Controversal question: When should cardiac rehabilitation be started after a cardiovascular event?




When should cardiac rehabilitation be started after a cardiovascular event?


1. C. Aguiar, Portugal
2. D. M. Aronov, Russia
3. F. Bacal, M. M. Fernandes da Silva, Brazil
4. K. Daly, Ireland
5. D. R. Dimulescu, Romania
6. N. M. Farag, Egypt
7. K. Naidoo, D. P. Naidoo, South Africa
8. H. Ong-Garcia, Philippines
9. A. A. A. Rahim, Malaysia
10. H. Rasmusen, Denmark
11. G. Sinagra, P. L. Temporelli, Italy
12. M. Zoghi, Turkey


1. C. Aguiar, Portugal

Carlos AGUIAR, MD
Cardiologist
Hospital de Santa Cruz
Carnaxide
PORTUGAL
(e-mail: ctaguiar@sapo.pt)

Halting the progression of atherosclerosis is possible, and it is an important objective in the treatment of coronary heart disease. It is achieved by correction of risk factors through lifestyle intervention and evidence-based pharmacotherapy.

Cardiac rehabilitation programs provide counseling on risk factor modification and exercise training for secondary prevention of coronary heart disease. For most patients with coronary heart disease (including the elderly), the benefits of cardiac rehabilitation are well documented; this includes patients with recent myocardial infarction (MI), those who have undergone myocardial revascularization, and patients with chronic stable angina. The benefits are cost effective and involve improvement in adherence to preventive medications, improved risk factor profiles, enhanced functional, psychosocial, and vocational status, better quality of life, less recurrent hospitalizations, reduced risk of reinfarction, and increased survival. Furthermore, exercise training per se lowers resting heart rate and enhances heart rate recovery in post-MI patients, suggesting that it improves autonomic function.

In the post-MI setting, the European Society of Cardiology (ESC) recommends enrolment in a secondary prevention or cardiac rehabilitation program, particularly for patients with multiple modifiable risk factors and moderate- to high-risk patients in whom supervised guidance is warranted. The ESC has recently stated that they consider such enrolment to be a performance measure for monitoring and improving the standards of post-MI care.1,2 The process should start as soon as possible after hospital admission, and be continued in the succeeding weeks and months.

For exercise training prescription, symptom-limited exercise testing can safely be performed between 1 and 2 weeks after primary percutaneous coronary intervention (PCI). Several factors should be considered when deciding on the appropriate timing for submaximal exercise testing (during the first month after an acute coronary syndrome); namely, clinical, hemodynamic, and electrophysiological stability, functional completeness of revascularization, degree of left ventricular (LV) dysfunction, prior physical condition, and orthopedic limitations.

A recent systematic review showed that exercise training has a beneficial effect on LV remodeling in clinically stable post-MI patients.3 The greatest benefit occurs when training starts early after MI (from 1 week) and lasts longer than 3 months. For each week that exercise was delayed, an additional month of training was required to achieve the same level of benefit on LV remodeling.

Cardiac rehabilitation and secondary prevention are also recommended for all revascularized patients, and should be initiated during hospitalization.4 Counseling regarding physical activity can start as early as the next day after uncomplicated PCI or coronary surgery.

Over the past decades, mortality from acute cardiovascular diseases such as MI has dramatically declined, but the increasing number of patients subsequently affected by chronic conditions such as heart failure has driven up the costs and needs of health systems. Exercise training in compensated heart failure is safe and has several benefits, including enhanced peak oxygen uptake, improved muscle energetics, restoration of autonomic function, reduced neurohormonal activation, and reverse LV remodeling; it thus leads to better functional capacity, an important objective of heart failure management. These benefits are apparent as early as 3 weeks after commencement of training. Evidence from randomized controlled trials further indicates that physical rehabilitation may ultimately reduce heart failure–related hospitalization and improve health-related quality of life in patients with mild to moderate systolic heart failure.

The ESC recommends exercise training for all stable chronic heart failure patients.5 For hospitalized patients, inpatient counseling and education should begin as soon as possible after hospital admission. _

References
1. Piepoli MF, Corrà U, Benzer W, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17:1-17.
2. Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for theManagement of Acute Coronary Syndromes (ACS) in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2999-3054.
3. Haykowsky M, Scott J, Esch B, et al. A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling. Trials. 2011;12:92.
4. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization. Eur Heart J. 2010;31:2501-2555.
5. McMurray JJ, Adamopoulos S, Anker SD, et al; ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33:1787-1848.


2. D. M. Aronov, Russia

David M. ARONOV, MD, PhD
Professor & Honored Worker
of Science of the RF
State Research Center for
Preventive Medicine
Moscow, RUSSIA
(e-mail: aronovdm@mail.ru)



This question was resolved definitively in as early as 1968 in a document prepared by a working group of the World Health Organization Regional Office for Europe entitled, “A programme for the physical rehabilitation of patients with acute myocardial infarction” (Copenhagen, 1968). In the document, the recommendation after hospital admission of a patient with acute myocardial infarction was “…to start physical rehabilitation as soon as possible.” Today, with significantly reduced lengths of stay in the cardiology department, the first rehabilitation measures can be started as soon as relief of pain and serious cardiovascular complications have been successfully addressed.

The objectives of in-hospital rehabilitation are as follows: (i) to prevent the development of hypokinesia caused by the patient’s limited physical activity; and (ii) to provide early educational and psychological support to the patient to allow him/her to understand the need for further complex stepwise rehabilitation, including special exercise training that transforms into a lifetime secondary prevention measure.

The first objective is achieved by permitting the patient to be active early, and by allowing patients with a complicated disease course to perform therapeutic exercises. These exercises are started from the first or second day of the patient’s stay in hospital. At the earliest stage, rehabilitation of the patient with acute coronary syndrome begins through discussion of the concepts of myocardial infarction (or acute coronary syndrome), the importance of drug treatment, application of rehabilitation methods, and further long-term secondary prevention.

