Cardiac rehabilitation: a comprehensive review

Scott A Lear, Andrew Ignaszewski, Scott A Lear, Andrew Ignaszewski

Abstract

Cardiac rehabilitation (CR) is a commonly used treatment for men and women with cardiovascular disease. To date, no single study has conclusively demonstrated a comprehensive benefit of CR. Numerous individual studies, however, have demonstrated beneficial effects such as improved risk-factor profile, slower disease progression, decreased morbidity, and decreased mortality. This paper will review the evidence for the use of CR and discuss the implications and limitations of these studies. The safety, relevance to special populations, challenges, and future directions of CR will also be reviewed.

Figures

Figure 1
Figure 1
Diagrammatic outline of the modern cardiac rehabilitation program. ECG, Electrocardiography.
Figure 2
Figure 2
Current challenges faced by today's cardiac rehabilitation programs and recommended future directions of study. CHF, Congestive heart failure.
Figure 3
Figure 3
Proposed organizational structure for new cardiac rehabilitation (CR) models. ECG, Electrocardiography.

References

    1. American Heart Association 2001 Heart and Stroke Statistical Update Dallas, TX: American Heart Association; 2000.
    1. Heart and Stroke Foundation of Canada The changing face of heart disease and stroke in Canada 2000. 1999.
    1. Klein RF, Dean A, Willson LM, Bogdonoff MD. The physician and postmyocardial infarction invalidism. JAMA. 1965;194:143–148.
    1. Ignaszewski A, Lear SA. Cardiac rehabilitation programs. Can J Cardiol. 1999;15(suppl G):110G–113G.
    1. American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs Champaign, IL: Human Kinetics Publishers; 1999.
    1. Canadian Association of Cardiac Rehabilitation Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention Winnipeg, Man: Canadian Association of Cardiac Rehabilitation; 1999.
    1. World Health Organization Rehabilitation of patients with cardiovascular disease: Report of a WHO expert committee WHO Technical Report Series No 270; 1964.
    1. Brousseau ME, Schaefer EJ. Diet and coronary heart disease: clinical trials. Curr Atheroscler Rep. 2000;2:487–493.
    1. Wilson K, Gibson N, Willan A, Cook D. Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med. 2000;160:939–944.
    1. Paffenbarger RS, Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol. 1978;108:161–175.
    1. Morris JN, Everitt MG, Pollard R, Chave SP, Semmence AM. Vigorous exercise in leisure-time: protection against coronary heart disease. Lancet. 1980;2:1207–1210.
    1. Sherman SE, D'Agostino RB, Cobb JL, Kannel WB. Physical activity and mortality in women in the Framingham Heart Study. Am Heart J. 1994;128:879–884.
    1. Wilhelmsen L, Sanne H, Elmfeldt D, Grimby G, Tibblin G, Wedel H. A controlled trial of physical training after myocardial infarction. Effects on risk factors, nonfatal reinfarction, and death. Prev Med. 1975;4:491–508.
    1. Shaw LW. Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after myocardial infarction. The National Exercise and Heart Disease Project. Am J Cardiol. 1981;48:39–46.
    1. Carson P, Phillips R, Lloyd M, Tucker H, Neophytou M, Buch NJ, Gelson A, Lawton A, Simpson T. Exercise after myocardial infarction: a controlled trial. J R Coll Phys Lond. 1982;16:147–151.
    1. Roman O, Gutierrez M, Luksic I, Chavez E, Camuzzi AL, Villalon E, Klenner C, Cumsille F. Cardiac rehabilitation after acute myocardial infarction. 9-year controlled follow-up study. Cardiology. 1983;70:223–231.
    1. Marra S, Paolillo V, Spadaccini F, Angelino PF. Long-term follow-up after a controlled randomized post-myocardial infarction rehabilitation programme: effects on morbidity and mortality. Eur Heart J. 1985;6:656–663.
    1. Kallio V, Hamalainen H, Hakkila J, Luurila OJ. Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction. Lancet. 1979;2:1091–1094.
