GUIDELINE TITLE
Cardiac rehabilitation
BIBLIOGRAPHIC SOURCE(S)
- Agency for Health Care Policy and Research (AHCPR), Cardiac Rehabilitation Guideline Panel. Cardiac rehabilitation. Rockville (MD): U. S. Department of Health and Human Services, Public Health Service, AHCPR ; 1995 Oct. 202 p. (Clinical practice guideline; no. 17). [334 references]
BRIEF SUMMARY CONTENT
RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
RECOMMENDATIONS
MAJOR RECOMMENDATIONS
The strength of evidence definitions are provided at the end of the "Major Recommendations" field.
Effects of Cardiac Rehabilitation Exercise Training
Exercise Tolerance
Recommendation:
Cardiac rehabilitation exercise training consistently improves objective measures of exercise tolerance, without significant cardiovascular complications or other adverse outcomes. Appropriately prescribed and conducted exercise training is recommended as an integral component of cardiac rehabilitation services, particularly for patients with decreased exercise tolerance. Continued exercise training is required to sustain improved exercise tolerance.
(Strength of Evidence = A)
Strength Training
Recommendation:
Strength training improves skeletal muscle strength and endurance in clinically stable coronary patients. Training measures designed to increase skeletal muscle strength can safely be included in the exercise-based rehabilitation of clinically stable coronary patients, when appropriate instruction and surveillance are provided.
(Strength of Evidence = B)
Exercise Habits
Recommendation:
Cardiac rehabilitation exercise training promotes increased participation in exercise in addition to rehabilitation exercise training in patients after myocardial infarction or CABG. This effect does not persist long-term after completion of exercise rehabilitation. Long-term cardiac rehabilitation exercise training is recommended to provide the benefit of enhanced physical activity and exercise habits.
(Strength of Evidence = B)
Symptoms
Recommendation:
Exercise rehabilitation decreases angina pectoris in patients with coronary disease and decreases symptoms of heart failure in patients with left ventricular systolic dysfunction. Exercise training is recommended as an integral component of the symptomatic management of these patients.
(Strength of Evidence = B)
Smoking
Recommendation:
Exercise training has little or no effect on smoking cessation. Smoking cessation is achieved by specific smoking cessation strategies.
(Strength of Evidence = B)
Lipids
Recommendation:
Cardiac rehabilitation exercise training is not recommended as a sole intervention for lipid modification because of its inconsistent effect on lipid and lipoprotein levels. Optimal lipid management requires specifically directed dietary and, as medically indicated, pharmacologic management, in addition to cardiac rehabilitation exercise training.
(Strength of Evidence = B)
Body Weight
Recommendation:
Cardiac rehabilitation exercise training as a sole intervention has an inconsistent effect on controlling overweight and is not recommended as a sole intervention for this risk factor. Optimal management of overweight requires multifactorial rehabilitation including nutritional education and counseling and behavioral modification in addition to exercise training.
(Strength of Evidence = C)
Blood Pressure
Recommendation:
Rehabilitative exercise training as a sole intervention has no demonstrable effect in lowering blood pressure levels. Multifactorial cardiac rehabilitation, including exercise training, has an inconsistent effect in lowering blood pressure levels; major confounding variables include the use of antihypertensive medication and medication changes.
(Strength of Evidence = B)
Psychological Well-Being
Recommendation:
Cardiac rehabilitation exercise training -- with and without other cardiac rehabilitation services -- generally results in improvement in measures of psychological status and functioning. Exercise training as a sole intervention does not consistently result in improvement in measures of anxiety and depression. Exercise training is recommended to enhance measures of psychological functioning, particularly as a component of multifactorial cardiac rehabilitation.
(Strength of Evidence = B)
Social Adjustment and Functioning
Recommendation:
Cardiac rehabilitation exercise training improves social adjustment and functioning. Exercise training is recommended to improve these social outcomes.
(Strength of Evidence = B)
Return to Work
Recommendation:
Cardiac rehabilitation exercise training exerts less influence on rates of return to work than many nonexercise variables including employer attitudes, prior employment status, economic incentives, and the like. Exercise training as a sole intervention is not recommended to facilitate return to work.