The patient must understand what, why, and in what time frame he or she should undertake activities, which are for lifesaving purposes, improvement of the disease course, fastest possible recovery of physical performance, and a return to work activities. Ensuring the patient’s awareness of the need for strict compliance with the medical and nonmedical recommendations of doctors during the stay in the coronary care unit is a good first step that will increase motivation for the upcoming treatment and rehabilitation and improve adherence to them.

Discussion with the patient and, if possible, with his or her relatives, has a favorable psychological effect. The doctor informs the patient about the purpose of rehabilitation, the methods, and the achievable results at different stages. The patients must understand that a combination of medical and nonmedical interventions (physical rehabilitation, adherence to an anti-atherosclerotic diet, a training program, psychotherapy, and modification of risk factors) will allow them to quickly recover and return to an active life and their professional activities. Patient awareness of these interventions has been found to increase motivation and improve compliance with implementation of the treatment, rehabilitation, and secondary prevention measures.1

There is also a physical aspect to rehabilitation. Depending on the severity of the patient’s state, the doctor will determine the tentative discharge date from hospital. In cases of uncomplicated myocardial infarction, patients can be discharged in about 1 week. They are not threatened by hypokinesia. However, if the prognosis is poor, the length of stay in hospital becomes longer. In such cases, the patient is prescribed a sparing regimen of physical activity and calisthenics in order to prevent hypodynamia and secure an early expansion of physical activity. So-called breathing exercises and exercises for small muscle groups are used, and are performed under the supervision of a physiotherapist or trained nurse.

Rehabilitation is carried out not only after myocardial infarction, but also after coronary artery bypass graft (CABG) and percutaneous coronary intervention. The 2011 recommendations of the American College of Cardiology Foundation/ American Heart Association state: “Cardiac rehabilitation is recommended for all eligible patients after CABG. Class I, Level of Evidence: A.” 2 _

References
1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82-e292.
2. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:2610-2642.


3. F. Bacal, M. M. Fernandes da Silva, Brazil

Fernando BACAL, MD, PhD
Professor of Cardiology, University of São
Paulo Medical School, Heart Institute (InCor)
Heart Failure and Heart Transplant Unit
BRAZIL
(e-mail: fbacal@uol.com.br)
Miguel Morita FERNANDES DA SILVA, MD
Cardiologist, Rehabilitation Department
Hospital Cardiológico Costantini
University of São Paulo, BRAZIL
(e-mail: miguelmorita@usp.br)



Almost 7 decades ago, healing of amyocardial infarction was described as taking 3 to 4 weeks, and a theoretical 6 to 8 weeks of bed rest was considered necessary after an acute myocardial infarction (AMI).1 With technological advances and improvements in the management of cardiac disease, recovery has become faster and long periods of inactivity are generally no longer needed. On the other hand, as more people survive after a cardiovascular event, there are more patients in a poor health condition and with comorbidities, and these patients are considered for cardiac rehabilitation (CR).

Although there is some controversy regarding the effects of CR on heart failure mortality, CR leads to a 26% reduction in cardiovascular mortality in coronary heart disease.2 The core component of CR is exercise training, which has known benefits including positive effects on quality of life, anti-inflammatory effects, improvement in autonomic and endothelial function, an increase in fibrinolysis, and a decrease in coagulability. Although recommended by the American Heart Association, American College of Cardiology, and European Society of Cardiology in the treatment of patients with coronary artery disease and heart failure,3 CR is still underused.

Before starting exercise training after a cardiovascular event, exercise testing is recommended to guide prescription. Safety concerns regarding when to perform testing—and thus when to initiate the exercise program—stem from the risk of triggering a fatal arrhythmia, prolonged ischemia during exercise sessions leading to myocardial necrosis, or worsening of ventricular function with an unfavorable outcome in the long term. In addition, acute exercise may lead to a transitory prothrombotic state and elevated wall stress, which can raise concerns in patients with a coronary stent, especially in areas that are not covered by endothelium.4 This issue was investigated in a study in which patients with no recent myocardial infarction (within 1 week) were randomized to symptom-limited treadmill exercise testing or not the day after uncomplicated percutaneous revascularization with stent placement. There was no difference in AMI or access site complications between the groups,5 indicating that this approach is safe. Given that this was a single-center study, and also allowing time for healing of the access site, it seems appropriate to perform exercise testing and initiate CR 5 to 7 days after an elective percutaneous coronary intervention.

After an acute coronary syndrome, including AMI or unstable angina, symptom-limited exercise testing can be performed 14 days after an uncomplicated event, when an exercise training program can also be initiated. After a large and/or complicated myocardial infarction including heart failure, arrhythmias, pericarditis, or mechanical complications, physical activity should start only after clinical stabilization. With regard to possible deleterious effects on ventricular function, aerobic exercise for 3 months initiated within 2 weeks after AMI does not appear to cause unfavorable left ventricular remodeling and still reduces myocardial ischemia after 6 months.6

Although low-intensity exercise can be started in hospital after cardiac surgery, the aim of this management phase is to prevent respiratory complications and profound venous thrombosis, and no study has specifically investigated when symptom- limited exercise testing can safely be performed. Upper body training can be started when the wound is stable. For patients submitted for cardiac transplantation, exercise training can start 2 to 3 weeks after the procedure, but should be discontinued during corticosteroid bolus therapy for rejection.3

Clinical trials have generally included heart failure patients receiving optimal treatment at stable doses in the previous 6 to 12 weeks. After an episode of decompensation, it would seem appropriate to initiate CR when the patient is clinically compensated with maximal tolerated doses, also allowing for the use of exercise testing for appropriate prognosis evaluation. _

References
1. [No authors listed] I National Consensus of Cardiovascular Rehabilitation. Arq Bras Cardiol. 1997;69:267-291.
2. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2012;1:CD001800.
3. Corra U, Piepoli MF, Carre F, et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31: 1967-1976.
4. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115:2358-2368.
5. Roffi M, Wenaweser P, Windecker S, et al. Early exercise after coronary stenting is safe. J Am Coll Cardiol. 2003;42:1569-1573.
6. Giallauria F, Acampa W, Ricci F, et al. Effects of exercise training started within 2 weeks after acute myocardial infarction on myocardial perfusion and left ventricular function: a gated SPECT imaging study. Eur J Cardiovasc Prev Rehabil. 2011 Sep 30. Epub ahead of print.