    1. Hamalainen H, Luurila OJ, Kallio V, Knuts LR, Arstila M, Hakkila J. Long-term reduction in sudden deaths after a multifactorial intervention programme in patients with myocardial infarction: 10-year results of a controlled investigation. Eur Heart J. 1989;10:55–62.
    1. Anonymous Comparison of a rehabilitation programme, a counselling programme and usual care after an acute myocardial infarction: results of a long-term randomized trial. PRECOR Group. Eur Heart J. 1991;12:612–616.
    1. Hedback B, Perk J, Wodlin P. Long-term reduction of cardiac mortality after myocardial infarction: 10-year results of a comprehensive rehabilitation programme. Eur Heart J. 1993;14:831–835.
    1. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA. 1988;260:945–950.
    1. O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS, Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234–244.
    1. Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, Brown L, Warnica JW, Arnold JM, Wun CC, Davis BR, Braunwald E. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 1996;335:1001–1009.
    1. Hamalainen H, Luurila OJ, Kallio V, Knuts LR. Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. 15 year follow-up study. Eur Heart J. 1995;16:1839–1844.
    1. Dorn J, Naughton J, Imamura D, Trevisan M. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). Circulation. 1999;100:1764–1769.
    1. Hedback B, Perk J. 5-year results of a comprehensive rehabilitation programme after myocardial infarction. Eur Heart J. 1987;8:234–242.
    1. Pitt B, Mancini GB, Ellis SG, Rosman HS, Park JS, McGovern ME. Pravastatin limitation of atherosclerosis in the coronary arteries (PLAC I): reduction in atherosclerosis progression and clinical events. PLAC I investigation. J Am Coll Cardiol. 1995;26:1133–1139.
    1. Schuler G, Hambrecht R, Schlierf G, Grunze M, Methfessel S, Hauer K, Kubler W. Myocardial perfusion and regression of coronary artery disease in patients on a regimen of intensive physical exercise and low fat diet. J Am Coll Cardiol. 1992;19:34–42.
    1. Niebauer J, Hambrecht R, Schlierf G, Marburger C, Kalberer B, Kubler W, Schuler G. Five years of physical exercise and low fat diet: effects on progression of coronary artery disease. J Cardiopulm Rehab. 1994;15:47–64.
    1. Schuler G, Hambrecht R, Schlierf G, Niebauer J, Hauer K, Neumann J, Hoberg E, Drinkmann A, Bacher F, Grunze M, Kubler W. Regular physical exercise and low-fat diet. Effects on progression of coronary artery disease. Circulation. 1992;86:1–11.
    1. Niebauer J, Hambrecht R, Marburger C, Hauer K, Velich T, von Hodenberg E, Schlierf G, Kubler W, Schuler G. Impact of intensive physical exercise and low-fat diet on collateral vessel formation in stable angina pectoris and angiographically confirmed coronary artery disease. Am J Cardiol. 1995;76:771–775.
    1. Niebauer J, Hambrecht R, Velich T, Hauer K, Marburger C, Kalberer B, Weiss C, von Hodenberg E, Schlierf G, Schuler G, Zimmermann R, Kubler W. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Circulation. 1997;96:2534–2541.
    1. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990;336:129–133.
    1. Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001–2007.
    1. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, Williams PT, Johnstone IM, Champagne MA, Krauss RM, Farquhar JW. 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;89:975–990.
    1. Teo KK, Burton JR, Buller CE, Plante S, Catellier D, Tymchak W, Dzavik V, Taylor D, Yokoyama S, Montague TJ. Long-term effects of cholesterol lowering and angiotensin-converting enzyme inhibition on coronary atherosclerosis: The Simvastatin/ Enalapril Coronary Atherosclerosis Trial (SCAT). Circulation. 2000;102:1748–1754.
    1. Bestehorn HP, Rensing UF, Roskamm H, Betz P, Benesch L, Schemeitat K, Blumchen G, Claus J, Mathes P, Kappenberger L, Wieland H, Neiss A. The effect of simvastatin on progression of coronary artery disease. The Multicenter coronary Intervention Study (CIS). Eur Heart J. 1997;18:226–234.
    1. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE, Heller RS, Rompf J, Gee D, Kraemer HC, Bandura A, Ghandour G, Clark M, Shah RV, Fisher L, Taylor CB. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721–729.