(Strength of Evidence = A)
Morbidity and Safety Issues
Recommendation:
Cardiac rehabilitation exercise training does not change the rates of nonfatal reinfarction. The safety of exercise rehabilitation is well established; rates of infarction and cardiovascular complications during exercise training are very low.
(Strength of Evidence = A)
On the basis of the meta-analytical data, total and cardiovascular mortality are reduced in patients following myocardial infarction who participate in cardiac rehabilitation exercise training, especially as a component of multifactorial rehabilitation.
(Strength of Evidence = B)
Pathophysiologic Measures
Extent of Coronary Atherosclerosis
Recommendation:
Cardiac rehabilitation exercise training as a sole intervention does not result in regression or limitation of progression of angiographically documented coronary atherosclerosis. When combined with intensive dietary intervention -- with and without lipid-lowering drugs -- exercise training may result in regression or limitation of progression of angiographically documented coronary atherosclerosis.
(Strength of Evidence for Lack of Efficacy of Exercise Training Only = A, Strength of evidence for Efficacy of Multifactorial Intervention = B)
Hemodynamic Measurements
Recommendation:
Cardiac rehabilitation exercise training has no apparent effect on development of a coronary collateral circulation and produces no consistent changes in cardiac hemodynamic measurements at cardiac catheterization. Exercise training in patients with heart failure and a depressed ventricular ejection fraction produces favorable hemodynamic changes in the skeletal musculature. Cardiac rehabilitation exercise training is recommended to improve skeletal muscle functioning; it does not enhance cardiac hemodynamic function or promote development of a coronary collateral circulation.
(Strength of Evidence = B)
Myocardial Perfusion and/or Evidence of Myocardial Ischemia
Recommendation:
Cardiac rehabilitation exercise training decreases myocardial ischemia as measured by exercise ECG testing, ambulatory ECG recording, and radionuclide perfusion imaging. Cardiac rehabilitation exercise training is recommended to improve these measures of myocardial ischemia.
(Strength of Evidence = B)
Myocardial Contractility, Ventricular Wall Motion
Abnormalities, and/or Ventricular Ejection Fraction
Recommendation:
Cardiac rehabilitation exercise training has little effect on ventricular ejection fraction and regional wall motion abnormalities. The effect of exercise training on left ventricular function in patients after anterior wall Q-wave myocardial infarction with left ventricular dysfunction is inconsistent. Cardiac rehabilitation exercise training is not recommended to improve measures of ventricular systolic function.
(Strength of Evidence = B)
Occurrence of Cardiac Arrhythmias
Recommendation:
Rehabilitative exercise training has inconsistent effects on ventricular arrhythmias.
(Strength of Evidence = B)
Patients With Heart Failure and Cardiac Transplantation
Heart Failure
Recommendation:
Rehabilitative exercise training in patients with heart failure and moderate-to-severe left ventricular systolic dysfunction improves functional capacity and improves symptoms. These changes usually occur without changes in left ventricular function. Cardiac rehabilitation exercise training in patients with heart failure and left ventricular systolic dysfunction is recommended to attain functional and symptomatic improvement but with a potentially higher likelihood of adverse events.
(Strength of Evidence = A)
Cardiac Transplantation
Recommendation:
Rehabilitative exercise training in patients following cardiac transplantation improves measures of exercise tolerance and is recommended for this purpose. Lack of control populations limits the ascertainment of spontaneous improvement.
(Strength of Evidence = B)
Elderly Patients
Recommendation:
Elderly coronary patients have exercise trainability comparable to that of younger patients participating in similar exercise rehabilitation. Elderly female and male patients show comparable improvement. Referral to and participation in exercise rehabilitation is less frequent at elderly age, especially for elderly females. No complications or adverse outcomes of exercise training at elderly age were described in any study. Elderly patients of both genders should be strongly encouraged to participate in exercise-based cardiac rehabilitation.
(Strength of Evidence = B)
Effects of Cardiac Rehabilitation Education, Counseling and Behavioral Interventions
Smoking
Recommendation:
A combined approach of education, counseling, and behavioral interventions in cardiac rehabilitation results in smoking cessation and relapse prevention and is recommended for cardiac risk reduction.
