Curriculum in CardiologyClinical evidence for a health benefit from cardiac rehabilitation: An update
Section snippets
Coronary heart disease
There has been significant progress in clarifying the pathophysiology of atherosclerosis and the benefits of comprehensive CR programs on coronary heart disease (CHD). Many of the multi-risk factor benefits occurring in CR mediate through the exercise training component of CR. Exercise training leads to increased fibrinolysis and decreased coagulability, thus promoting conditions that benefit patients with existing coronary artery disease (CAD).20, 21 Inflammation is moderated and, thus,
Cardiovascular disease risk
Cardiac rehabilitation facilitates a systematic approach to exercise training and risk factor management through regular patient evaluation and monitoring, and support of compliance and adherence. Intensive interventions directed at inactivity, dyslipidemia, metabolic syndrome, excess body weight, elevated blood glucose, hypertension, and tobacco addiction, as well as the reduction of stress, anxiety, and depression,39, 40 are critical components of CR.1, 2
Acute Myocardial Infarction
Cardiac rehabilitation has long been recognized as integral to the comprehensive management of patients after a hospitalization for MI. The survival benefit after CR is well established.41, 42, 43 Meta-analyses of clinical trials of CR after MI41, 42 documented a 24% and 20% decrease in total mortality, respectively, and a 25% and 22% decrease in cardiovascular mortality at 3 years of follow-up. The review of Jolliffe et al43 included more women and older patients, and included not only MI, but
Coronary artery bypass graft surgery
At entrance to CR, patients who have undergone CABG surgery have a significantly reduced exercise capacity, and older patients, particularly women, are a severely disabled group. Consequently, a primary role of CR is to provide an effective means for returning these patients to an appropriate level of functional independence. The ability of CR to improve functional capacity in older patients, particularly women, has been consistently demonstrated.17, 18, 47, 48
A controlled trial of CR versus
Stable angina
It has been known for >30 years that exercise training improves exercise tolerance in patients with chronic stable angina by increasing the anginal threshold and delaying the onset of ischemia as identified by the electrocardiogram. Furthermore, in many patients, angina can no longer be precipitated even with maximal exercise after exercise training. Improved endothelium-dependent vasodilation of the coronary arteries resulting from exercise training may represent the most important mechanism
Percutaneous coronary intervention
Between 1987 and 2002, the number of PCIs increased by 324% to 1.2 million cases per year.5 Fifty percent of these procedures were performed in patients age ≥65 years old. Participation in CR post-PCI is associated with marked improvement in functional capacity, blood lipid profile, exercise tolerance and peak V˙o2, and morbidity (decreased clinical events), decreased hospital readmission rate, improved sympathovagal balance, improved health-related QOL, and decreased inflammation as indicated
Chronic heart failure
Randomized clinical trials conducted over the last 15 years demonstrate that exercise-based CR favorably improves exercise tolerance, disease-related symptoms, and QOL in patients with CHF, without negatively impacting left ventricular function. No adverse exercise training–related effects have been reported despite that these patients would appear to be at higher risk for events given their left ventricular dysfunction and heightened state of sympathetic activity.
Exercise training contributes
Heart transplant
Patients who undergo heart transplantation face a myriad of medical problems including persistent heart failure pathophysiology, deconditioning due to convalescence before and after surgery, the side effects of immunosuppressive medications (sarcopenia, osteopenia, overall fat mass, particularly central body fat gain, and infections), and risk of organ rejection. Peak V˙o2 among patients having undergone heart transplant is 40% to 50% lower compared with age-matched, healthy control subjects.35
Heart valve replacement
Before cardiac valve surgery, patients are frequently extremely symptomatic as well as highly deconditioned, with most identified as New York Heart Association Functional Classification III to IV.68, 69 This level of exercise capacity is 30% of that of age-matched control patients. In addition, the cardiovascular hemodynamics and symptoms in these patients are similar to those of patients with heart failure with elevated pulmonary capillary wedge pressures, depressed cardiac indices, and
Conclusions
Because of the aging population, and the shift of cardiovascular disease from an acutely fatal event to a chronic disease, there is a marked and growing need for medical services that help patients improve their QOL, lessen symptoms, increase functional capacity, decrease disability, and reduce the risk of subsequent morbidity and mortality (Table I). Although CR is currently underused in patients who had acute MI or undergone CABG surgery, PCI, heart transplantation, and heart valve surgery,
References (74)
- et al.