4. K. Daly, Ireland

Kieran DALY, MB Dch, FRCPI, FESC, FACC
Consultant Cardiologist, Cardiology
Department, University College Hospital
Galway, IRELAND
(e-mail: Kieran.daly@hse.ie)



Cardiac rehabilitation (CR) has been shown to accelerate physical and psychological recovery and reduce mortality after acute cardiac events. The programs help modify risk factors and increase the likelihood of a return to work. It is a cost-effective intervention that improves prognosis and reduces recurrent hospitalization and health care expenditure. When originally introduced, CR was primarily aimed at patients after cardiac surgery and myocardial infarction without intervention. Traditionally, Phase II CR commenced 4 to 6 weeks after the event when wound healing had occurred.

Over the past decade, the profile of patients that would benefit from CR has changed greatly. The duration of hospitalization following percutaneous coronary intervention (PCI) and even primary angioplasty has greatly reduced. Patients undergoing these procedures are fully mobile on discharge and mostly keen to return to work and normal activity. Yet recent surveys have indicated that less than 35% of heart attack and other cardiac event patients attend CR programs. The cause is likely multifactorial, and includes a lack of services, patient anxiety and lack of motivation, lack of social support, travel time, and needing to take time off from work. A major factor is undoubtedly the length of time between discharge and commencement of outpatient CR, during which many patients will have attempted to return to normal work and activity, and while remaining concerned as to the appropriate lifestyle and exercise level, they find themselves unable to engage in a delayed program.

Concern has existed regarding possible adverse effects of early CR after discharge from hospital. However, there is now extensive evidence that early CR does not have any adverse effect on left ventricular size or myocardial function, and that rates of completion of CR are greater if started within 14 days post discharge. Equally, CR exercise programs can be safely started—even in the elderly—2 weeks after discharge following cardiac surgery, and they lead to better exercise tolerance.

Ensuring higher levels of participation in CR will require significant multidisciplinary organization. Intensive in-hospital Phase I CR, enthusiastic physician endorsement, more accessible early programs, and tailoring of programs to patients’ needs, sex, and age are necessary. Community- rather than hospital-based programs should be more acceptable to patients, and initiatives such as home-based telemonitored exercise programs could support traditional CR. Issues such as the relatively poor take-up of CR by women will need to be addressed.

In summary, the value of CR is beyond doubt. The current low level of participation by patients following cardiac events will only be addressed by an enthusiastic multidisciplinary Phase I approach, followed by early (2 weeks ideally) enrolment in Phase II programs with a strong community element. Barriers to CR participation need to be identified. Databases on cardiac intervention, acute coronary syndromes, and cardiac surgery need to be linked to CR programs with regular local and national audit. _

5. Doina R. DIMULESCU, Romani

Doina R. DIMULESCU, MD, PhD, FESC
Professor, University of Medicine
and Pharmacy “C. Davila”
Head of Cardiology Clinic
Elias University Hospital
17, Bd. Marasti, Sector 1
Bucharest, ROMANIA
(e-mail: doina.dimulescu@gmail.com)



Prolonged bed rest and hospitalization was the standard care for patients after acute myocardial infarction (AMI) some decades ago; exercise helped to reduce the hospitalization period and physical deconditioning, and to delay the onset of angina after AMI before the era of myocardial revascularization. With the advent of modern effective therapeutic interventions in AMI, physical training is now also aimed at improving psychological wellbeing, controlling depression and anxiety, improving adherence to medication, and controlling risk factors.

Exercise training after AMI has beneficial hemodynamic effects, producing an average 20% improvement in aerobic capacity. Improved functional capacity allows patients to return to work and helps elderly patients maintain independent living.1 A reduction in recurrent myocardial infarction and mortality in coronary artery disease patients included in physical training programs has been documented in a meta-analysis, and the results do not differ from those of trials conducted in the era of cardiac revascularization.2 A recent large observational study in more than 600 000 patients aged >65 years discharged after hospitalization for coronary disease showed a 21% to 34% decrease in all-cause mortality at 5 years in those patients included in physical training programs compared with controls.3

When should physical training start after an acute coronary syndrome? The European Society for Cardiology (ESC) guidelines for the management of ST-segment elevation myocardial infarction recommend risk stratification and exercise testing.4 A position paper from the ESC on cardiac rehabilitation in secondary prevention makes recommendations as to the timing and intensity of physical training after AMI and in heart failure patients.5 In uncomplicated AMI, ambulation should begin after 12 to 24 hours (Class I); predischarge physical training may start in hospital after an electrocardiogram stress test. Patients with preserved exercise capacity may resume physical activity for 30 to 60 minutes daily at 75% to 80% of peak heart rate (Class I). After large or complicated infarcts with heart failure, shock, or arrhythmias, patients should maintain bed rest for longer and physical activity should begin only after stabilization. Patients with left ventricular systolic dysfunction should be tested for peak exercise capacity with maximal symptom-limited cardiopulmonary exercise testing, and physical training should resume gradually at 50% of maximal exercise capacity in hospital to verify clinical tolerability and stability. Daily moderate-intensity exercise after hospitalization is recommended (Class I).5

Each stage of increased physical work capacity is associated with an 8% to 14% reduction in all-cause mortality risk.5 Physical training is safe, and data reported in clinical trials show one event (AMI, cardiac arrest) in 50 000 to 100 000 supervised patient-hours of physical training.1

In patients with heart failure, which frequently has an ischemic etiology, the benefits of physical training are less clear. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized 2331 patients with left ventricular ejection fraction ≤35% to exercise training or control. There was an 11% decrease in total mortality or hospitalization (P=0.03) and a 15% decrease in cardiovascular mortality and cardiovascular hospitalization (P=0.03) with exercise training, suggesting that this has some beneficial effects in patients with heart failure—findings consistent with the results of 33 previous clinical trials and a meta-analysis.