(Strength of Evidence = B)
Lipids
Recommendation:
Intensive nutritional education, counseling, and behavioral interventions improve dietary fat and cholesterol intake. Education, counseling, and behavioral interventions about nutrition -- with and without pharmacologic lipid-lowering therapy -- result in significant improvement in blood lipid levels and are recommended as components of cardiac rehabilitation.
(Strength of Evidence = B)
Body Weight
Recommendation:
Multifactorial rehabilitation that combines dietary education, counseling, and behavioral interventions designed to reduce body weight can help patients lose weight. Education as a sole intervention is unlikely to achieve and maintain weight loss. These multifactorial cardiovascular risk-reduction interventions are recommended as components of comprehensive cardiac rehabilitation.
(Strength of Evidence = B)
Blood Pressure
Recommendation:
Expert opinion supports education as an important component of a multifactorial education, counseling, behavioral intervention, and pharmacologic approach to the management of hypertension. This approach is documented to be effective in nonrehabilitation populations and should also be included in cardiac rehabilitation. Education, counseling, and behavioral interventions as sole modalities have not been shown to control elevated blood pressure levels.
(Strength of Evidence = B)
Exercise Tolerance
Recommendation:
Cardiac rehabilitation education, counseling, and behavioral interventions without exercise training are unlikely to improve exercise tolerance and are not recommended for that purpose.
(Strength of Evidence = C)
Symptoms
Recommendation:
Cardiac rehabilitation education, counseling, and behavioral interventions are recommended alone, or as components of multifactorial cardiac rehabilitation, to reduce symptoms of angina.
(Strength of Evidence = B)
Return to Work
Recommendation:
Education, counseling, and behavioral interventions have not been shown to improve rates of return to work, which are contingent on many social and policy issues. In selected patients, formal cardiac rehabilitation vocational counseling may improve rates of return to work.
(Strength of Evidence = C)
Stress and Psychological Well-Being
Recommendation:
Education, counseling, and psychosocial interventions -- either alone or as components of multifactorial cardiac rehabilitation -- result in improved psychological well-being. Education, counseling, and behavioral interventions are recommended to complement the psychosocial benefits of exercise training.
(Strength of Evidence = A)
Morbidity
Recommendation:
Education, counseling, and behavioral interventions are recommended as part of multifactorial risk intervention for patients with CHD to decrease progression of coronary atherosclerosis and lower coronary event rates. Cardiac rehabilitation education as a sole intervention appears ineffective in altering morbidity.
(Strength of Evidence = B)
Education, counseling, and behavioral interventions reduce cardiac and overall mortality rates and are recommended in the multifactorial rehabilitation management of patients with CHD.
(Strength of Evidence = B)
Intake Assessment and Risk Stratification for Exercise Surveillance
Alternate Approaches to the Delivery of Cardiac Rehabilitation Services
Recommendation:
Alternate approaches to the delivery of cardiac rehabilitation services, other than traditional supervised group interventions, can be implemented effectively and safely for carefully selected clinically stable patients. Transtelephonic and other means of monitoring and surveillance of patients can extend cardiac rehabilitation services beyond the setting of supervised, structured, group-based rehabilitation. These alternate approaches have the potential to provide cardiac rehabilitation services to low- and moderate-risk patients who comprise the majority of patients with stable coronary disease, most of whom do not currently participate in supervised, structured rehabilitation.
(Strength of Evidence = A)
Adherence
Recommendation:
Adherence to cardiac rehabilitation services may improve patient outcomes. Adherence to cardiac rehabilitation services may be enhanced by clear communication; emotional support; understanding of the patient's (and family's) values, viewpoints, and preferences; and integration of the intervention into the patient's lifestyle.
(Strength of Evidence = C)
Cost
Recommendation:
Limited data suggest that multifactorial cardiac rehabilitation is a cost-effective use of medical care resources.
(Strength of Evidence = B)
Definitions:
Ratings reflect both the quality of the studies, including study design and methods used, and the consistency of the results of the scientific evidence:
A: Scientific evidence provided by well-designed, well-conducted, controlled trials (randomized and nonrandomized) with statistically significant results that consistently support the guideline recommendation.
B: Scientific evidence provided by observational studies or by controlled trials with less consistent results to support the guideline recommendation.