Cardiac rehabilitation after myocardial infarction in the community
J Am Coll Cardiol
(2004) - et al.
Effects of exercise and cardiac rehabilitation on cardiovascular outcomes
Cardiol Clin
(2003) - et al.
Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery and for chronic heart failure
Chest
(2003) - et al.
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials
Am J Med
(2004) - et al.
Reduction in C-reactive protein through cardiac rehabilitation and exercise training
J Am Coll Cardiol
(2004) - et al.
Effects of exercise training on vascular function and myocardial perfusion
Cardiol Clin
(2001) - et al.
Autonomic tone as a cardiovascular risk factor: the dangers of chronic fight or flight
Mayo Clin Proc
(2002) - et al.
Effects of cardiac rehabilitation and exercise training on autonomic regulation in patients with coronary artery disease
Am Heart J
(2002) - et al.
The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology
J Am Coll Cardiol
(2005) - et al.
Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training
Mayo Clin Proc
(2005)
Effects of early rehabilitation on consumption of medical care during the first year after myocardial infarction in patients greater than or equal to 65 years of age
Am J Cardiol
Effects of cardiac rehabilitation programs on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in la large elderly cohort
Am J Cardiol
Early exercise training in patients ≥65 years compared with that in younger patients after acute myocardial infarction or coronary bypass grafting
Am J Cardiol
Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery
Am J Cardiol
Exercise training intervention after coronary angioplasty: the ETICA Trial
J Am Coll Cardiol
Poor functional recovery may indicate restenosis in patients after coronary angioplasty
Arch Phys Med Rehabil
Effects of exercise training in patients with heart failure: the exercise rehabilitation trial (EXERT)
Am Heart J
Anti-inflammatory effects of exercise training in the skeletal muscle of patients with chronic heart failure
J Am Coll Cardiol
The effects of exercise training on sympathetic neural activation in advanced heart failure
J Am Coll Cardiol
Exercise training in heart failure
Prog Cardiovasc Dis
Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity
Am J Med
Resistance exercise training restores bone mineral density in heart transplant recipients
J Am Coll Cardiol
AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2006 update
Circulation
Core components of cardiac/secondary prevention programs
Circulation
Medicare coverage database
Cardiac rehabilitation
Heart disease and stroke statistics 2006—update
Cardiac rehabilitation and secondary prevention of coronary heart disease
N Engl J Med
Disparities in women's referral to and enrollment in outpatient cardiac rehabilitation
J Gen Intern Med
Cardiac rehabilitation and secondary prevention of coronary heart disease
Circulation
Pathophysiology of coronary artery disease
Circulation
Endothelial function: cardiac events
Circulation
Physical activity in prevention and treatment of coronary disease: the battle is in exercise cell biology
Med Sci Sports Exerc
Long-term effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention
Health Psychol
Resistance training on physical performance in disabled older female cardiac patients
Med Sci Sports Exerc
Secondary prevention of coronary heart disease in the elderly (with emphasis on patients ≥75 years of age)
Circulation
Cited by (161)
The effect of stress management in patients post-acute myocardial infarction
2023, Hellenic Journal of CardiologyCardiac Rehab in the COVID-19 Pandemic
2021, American Journal of MedicineChanges in body composition after a phase II cardiac rehabilitation programme
2020, Revista Colombiana de CardiologiaA Pragmatic Preoperative Prediction Score for Nonhome Discharge After Cardiac Operations
2018, Annals of Thoracic SurgeryEffects of the Strong Hearts program after a major cardiovascular event in patients with cardiovascular disease
2023, Journal of Osteopathic MedicineEffect of Early Rehabilitation Nursing on Patients with Myocardial Infarction: A Meta-analysis
2023, American Journal of Health Behavior