Questions about the role of exercise training remain unanswered: the optimal amount, intensity, and combination of exercise training modalities in patients with systolic heart failure, as well as its utility in patients with cardiac resynchronization therapy.6 Although recognized as a core component of multifactorial cardiac rehabilitation, physical training is still underused (less than 50% in observational studies). Lack of knowledge, skills, and motivation on the part of health care providers, as well as patients’ lack of adherence in changing their lifestyle and insufficient insurance funding, are all possible causes and must be addressed. _

References
1. Wenger KN. Current status of cardiac rehabilitation. JACC. 2008;51:1619-1631.
2. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682-692.
3. Suaya JA, Stason WB, Ades PhA, et al. Cardiac rehabilitation and survival in older coronary patients. JACC. 2009;54:25-33.
4. Management of acute myocardial infarction in patients with persistent ST-segment elevation. The Task Force on the Management of ST-Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008;29: 2909-2945.
5. Corra U, Piepoli MF, Carre F, et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31: 1967-1976.
6. Kraus WE. Exercise in heart failure. In: Mann DL, ed. Heart Failure. A Companion to Braunwald’s Heart Disease. 2nd ed. St. Louis, MO: Elsevier Saunders; 2011: 834-844.


6. N. M. Farag, Egypt

Nabil M. FARAG, MD, FSCAI
Professor of Cardiology, Ain Shams University
Chairman of Cardiology Department
Dar Alfouad Hospital
71 Elhegaz Street, Elmahkama Square
Heliopolis, Cairo, EGYPT
(e-mail: faragnabil@hotmail.com)



In recent years, there has been impressive progress in pharmacological therapies and sophisticated technology-based diagnostic and therapeutic procedures in cardiovascular diseases. As a consequence, a greater number of men and women now survive acute events, but with a heavier subsequent burden of chronic conditions and clinical need. Cardiac rehabilitation includes patient assessment, counseling on physical activity, exercise training, diet/nutritional counseling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and management of psychosocial well-being.

Inpatient and outpatient cardiac rehabilitation for eligible cardiovascular patients is an essential component of care that should be incorporated into treatment plans. Increasing the number of people who participate in cardiac rehabilitation can also reduce health care costs associated with recurrent events and reduce the burden for families and caregivers of patients with serious sequelae.1

Exercise training should be recommended to all patients after acute coronary syndrome or primary percutaneous coronary intervention (PCI) (supervised or monitored in moderate- to high-risk patients). The training program should include at least 30 minutes of aerobic exercise, 5 days per week. After uncomplicated procedures, physical activity can start the next day. After substantial and/or complicated myocardial damage, physical activity should start after clinical stabilization and be increased slowly according to the patient’s symptoms.2-5 Inpatient rehabilitation is focused on early mobilization, and starts as soon as patients are hemodynamically stable and free of symptoms of ischemia, arrhythmia, or heart failure. As the patient progresses to ECG telemetry, progressive ambulation becomes appropriate, initially with assistance and hemodynamic assessment before, during, and after exercise. Patients should first try to sit up, stand, and walk in their room. Subsequently, they should start to walk in the hallway at least twice daily, for certain specific distances or as tolerated, and should not be unduly pushed or held back.

Early outpatient rehabilitation includes surveillance of symptoms, hemodynamics, glycemic response to exercise (in diabetics), weight, tobacco use, emotional status, and adherence with medications, diet, and home exercise. It also includes review of each individual’s pharmacological and device therapy to ensure adherence with consensus guidelines. This monitoring phase is an intensive, multidisciplinary intervention focused on educating the individual about the disease, its manifestations, and all aspects of its treatment. This provides participants with the tools needed to slow disease progression, maintain optimal functional status, and become an informed and active participant in managing their condition.

Most cardiac rehabilitation participants progress to independent exercise without a transitional “Phase III.” The main goal of maintenance lifetime rehabilitation is to promote habits that lead to a healthy satisfying lifestyle. In patients with stable coronary artery disease and post–elective PCI, symptom-limited exercise testing can safely be performed the day after the intervention, but it scarcely is. In patients with multiple risk factors and moderate-to-high risk (ie, recent heart failure episode), medically supervised exercise training programs are recommended at initiation, and ensure the patient’s motivation for long-term adherence.2,5

Exercise training in heart failure can improve both cardiac and non-cardiac indices.6 Experience has shown that exercise is safe and well tolerated if appropriately prescribed. During the initial stage (first 1 to 2 weeks), intensity should be kept at a low level in patients with NYHA functional Class III (50% of peak VO2), and the duration should be increased from 20 to 30 minutes according to the perceived symptoms and clinical status. During the improvement stage, a gradual increase in intensity (60% of peak VO2, then 70% to 80%, if tolerated) is the primary aim. Prolongation of exercise is a secondary goal. _

References
1. Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil. 1997;17:222-231.
2. Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. Eur Heart J. 2008;29:2909-2945.
3. Bassand JP, Hamm CW, Ardissino D, et al; Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1598-1660.
4. Antman EM, HandM, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247.
5. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. A statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107:3109-3116.
6. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Eur Heart J. 2008;29:2388-2442.


