blocked coronary arteries—and the approximately 2,000 patients who have heart transplants each year. About half of all these patients are elderly. Heart disease patients also include about 7 million persons with angina—recurring chest pain—and 4.7 million who have stable heart failure.

According to Nanette K. Wenger, M.D., Co-Chair of the 19-member private-sector panel that developed the guideline, and Professor of Medicine at the Emory University School of Medicine in Atlanta, GA, physicians know about cardiac rehabilitation, but not enough refer their patients for services. She points out that cardiac rehabilitation should be part of the discharge plans for all heart disease patients, and even though some doctors prescribe individual components of cardiac rehabilitation, such as exercise training or education, individual activities by themselves are less effective. Dr. Wenger is a cardiologist and consultant to the Emory Heart Center and Director of the Cardiac Clinics at Grady Memorial Hospital.

The goals of a well-designed cardiac rehabilitation program are to:

• Increase exercise tolerance: The most consistent benefits occur when patients exercise three times a week, 20 to 40 minutes at a time, at 70 to 85 percent of the baseline exercise test heart rate. Exercise training should last 12 weeks or more. The guideline recommends that patients continue exercising to maintain the benefits of exercise training.
• Improve symptoms: Cardiac rehabilitation decreases anginal pain and improves heart failure symptoms, such as shortness of breath and fatigue.
• Improve blood fat levels: Nutritional education and counseling, behavioral interventions, and exercise training improve cholesterol levels. Some patients also may need cholesterol-lowering drugs.
• Decrease smoking: As many as 25 percent of patients who smoke cigarettes will quit after participating in a smoking cessation program as part of cardiac rehabilitation.
• Improve psychosocial well-being and reduce stress: Education, counseling, and psychosocial interventions, as well as exercise training, improve these outcomes.
• Reduce mortality: Comprehensive cardiac rehabilitation has been shown to reduce death rates in patients after heart attack by 25 percent.

Erika Sivarajan Froelicher, R.N., Ph.D., Co-Chair of the panel, said heart disease patients should ask for cardiac rehabilitation if it is not offered, and they should look for flexibility in a program so that they can stick with it. Dr. Froelicher is a Professor of Nursing and Adjunct Professor of Medicine at the University of California, San Francisco.

The guideline was cosponsored by the National Heart, Lung, and Blood Institute and AHCPR and developed under an AHCPR contract awarded to the American Association of Cardiovascular and Pulmonary Rehabilitation. The panel convened by the association included physicians, nurses, exercise physiologists, behavioral specialists, dieticians, physical and occupational therapists, and consumers.

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