This chapter presents an account of cardiac rehabilitation that reflects both American and European perspectives. The authors find that the distinction between prevention and rehabilitation is becoming obsolete. The sections on risk estimation and prevention guidelines have a European flavor to complement Chap. 51. It should be stressed that the main objectives and targets are in close agreement. Both stress the need for total risk estimation as a first step in implementing practical preventive measures.
Atherosclerotic cardiovascular disease, particularly coronary heart disease (CHD) and stroke, is now the largest cause of death across the world except in sub-Saharan Africa.1 The creation of coronary care units in 1961 and associated advances in medical and nursing care are thought to be responsible for the decrease in mortality in patients with myocardial infarctions from 25%-30% to 18% in the prethrombolytic era of the mid-1980s2 to as low as 10% by 1997.2,3 In Europe, the annual incidence of non–ST-segment elevation myocardial infarction–acute coronary syndrome (NSTEMI-ACS) is higher than that of ST-segment elevation myocardial infarction (STEMI). Over time, the proportion of NSTEMI-ACS has increased compared with STEMI without any clear explanation for the reasons. The pattern of change could be related to improved diagnostics and management of CHD over the last 20 years,4,5 resulting in decreased 30-day mortality rates in NSTEMI-ACS of 3.4% and STEMI of 6.4%.5 In parallel with these changes, cardiac rehabilitation has evolved to meet the needs of patients with angina pectoris and acute coronary syndromes and of patients who are post cardiac surgery.
Substantial changes have occurred in our concepts of cardiac rehabilitation in recent years. In Eastern Europe, rehabilitation often involved inpatient assessment and care, whereas in North America and Western Europe, structured outpatient programs were favored. Comparatively, little communication existed between the disciplines of epidemiology, prevention, and rehabilitation, despite the fact that prevention requires advice on exercise and rehabilitation involves risk factor management. These issues have been addressed by many interested groups coming together to formulate guidelines that facilitate more integrated patient care.
The differentiation between primary and secondary prevention limits thinking on optimal public health and may be challenged. Pathologic studies indicated decades ago that atherosclerosis, the underlying cause of CHD, starts in childhood, develops insidiously over decades, and is generally advanced by the time symptoms occur. A person with asymptomatic plaque on carotid ultrasound or coronary artery calcification on computed tomography scanning should be managed no less vigorously than a patient who has had a clinical event.
Newer diagnostic tests for acute coronary syndromes have taught us that myocardial infarction represents a continuum of damage and does not occur suddenly when cardiac enzymes reach "two times the upper limit of normal." Newer therapies, especially focusing on rapid reperfusion of occluded coronary arteries, mean that, at least for those who reach medical care in time, major heart muscle loss with consequent complications such as shock ...