7. K. Naidoo, D. P. Naidoo, South Africa

Kumari NAIDOO, MD, ChB
University of KwaZulu-Natal
Durban, SOUTH AFRICA
Datshana P. NAIDOO,MD
Professor of Cardiology
Head of the Cardiology Department
Nelson R. Mandela School of Medicine
University of KwaZulu-Natal
Durban, SOUTH AFRICA
(e-mail: naidood@ukzn.ac.za)



Cardiac rehabilitation (CR) is aimed at improving physical and psychosocial functioning after a cardiovascular event, and targets the underlying disease process to prevent further events. CR is today relevant to a more diverse patient population than previously. The epidemic of chronic disease has resulted in younger patients of all ethnicities being affected by coronary events. Advances in cardiology have also led to more patients surviving major cardiac events and living with disabilities.

Today, CR extends beyond post-infarct to revascularized patients post–coronary artery bypass graft or percutaneous coronary intervention. It also includes patients with chronic stable angina and those who have sustained repeated events resulting in myocardial dysfunction and heart failure (HF). The stepwise process of rehabilitation begins immediately after the cardiac event and continues throughout life, with different interventions introduced at appropriate stages. Standard drug therapy for post-infarct and HF patients is usually instituted while the patient is still in hospital. Target blood pressure is 140/90 mm Hg (lower in diabetes and chronic kidney disease). HbA1C should be maintained at <7% in diabetics. Latest guidelines recommend lower lipid targets, with statins as baseline therapy. Provided the patient is clinically stable, physical activity should begin in hospital. This prevents complications of prolonged immobilization and acts as a psychological booster. After being able to sit up, patients may walk in the corridors for 2 to 5 minutes, 4 times daily. Heart rate (HR) should not exceed 120 beats per minute, while patients with resting tachycardia should not exceed a 20-beat increase from resting HR. A graded exercise program is implemented at Phase III, and begins with a risk assessment based on history, physical examination, and resting electrocardiogram (ECG). Exercise stress testing and ECG is required in high-risk patients for assessment of ventricular function and residual ischemia and those who wish to participate in high-intensity exercise. High risk patients (with residual ischemia or significant left ventricular dysfunction) require constant monitoring and the presence of health care professionals trained in advanced life support. HR should not be allowed to exceed 10 beats below the rate at which ischemia was provoked on stress testing. Impaired chronotropic response (failure to reach 80% of maximum HR) is associated with increased mortality post–myocardial infarction, especially with HF, and may be improved by β-blockade and ivabradine. The following factors preclude participation in an exercise program: (i) myocardial infarction complicated by persistent HF, cardiogenic shock, or complex ventricular arrhythmias; (ii) angina or breathlessness at low levels of exercise; (iii) ST-segment depression >1 mm on resting ECG; and (iv) marked ST segment depression (>2 mm) or symptoms experienced at <5 metabolic equivalent tasks during exercise stress testing. Patients should be encouraged to stop smoking at every opportunity and be educated on other risk factor targets. The basic principles of a cardioprotective diet should be adhered to. Target body mass index is 21 to 25 kg/m2. Overweight patients should aim for 10% initial weight loss through exercise and diet. Low mood, anxiety, irritability, and tearfulness are natural after a cardiac event; however, persisting symptoms may suggest clinical depression or anxiety. A truly comprehensive rehabilitation program strives to assist in reintegrating the patient into the home, family, and work environments. Patients may return to work as soon as they are physically capable. Patients may return to sexual activity 2 to 3 weeks after an uncomplicated myocardial infarction. There is strong evidence that exercise-based rehabilitation yields a 20% reduction in total mortality and a 26% reduction in cardiac mortality, compared with usual medical care. It is an essential component of the management of all patients with cardiovascular disease and should start immediately after an event and be maintained long term. _

Further reading
– Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363-2372.
– Contractor AS. Cardiac rehabilitation after myocardial infarction. J Assoc Physicians India. 2011;59(suppl):51-55.


8. H. Ong-Garcia, Philippines

Helen ONG-GARCIA, MD, FPCP, FPCC
President, Cardiac Rehabilitation
Society of the Philippines
Room 1115, South Tower
Cathedral Heights Building
St. Luke’s Medical Center
Quezon City, PHILIPPINES
(e-mail: ongh63@yahoo.com)



Being a cardiac patient with multiple issues is never easy. An acute cardiac event is always devastating and persistently debilitating, so that complete management can never be truly accomplished. Assuming that all algorithms for recognized standards of care have been implemented, improvement of the condition does not necessarily indicate better overall functionality and disposition. Thus, the evolution of cardiac rehabilitation as a discipline has come about. The benefits of cardiac rehabilitation are multifaceted; exercise rehabilitation has a positive impact on a number of factors, including improvement in a patient’s lipid profile, blood pressure reduction, and prevention or treatment of type 2 diabetes. Other potentially contributory factors to the benefits of cardiac rehabilitation and exercise training include a reduction in inflammation, as indicated by a decrease in serum C-reactive protein, possible ischemic preconditioning, improved endothelial function, and a more favorable fibrinolytic balance.1 Such neurochemical improvements would thus anticipate the positive clinical outcomes seen in several studies involving patients who underwent cardiac rehabilitation.

Studies involving cardiac patients, particularly those investigating changes in clinical functional parameters and quality of life measures, have indicated that cardiac rehabilitation, whether exercise-based or focused on a comprehensive risk factor prevention program (which remains a contentious issue), has significant benefits. Exercise rehabilitation, with or without risk factor education and counseling, produced greater reductions in total cholesterol, triglycerides, systolic blood pressure, and self-reported smoking than control conditions, without significant differences in low-density lipoprotein or high-density lipoprotein cholesterol levels.2 Quality of life improved to a similar degree with both cardiac rehabilitation and usual care, although some studies found a trend toward a superior improvement with cardiac rehabilitation.