    1. Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, McKillop JH, Packard CJ. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med. 1995;333:1301–1307.
    1. Miller NH, Warren D, Myers D. Home-based cardiac rehabilitation and lifestyle modification: the MULTIFIT model. J Cardiovasc Nurs. 1996;11:76–87.
    1. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA. 1982;247:2535–2538.
    1. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med. 1984;311:874–877.
    1. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med. 1993;329:1677–1683.
    1. Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F, Schroder R. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med. 1993;329:1684–1690.
    1. Burke AP, Farb A, Malcom GT, Liang Y, Smialek JE, Virmani R. Plaque rupture and sudden death related to exertion in men with coronary artery disease. JAMA. 1999;281:921–926.
    1. Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA. 1986;256:1160–1163.
    1. Vongvanich P, Paul-Labrador MJ, Merz CN. Safety of medically supervised exercise in a cardiac rehabilitation center. Am J Cardiol. 1996;77:1383–1385.
    1. Franklin BA, Bonzheim K, Gordon S, Timmis GC. Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest. 1998;114:902–906.
    1. Hambrecht R, Gielen S, Linke A, Fiehn E, Yu J, Walther C, Schoene N, Schuler G. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. JAMA. 2000;283:3095–3101.
    1. Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999;99:1173–1182.
    1. Warner JG, Brubaker PH, Zhu Y, Morgan TM, Ribisl PM, Miller HS, Herrington DM. Long-term (5-year) changes in HDL cholesterol in cardiac rehabilitation patients. Do sex differences exist? Circulation. 1995;92:773–777.
    1. Balady GJ, Jette D, Scheer J, Downing J. Changes in exercise capacity following cardiac rehabilitation in patients stratified according to age and gender. Results of the Massachusetts Association of Cardiovascular and Pulmonary Rehabilitation Multicenter Database. J Cardiopulm Rehab. 1996;16:38–46.
    1. Ades PA, Waldmann ML, Gillespie C. A controlled trial of exercise training in older coronary patients. J Gerontol A Biol Sci Med Sci. 1995;50A:M7–M11.
    1. Lavie CJ, Milani RV. Effects of cardiac rehabilitation programs on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in a large elderly cohort. Am J Cardiol. 1995;76:177–179.
    1. Gaw-Ens B, Laing GP. Risk factor reduction behaviours in coronary angioplasty and myocardial infarction patients. Can J Cardiovasc Nurs. 1994;5:4–12.
    1. Bunker S, McBurney H, Cox H, Jelinek M. Identifying participation rates at outpatient cardiac rehabilitation programs in Victoria, Australia. J Cardiopulm Rehab. 1999;19:334–338.
    1. Wallner S, Watzinger N, Lindschinger M, Smolle KH, Toplak H, Eber B, Dittrich P, Elmadfa I, Klein W, Krejs GJ, Wascher TC. Effects of intensified lifestyle modification on the need for further revascularization after coronary angioplasty. Eur J Clin Invest. 1999;29:372–379.
    1. Engblom E, Korpilahti K, Hamalainen H, Puukka P, Ronnemaa T. Effects of five years of cardiac rehabilitation after coronary artery bypass grafting on coronary risk factors. Am J Cardiol. 1996;78:1428–1431.
    1. Kobashigawa JA, Leaf DA, Lee N, Gleeson MP, Liu H, Hamilton MA, Moriguchi JD, Kawata N, Einhorn K, Herlihy E, Laks H. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med. 1999;340:272–277.
    1. Vanhees L, Schepers D, Defoor J, Brusselle S, Tchursh N, Fagard R. Exercise performance and training in cardiac patients with atrial fibrillation. J Cardiopulm Rehab. 2000;20:346–352.
    1. Douard H, Chevalier L, Labbe L, Choussat A, Broustet JP. Physical training improves exercise capacity in patients with mitral stenosis after balloon valvuloplasty. Eur Heart J. 1997;18:464–469.
    1. Evenson KR, Rosamond WD, Luepker RV. Predictors of outpa-tient cardiac rehabilitation utilization: the Minnesota Heart Surgery Registry. J Cardiopulm Rehab. 1998;18:192–198.