C: Expert opinion that supports the guideline recommendation because the available scientific evidence did not present consistent results, or controlled trials were lacking.
CLINICAL ALGORITHM(S)
A decision tree provides a summary of the highlights of the recommendations for cardiac rehabilitation services. The decision tree is divided into three components: patient categories; assessment and individualization of the treatment plan for exercise training; and assessment and individualization of the treatment plan for risk factor modification and psychosocial status.
EVIDENCE SUPPORTING THE RECOMMENDATIONS
TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of evidence (randomized or nonrandomized controlled trial, observational studies, or expert opinion) is identified and graded for each recommendation.
IDENTIFYING INFORMATION AND AVAILABILITY
BIBLIOGRAPHIC SOURCE(S)
- Agency for Health Care Policy and Research (AHCPR), Cardiac Rehabilitation Guideline Panel. Cardiac rehabilitation. Rockville (MD): U. S. Department of Health and Human Services, Public Health Service, AHCPR ; 1995 Oct. 202 p. (Clinical practice guideline; no. 17). [334 references]
ADAPTATION
Not applicable: The guideline was not adapted from another source.
DATE RELEASED
1995 Oct (reviewed 2000)
GUIDELINE DEVELOPER(S)
Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]
SOURCE(S) OF FUNDING
United States Government
GUIDELINE COMMITTEE
Cardiac Rehabilitation Guideline Panel
COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE
Names of Panel Members: Nanette Kass Wenger, MD (Panel Co-Chair); Erika Sivarajan Froelicher, RN, PhD (Panel Co-Chair); L. Kent Smith, MD, MPH (Project Director); Philip A. Ades, MD; Kathy Berra, BSN; James A. Blumenthal, PhD; Catherine M. E. Certo, ScD, PT; Anne M. Dattilo, PhD, RD; Dwight Davis, MD; Robert F. DeBusk, MD; Joseph P. Drozda, Jr., MD; Barbara J. Fletcher, RN, MN; Barry A. Franklin, PhD; Helen Gaston; Philip Greenland, MD; Patrick E. McBride, MD, MPH; Christopher G. A. McGregor, MB, FRCS; Neil B. Oldridge, PhD; Joseph C. Piscatella; Felix J. Rogers, DO.
FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST
Not stated
ENDORSER(S)
American College of Cardiology Foundation - Medical Specialty Society
GUIDELINE STATUS
This is the current release of the guideline. Per a recent Evidence-based Practice Center (EPC) report commissioned by the Agency for Healthcare Research and Quality (AHRQ), the guideline is considered, in whole or in part, to still be current.
GUIDELINE AVAILABILITY
Electronic copies: Available from the National Library of Medicine's HSTAT database.
Print copies: Information regarding the availability of these publications can be found in the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) Publications Catalog or the Clinical Practice Guidelines section of the AHRQ Web site.
AVAILABILITY OF COMPANION DOCUMENTS
The following are available:
- Cardiac rehabilitation through secondary prevention. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Oct 1995. (Quick reference guide for clinicians; no. 17). AHCPR Publication No. 96-0673. Available from the National Library of Medicine's HSTAT database.
- Cardiac rehabilitation. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Oct 1995. (Guideline technical report; no. 17).
Print copies: Information regarding the availability of these publications can be found in the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) Publications Catalog or the Clinical Practice Guidelines section of the AHRQ Web site.
PATIENT RESOURCES
The following are available:
- Recovering from heart problems through cardiac rehabilitation. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Oct 1995. (Consumer guide; no. 17). AHCPR Publication No.96-0674. Available from the National Library of Medicine's HSTAT database.
- La recuperación de los problemas cardíacos a través de la rehabilitación. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Oct 1995. (Consumer guide, Spanish; no. 17). AHCPR Publication No.96-0675. Available from the National Library of Medicine's HSTAT database.
Print copies: Information regarding the availability of these publications can be found in the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) Publications Catalog, which is available at the AHRQ Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This summary was completed by ECRI on October 1, 1998. The information was verified by the guideline developer on December 1, 1998.
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From the National Guideline Clearinghouse
Date Modified: 12/27/2004
Reproduced with permission
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