In a study of over 500 consecutive coronary patients enrolled in a cardiac rehabilitation program, depressive symptoms were assessed by questionnaire and mortality was evaluated at a mean follow-up of 40 months. Depressed patients had a fourfold higher mortality than non-depressed patients, and depressed patients who completed rehabilitation had a 73% lower mortality rate than control patients not completing rehabilitation. Only a mild improvement in fitness level was needed to produce the benefit on depressive symptoms and the associated decrease in mortality.3

As of March 2006, the US Centers for Medicare and Medicaid Services concluded that cardiac rehabilitation is reasonable and necessary after acute myocardial infarction (within the prior 12 months), coronary artery bypass graft surgery, stable angina pectoris, percutaneous coronary intervention with or without stenting, heart valve repair or replacement, and heart or heart-lung transplantation. Despite this, enrolment remains low and the discipline is underutilized. It has also been documented that earlier enrolment stands to produce a greater reduction in symptoms and better cardiovascular outcomes. As it is, with an underrated and underappreciated modality that has confirmed benefits, the dictums of “the earlier the better” and “the more the merrier” are a must. _

References
1. Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol. 2004;43:1056-1061.
2. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682-692.
3. Milani RV, Lavie CJ. Impact of cardiac rehabilitation on depression and its associated mortality. Am J Med. 2007;120:799-806.


9. A. A. A. Rahim, Malaysia

Aizai Azan Abdul RAHIM, MD, MMed
Consultant Cardiologist
Department of Cardiology
National Heart Institute
Kuala Lumpur
MALAYSIA
(e-mail: aizai@ijn.com.my)



The role of cardiac rehabilitation (CR) in the continuum of care in cardiovascular disease is undisputed. It is a Class I recommendation inmost evidence-based guidelines, but remains underutilized. Historically, in the early 1930s, patients with acute myocardial infarction (AMI) were recommended bed rest for 6 weeks. Chair therapy was introduced in the 1940s, but by the 1950s, clinicians realized that early ambulation was not harmful and could help avoid many of the complications associated with prolonged rest, and daily walking exercises beginning 4 weeks post-AMI were advocated. Comprehensive CR programs have since come a long way, but questions remain regarding the optimum initiation time.

Previously, CR patients were post–coronary artery bypass graft (CABG) surgery, post–valvular repair/replacement surgery, or post–acute coronary syndrome (ACS), and they attended an outpatient CR program typically 4 to 6 weeks after discharge. Recently, eligibility for CR has evolved to include patients after percutaneous coronary intervention (PCI) and heart transplantation, those with pacemakers, implantable cardiac defibrillators, and ventricular assist devices, and those with peripheral arterial disease, pulmonary arterial hypertension, heart failure (HF) with preserved ejection fraction, stable angina, and compensated chronic HF with impaired ejection fraction. Patients are increasingly older with multiple comorbidities. These complexities make the decision regarding how soon to implement CR more challenging.

There is no evidence as to when exercise training (ET) should commence after ACS or PCI to derive maximal benefits.1,2 Nevertheless, many national associations have formulated their own guidelines on a consensus basis. Most CR programs delay ET until ≥4 to 6 weeks after AMI and 3 weeks post- PCI.3 There are suggestions that clinically stable patients after uncomplicated AMI may begin 1 week after discharge, continuing for up to 6 months to achieve maximal anti remodeling benefits. There is no evidence that this causes any harm.4 Trials have shown no increase in the risk of complications with earlier physical activity. No additional adverse events occurred during 6-month ET sessions initiated approximately 1 week post AMI in patients with mild to moderate left ventricular (LV) systolic dysfunction.5 Earlier commencement of ET markedly increases participation in secondary preventive programs. Observational studies report that CR initiation after 1 week leads to a 90% increase in participation compared with initiation at 4 weeks, with an earlier return to work.

Drug-eluting stents may require 9 to 12 months before complete vessel healing occurs, but should we delay ET in these patients? There is no evidence of an increased risk from moderate exercise, and in a recent retrospective analysis, participation in CR following PCI was associated with a decrease in all-cause mortality.6

Following CABG and surgical valvular procedures, 6 weeks are usually needed for adequate healing. Light weights, breathing exercises, and walking are possible before this time. Consensus papers recommend that CR commence 2 to 4 weeks post-CABG and valvular procedures in patients with normal/ slightly reduced LV function, 4 to 6 weeks following cardiac transplantation, and 1 to 2 weeks following minimally invasive heart surgery.

Patients with stable compensated HF were shown to benefit from ET in HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of exercise traiNing) but there was no indication as to how early or late the training started after discharge. The ongoing EJECTION-HF (Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure) may shed light on this matter.

Many issues regarding optimal ET wait times in CR programs remain unanswered, and there is no internationally accepted policy. Many factors need to be considered, including the resources and facilities available in each country. These in turn must then be guided by emerging science and results of future studies. _

References
1. Dafoe W, Arthur H, Stokes H, et al. Universal access but when? Treating the right patient at the right time: access to cardiac rehabilitation. Can J Cardiol. 2006;22: 905-911.
2. Piepoli M, Corra U, Benzer W, et al. Secondary prevention through cardiac rehabilitation: physical activity counseling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010; 31:1967-1976.
3. Clark AM, Hartling L, Vandermeer B, et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005;143: 659-672.
4. Kovoor P, Lee AK, Carrozzi F, et al. Return to full normal activities including work at two weeks after acute myocardial infarction. Am J Cardiol. 2006;97:952-958.
5. Giallauria F, Cirillo P, Lucci R, et al. Left ventricular remodeling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide. Eur J Cardiovasc Prev Rehabil. 2008;15:113-118.
6. Goel K, Lennon RJ, Tilbury RT, et al. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011;123:2344-2352.