    1. Bittner V, Sanderson B, Breland J, Green D. Referral patterns to a University-based cardiac rehabilitation program. Am J Cardiol. 1999;83:252–255.
    1. King KM, Humen DP, Teo KK. Cardiac rehabilitation: the forgotten intervention. Can J Cardiol. 1999;15:979–985.
    1. Blackburn GG, Foody JM, Sprecher DL, Park E, Apperson-Hansen C, Pashkow FJ. Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias. J Cardiopulm Rehab. 2000;20:189–195.
    1. Thomas RJ, Miller NH, Lamendola C, Berra K, Hedback B, Durs-tine JL, Haskell W. National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns. J Cardiopulm Rehab. 1996;16:402–412.
    1. Lauer MS, Pashkow FJ, Snader CE, Harvey SA, Thomas JD, Marwick TH. Sex and diagnostic evaluation of possible coronary artery disease after exercise treadmill testing at one academic teaching center. Am Heart J. 1997;134:807–813.
    1. Halm M, Penque S, Doll N, Beahrs M. Women and cardiac rehabilitation: referral and compliance patterns. J Cardiovasc Nurs. 1999;13:83–92.
    1. Anonymous Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;4:1383–1389.
    1. King KM, Teo KK. Cardiac rehabilitation referral and attendance: not one and the same. Rehab Nurs. 1998;23:246–251.
    1. Mullinax CH. Cardiac rehabilitation programs and the problem of patient dropout. Rehab Nurs. 1995;20:90–92.
    1. Evenson KR, Fleury J. Barriers to outpatient cardiac rehabilitation participation and adherence. J Cardiopulm Rehab. 2000;20:241–246.
    1. Suter PM, Suter WN, Perkins MK, Bona SL, Kendrick PA. Cardiac rehabilitation survey: maintenance of lifestyle changes and perception of program value. Rehab Nurs. 1996;21:192–195.
    1. Moore SM, Ruland CM, Pashkow FJ, Blackburn GG. Women's patterns of exercise following cardiac rehabilitation. Nurs Res. 1998;47:318–324.
    1. Lear S, Ignaszewski A, Laquer E, Pritchard P, Frohlich J. Extensive Lifestyle Management Intervention Following Cardiac Rehabilitation: Pilot Study. Rehab Nurs.
    1. Brubaker PH, Rejeski WJ, Smith MJ, Sevensky KH, Lamb KA, Sotile WM, Miller HS. A home-based maintenance exercise program after center-based cardiac rehabilitation: effects on blood lipids, body composition, and functional capacity. J Cardiopulm Rehal. 2000;20:50–56.
    1. Willich SN, Muller-Nordhorn J, Kulig M, Binting S, Gohlke H, Hahmann H, Bestehorn K, Krobot K, Voller H. Cardiac risk factors, medication, and recurrent clinical events after acute coronary disease; a prospective cohort study. Eur Heart J. 2001;22:307–313. doi: 10.1053/euhj.2000.2294.
    1. Engblom E, Hietanen EK, Hamalainen H, Kallio V, Inberg M, Knuts LR. Exercise habits and physical performance during comprehensive rehabilitation after coronary artery bypass surgery. Eur Heart J. 1992;13:1053–1059.
    1. Dylewicz P, Bienkowska S, Szczesniak L, Rychlewski T, Przy-warska I, Wilk M, Jastrzebski A. Beneficial effect of short-term endurance training on glucose metabolism during rehabilitation after coronary bypass surgery. Chest. 2000;117:47–51.
    1. Froelicher V, Jensen D, Genter F, Sullivan M, McKirnan MD, Witztum K, Scharf J, Strong ML, Ashburn W. A randomized trial of exercise training in patients with coronary heart disease. JAMA. 1984;252:1291–1297.
    1. Miller NH, Haskell WL, Berra K, DeBusk RF. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation. 1984;70:645–649.
    1. 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;22:468–477.
    1. Gulanick M. Is phase 2 cardiac rehabilitation necessary for early recovery of patients with cardiac disease? A randomized, controlled study. Heart Lung. 1991;20:9–15.
    1. Oldridge N, Guyatt G, Jones N, Crowe J, Singer J, Feeny D, McK-elvie R, Runions J, Streiner D, Torrance G. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. Am J Cardiol. 1991;67:1084–1089.
    1. Bar F, Hoppener P, Diederiks J. Cardiac rehabilitation contributes to the restoration of leisure and social activities after myocardial infarction. J Cardiopulm Rehab. 1992;12:117–125.

Source: PubMed

3
Subscribe