Cardiac Rehabilitation: Guidelines and Recommendations
Cardiac rehabilitation has been shown to improve exercise tolerance and symptomatology in patients experiencing angina or heart failure and reduce long term mortality after myocardial infarction, with a good cost-effectiveness ratio. In addition to these `hard' endpoints, cardiac rehabilitation improves the patient's quality of life and risk factor profile through a multifactorial intervention. Indeed, cardiac rehabilitation is no longer restricted to physical reconditioning, but should now be understood as the long term care of cardiac patients through a personalised and periodically updated programme. The components of a comprehensive cardiac rehabilitation programme should comprise risk stratification of the patient, physical reconditioning programmes, secondary prevention and vocational counselling. This article is a synthesis of the principal guidelines and recently published recommendations on cardiac rehabilitation. It focuses on the practical modalities of a cardiac rehabilitation programme, the setting up of the multidisciplinary team, the different facilities according to local possibilities and the patient's clinical status, the prescription of a personalised programme, safety measures and emergency procedures. Together with these general considerations, special populations which constitute new but growing indications for cardiac rehabilitation are addressed: patients with heart failure, elderly patients and women, who need specific management. In the future, cardiac rehabilitation should be characterised by a likely increase in its indications because of: 1. a predicted high prevalence of coronary artery disease (due to an aging population and an improvement in survival after a cardiac event) despite a lower mortality rate; 2. an expansion of the indications in both low and high risk patients. In low risk patients, the goals of cardiac rehabilitation will be to prevent further progression of coronary atheroma and preserve ventricular function by preventive measures such as lifestyle and medical treatment. The needs of high risk patients (who are essentially heart failure patients) are the restoration of autonomy, when lost, and a better quality of life through the improvement of exercise capacity: those patients who were formerly excluded from cardiac rehabilitation programmes are in fact those who are now deriving the greatest benefit from exercise training. Owing to the proven benefits of this new concept of the multifactorial approach, cardiac rehabilitation has, nowadays, become an integral part of the treatment of cardiac patients.
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