10. H. Rasmusen, Denmark

Hanne RASMUSEN, PhD, MD
Consultant Cardiologist
Department of Cardiology
Bispebjerg University Hospital
Copenhagen, DENMARK
(e-mail: hras0044@bbh.regionh.dk)



Although the incidence and mortality rates of coronary heart disease (CHD) have been decreasing in most countries, CHD still accounts for one third of deaths globally, and in Europe, it is the most common cause of death.1

Nearly half of the decrease in CHD mortality has been attributed to treatment (including 11% attributed to secondary prevention, 13% to heart failure treatment, 8% to initial treatment of acute myocardial infarction, and 3% to hypertension treatment), and about 50% of the decline has been attributed to population-wide risk factor reduction.2

Cardiac rehabilitation (CR) aids recovery from a cardiac event and reduces the likelihood of further illness.3 CR has been defined as the “coordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease.”4

Core components of CR in patients post–acute coronary syndrome, used in individually tailored programs, include systematic risk factor management and clinical assessment, patient education, counseling on physical activity and exercise training, diet/nutritional counseling and weight control management, lipid management, blood pressure monitoring, smoking cessation, and management of psychosocial wellbeing.5

Despite the high number of patients suffering from a cardiovascular event and the proven beneficial effects of CR, no study has addressed the question of when exactly the optimal time to start CR is. A CR program usually has three phases: Phase I, during hospital admission; Phase II, hospital based outpatient cardiac rehabilitation; and Phase III, the late maintenance and follow-up phase. Most studies have focused on the effect of CR in Phase II; nevertheless, Phase I is of equal importance in improving patient uptake and increasing patient adherence to CR after discharge. Starting CR during hospital admission helps to emphasize that ischemic heart disease is a chronic disease that is not only treated with acute invasive treatment. CR is considered—and recommended to be—part of the overall treatment.

In recent years, attention has increasingly focused on the fact that patients are especially vulnerable during the transitions between phases due to a lack of coordination between the different phases and the efforts of all those involved, with the risk of a loss of the health benefits achieved. This emphasizes the importance of systematic assessment of all patients to determine their CR needs. Not all patients need CR, but all patients should be offered risk stratification, optimal medication, and counseling regarding their needs and the resources available.

Almost all clinical trials of CR have exclusively enrolled low risk, middle-aged men after myocardial infarction. The exclusion or underrepresentation of women, elderly people, and other cardiac groups (post–revascularization and angina pectoris) not only limits the applicability of the evidence to contemporary cardiovascular practice, but also fails to consider those who may benefit most from rehabilitation.

In conclusion, CR is cost effective, reduces mortality and morbidity, and should be offered to all patients following a cardiovascular event. Optimally, CR starts during hospital admission to ensure that all patients know how to manage their disease after discharge and the importance of reducing risk factors and receiving optimal medical treatment. Phase II CR focuses on risk factor intervention, exercise training, psychosocial management, and patient education. Unfortunately, very few studies have focused on Phase III, the maintenance of CR. While it is important that CR begins during Phase I, it is equally important that interventions carried out during Phase II are maintained during Phase III, in order to maintain the effects of the interventions in Phase II. _

References
1. World Health Organization, World Heart Federation, World Stroke Organization. Global Atlas on Cardiovascular Disease Prevention and Control. Available at: http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf. Accessed June 26th, 2012.
2. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356:2388-2398.
3. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800.
4. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104:1694-1740.
5. Piepoli MF, Corra U, Benzer W, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17:1-17.


11. G. Sinagra, P. L. Temporelli, Italy

Gianfranco SINAGRA, MD, FESC
Chief, Cardiovascular Department
Ospedali Riuniti, University of Trieste
ITALY
Pier Luigi TEMPORELLI,MD
Director, Laboratorio Per Lo Studio
Del Rimodellamento Ventricolare
Ed Emodinamica Non-Invasiva
IRCCS Fondazione Salvatore Maugeri
Pavia, ITALY
(e-mail: gianfranco.sinagra@aots.sanita.fvg.it)



Cardiovascular disorders are the leading cause of mortality and morbidity worldwide. The survivors represent an additional reservoir of cardiovascular disease morbidity. Cardiac rehabilitation (CR) programs, first developed in the 1960s, are associated with significant reduction in mortality rates in individuals with coronary artery disease.1 At the beginning, exercise was the primary component of these programs, and they were predominantly offered to survivors of uncomplicated myocardial infarction and initiated at a time remote from the acute event.2 In recent years, there has been growing evidence to support a benefit of CR for patients with chronic heart failure,3 peripheral artery disease, and those who have undergone cardiac surgical procedures such as valvular or coronary artery bypass surgery.4

Today, CR is a multifaceted and multidisciplinary intervention that improves functional capacity, recovery, and psychological well-being.4 The rehabilitation team includes a physician, one or more nurses with coronary care experience, and at least one exercise physical therapist. Other complementary staff such as a dietician and psychologist may be included, whether accessed onsite or through associated private practices. Core components of CR or secondary prevention programs are baseline patient assessment, physical activity counseling and exercise training, nutritional counseling, risk factor management (lipids, hypertension, weight, diabetes, and smoking), psychosocial management, vocational counseling, and optimized medical therapy.4

CR should be started soon after discharge from the acute care setting. In disabled and unstable patients, the more immediate objectives of CR services are to achieve clinical stability, limit the physiological and psychological effects of cardiac illness, improve the overall functional status, and help the patient maintain their independence with an emphasis on quality of life. In the longer term, the objectives are to reduce the risk of future cardiovascular events, delay progression of the underlying atherosclerotic process and clinical deterioration, and ultimately, reduce morbidity and mortality.

CR programs vary in length, content, and the place of delivery. Different patterns of rehabilitative care are currently delivered by specialized hospital-based teams: (i) residential CR for more complicated, disabled patients; and (ii) outpatient CR for more independent, low-risk and clinically stable patients requiring less supervision.4

Residential CR programs should be followed up with a long term outpatient risk reduction and secondary prevention program, with appropriate clinical and functional monitoring. Some patients may benefit from a home-based comprehensive CR program validated for patients after myocardial infarction that incorporates education, exercise, and stress management components, with follow-up sessions with a trained facilitator.5 This should be offered to patients as part of a menu-based approach, but should not be used to replace a multidisciplinary hospital-based program, particularly for patients with complex conditions that need specialist assessment. A home based program produces similar gains to hospital programs, and has been shown to be preferred by many patients.

