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Chapter Summary

This chapter discusses the indications for referral, evidence-based benefits, utility in specific populations, barriers to participation, and evolving trends in cardiac rehabilitation. Cardiac rehabilitation has evolved into a multidimensional, secondary prevention program that includes five core competencies: exercise training, patient education, dietary counseling, psychosocial interventions, and risk factor modification (see Fuster and Hurst’s Central Illustration). Cardiac rehabilitation usually consists of 36 sessions, delivered as 2 to 3 sessions per week over 12 to 18 weeks, and it is indicated for patients following acute myocardial infarction (MI), coronary artery bypass graft surgery, percutaneous coronary intervention (PCI), valvular repair or replacement, and cardiac transplantation, and for patients with chronic angina, peripheral vascular disease, and heart failure. Cardiac rehabilitation is associated with a reduced risk of death, cardiac death, MI, and hospitalization, as well as lower medical costs. In addition, it leads to improved quality of life and reduced depression and anxiety symptoms. Despite these benefits, current referral and enrollment in cardiac rehabilitation is suboptimal. Lower participation is observed among older adults, women, and individuals with less education or fewer socioeconomic resources. Home-based programs, which may reduce costs and increase availability, are currently hindered in the United States due to limited insurance coverage. The future may include the development of hybrid programs that combine center-based and home-based, supervised activities.

eFig 22-01 Chapter 22: Cardiac Rehabilitation: Current Practice and Future Directions


Cardiac rehabilitation is a clinically proven, multidisciplinary exercise training and risk factor modification program that enhances survival, reduces the risk of recurrent cardiac events, and improves physical and psychological well-being among patients with cardiovascular disease (CVD). The program is built around the promotion of exercise and associated lifestyle changes, while providing facilitative care for referring physicians’ clinical management of cardiac disease and control of CVD risk factors. Despite these broad dimensions, the term rehabilitation is still ubiquitously applied to refer to this secondary cardiac prevention program, reflecting its storied and unique origins.

In the early decades of the 20th century, physicians treated myocardial infarction (MI) with as much as 6 to 8 weeks of bedrest due to the concern that early exertion after acute MI could led to recurrent cardiac events or aneurysmal rupture of the left ventricle. Due to this prolonged bedrest, patients became unnecessarily debilitated post-MI, and many never returned to their former employment. In the 1940s, cardiologists began to warn against the dangers of prolonged bedrest post-MI, and by the early 1950s, Levine and Lown called for early “armchair” ambulation, consisting of progressive periods of getting out of bed to sit in a chair within 1 day of acute MI.1 Data accumulated over the next decade demonstrated that early ambulation was both safe and useful for reducing morbidity following acute MI.

During the 1960s, inpatient cardiac ...

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