On the basis of the body of evidence in favor of the positive effects of CR, clinical guidelines identify CR as an essential component (Class I level recommendation) in the care of patients following myocardial infarction or acute coronary syndrome, chronic stable angina, heart failure, coronary artery bypass surgery or percutaneous coronary intervention, valve surgery, or cardiac transplantation.6

In conclusion, CR is a structured program of care that helps patients through lifestyle modification and appropriate use of medication. There is a large body of evidence addressing the efficacy of short- and long-term CR programs for the secondary prevention of cardiovascular events. Consequently, effort should be made to include CR in every patient’s hospital discharge prescription. _

References
1. Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011;123:2344-2352.
2. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary prevention through cardiac rehabilitation: position paper of theWorking Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J. 2003; 24:1273-1278.
3. Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail. 2010;12:706-715.
4. Balady GJ, Ades PA, Bittner VA, et al; American Heart Association Science Advisory and Coordinating Committee. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011;124: 2951-2960.
5. Taylor R, Dalal H, Jolly K,MoxhamT, Zawada A.Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2010;(1):CD007130.
6. Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). Circulation. 2010;122:1342-1350.


12. M. Zoghi, Turkey

Mehdi ZOGHI, MD, FESC
Professor and Board Member,
Heart Failure Working Group of
Turkish Society of Cardiology
Ege University Department of Cardiology
Bornova, 35100, Izmir
TURKEY
(e-mail: mehdi.zoghi@ege.edu.tr)



Start in hospital, continue at home.” There are several pieces of evidence supporting the benefits of cardiac rehabilitation and secondary prevention programs following a cardiovascular event such as myocardial infarction or heart failure, coronary artery bypass graft surgery, or heart transplantation.1

The exercise training component of cardiac rehabilitation programs produces enhanced peak VO2, oxygen utilization, and endothelial function, improvement in cardiac symptoms and mortality, and reduced sympathetic tonus and neurohumoral activity comparable to that of younger patients with heart failure.2 Despite the effectiveness of cardiac rehabilitation, only one in four patients is referred for cardiac rehabilitation. In Turkey, the proportion of eligible patients who attend any cardiac rehabilitation program is very low compared with other European countries; 7.3% of patients after an index event.3 Clinical status, as well as demographics, the presence of comorbidities, logistics, and socioeconomic status are all barriers to enrolment in cardiac rehabilitation and secondary prevention programs after hospitalization. Cardiovascular event rates and hospitalization are higher in elderly patients. However, it is notable that patients over 75 years of age, as well as female patients and patients with comorbidities, are less likely attend to these programs. Dobson et al demonstrated that the mortality benefits for these patient populations are greater than those in a young male cohort.4

Heart failure is the most common discharge diagnosis, particularly in elderly hospitalized patients. Although cardiac rehabilitation is recommended for all eligible patients with stable coronary artery disease and New York Heart Association Class I–III heart failure (no serious arrhythmias or limitations to exercise), the start of cardiac rehabilitation is often delayed while waiting for the initiation of an exercise program. Exercise is the cornerstone of cardiac rehabilitation, but cardiac rehabilitation is a multidisciplinary approach and exercise prescriptions should be combined with psychological and medical educational components. Starting exercise programs immediately after hospitalization is not possible for most patients, and rehabilitation programs should not be delayed for the exercise prescription. Although most programs are outpatient based, cardiac rehabilitation should be started as soon as possible in hospital, and exercise programs should be added within 1 to 3 months after discharge. The duration and frequency of the exercise prescription are important elements in the cardiac rehabilitation program. Exercise should be practiced for 30 minutes 3 days a week, taking into consideration the results of HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of exercise traiNing).5

The regular continuation of a cardiac rehabilitation program is as fundamentally important as starting the program immediately. Long-term rehabilitation programs reduce cardiovascular mortality by approximately 1.5-fold compared with short-term interventions. A clinical nurse specialist and/or physiotherapist is the most likely person to coordinate the rehabilitation program.6 Home-based strategies can overcome the problems related to hospital-based programs. Home-based exercise programs are as effective as hospital-based programs in improving functional capacity, left ventricular ejection fraction, quality of life, and significantly reducing depression symptoms.6 A home-based cardiac rehabilitation program is more effective at ensuring patients remain in their rehabilitation program, and should absolutely be considered in countries that have a limited number of outpatient heart failure clinics.

Aside from patient characteristics, certain barriers to cardiac rehabilitation may be unique to each country and be related to the level and number of cardiac rehabilitation services, public health care, and insurance policies. With the current economic problems, home-based rehabilitation is increasingly coming to the fore. Cardiac rehabilitation is an essential component of the management of patients of all ages with heart failure and/or coronary artery disease. Ideally, it should be started in hospital, combined with exercise training programs within 1 to 3 months after discharge, and must be continued for the patient’s lifetime. _

References
1. Forman DE, Rich MW, Alexander KP, et al. Cardiac care for older adults. Time for a new paradigm. J Am Coll Cardiol. 2011:57:1801-1810.
2. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J; American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/ American Heart Association Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/ secondary prevention services. Circulation. 2007;116:1611-1642.
3. Tokgözoğlu L, Kaya EB, Erol C, Ergene O; EUROASPIRE III Turkey Study Group. EUROASPIRE III: a comparison between Turkey and Europe. Turk Kardiyol Dern Ars. 2012;38:164-172.
4. Dobson LE, Lewin RJ, Doherty P, Batin PD, Megarry S, Gale CP. Is cardiac rehabilitation still relevant in the new millennium? J Cardiovasc Med (Hagerstown). 2012 Jan;13(1):32-37.
5. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450.
6. Horgan J, Bethel H, Carson P, et al. Working party report of cardiac rehabilitation. Br Heart J. 1992;67:412-418.