Cardiac Rehabilitation Beneficial but Under-used, Say New AHCPR Guidelines

Press Release Date: October 10, 1995

Guidelines released today by the Agency for Health Care Policy and Research say cardiac rehabilitation services—medically supervised interventions aimed at limiting physical and other damage from heart disease that reduce the risk of death and help patients resume a normal life—are widely under-used in spite of their proven benefits.

"Less than a third of heart patients participate in cardiac rehabilitation programs even though potentially all of them could benefit from the services," said Douglas B. Kamerow, M.D., M.P.H., AHCPR's director of Clinical Practice Guideline Development. The guideline panel found that cardiac rehabilitation is safe and beneficial when patients have been appropriately screened.

The clinical practice guidelines, which AHCPR is disseminating widely to health professionals and heart disease patients, recommend a comprehensive approach that includes exercise training to improve exercise tolerance and stamina, and education, counseling and behavioral interventions to assist patients in achieving and maintaining optimal health. The guidelines also recommend considering home-based cardiac rehabilitation, guided by a health care professional, as an alternate approach for low- or moderate-risk patients who cannot participate in traditional, structured group cardiac rehabilitation, which is generally conducted in hospitals or other health or community facilities.

Michael Horan, M.D., director of the Division of Heart and Vascular Diseases with the National Heart, Lung, and Blood Institute, whose institute co-sponsored the development of the guidelines, said cardiac rehabilitation is an important part of the continuum of care for heart disease. "The guidelines are a major step in the fight against heart disease," added Dr. Horan.

An estimated 13.5 million Americans have coronary heart disease, including almost one million who survive heart attacks each year, the more than 600,000 annually who undergo coronary artery bypass surgery or balloon angioplasty—an invasive procedure used to open blocked coronary arteries—and the approximately 2,000 patients who have heart transplants each year. About half of all these patients are elderly. Heart disease patients also include about seven million persons with angina—recurring chest pain—and 4.7 million who have stable heart failure.

Nanette K. Wenger, M.D., co-chair of the 19-member private-sector panel that developed the guidelines, and Professor of Medicine at the Emory University School of Medicine in Atlanta, Ga., said physicians know about cardiac rehabilitation, but not enough refer their patients for services. "Cardiac rehabilitation should be part of the discharge plans for all heart disease patients," said Dr. Wenger, a cardiologist and consultant to the Emory Heart Center and Director of the Cardiac Clinics at Grady Memorial Hospital.

Dr. Wenger said some doctors prescribe individual components of cardiac rehabilitation, such as exercise training or education, but that individual activities by themselves are less effective.

The guidelines say the benefits of well-designed cardiac rehabilitation are:

• Increase Exercise Tolerance: The most consistent benefits occur when patients exercise three times a week, 20 to 40 minutes at a time, at 70 to 85 percent of the baseline exercise test heart rate. Exercise training should last 12 weeks or more. The guidelines recommend that patients continue exercising to maintain the benefits of exercise training.
• Improve Symptoms: Cardiac rehabilitation decreases anginal pain and improves heart failure symptoms, such as shortness of breath and fatigue.
• Improve Blood Fat Levels: Nutritional education counseling, behavioral interventions, and exercise training improve cholesterol levels. Many patients may also need cholesterol-lowering drugs.
• Decrease Smoking: As many as 25 percent of patients who smoke cigarettes will quit after participating in a smoking cessation program as part of cardiac rehabilitation.
• Improve Psychosocial Well-Being and Stress Reduction: Education, counseling and psychosocial interventions, as well as exercise training, improve these outcomes.
• Reduce Mortality: Comprehensive cardiac rehabilitation has been shown to reduce death rates in patients after heart attack by 25 percent.

Erika Sivarajan Froelicher, R.N., Ph.D., co-chair of the panel, said heart disease patients should ask for cardiac rehabilitation if it is not offered. "Patients should look for flexibility in a program so that they can stick with it," said Dr. Froelicher, a professor of nursing and adjunct professor of medicine at the University of California, San Francisco.

The guidelines were developed under an AHCPR contract, co-sponsored by NHLBI, awarded to the American Association of Cardiovascular and Pulmonary Rehabilitation. The panel convened by the association included physicians, nurses, exercise physiologists, behavioral specialists, dieticians, physical and occupational therapists, and consumers.

The panel's recommendations are based on an extensive review of the scientific literature and on expert opinion. The guidelines were peer-reviewed before being turned over to AHCPR for publication and dissemination.

A quick reference guide for clinicians, Cardiac Rehabilitation: Exercise Training and Education, Counseling, and Behavioral Interventions, and patient guide—Recovering from Heart Problems through Cardiac Rehabilitation—are available free of charge from the AHCPR Publications Clearinghouse. Call toll-free 800-358-9295, or write Cardiac Rehabilitation, AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, Md. 20907.

The full guideline—Cardiac Rehabilitation—will be available on Internet and can be accessed by using a Web browser and specifying URL http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.6677

For other online options, request Online Access for Clinical Practice Guidelines, AHCPR Publication No. 94-0075, by calling the AHCPR Clearinghouse. The full guideline also may be purchased from the U.S. Government Printing Office by calling (202) 512-1800.

For additional information, contact AHCPR Public Affairs: Karen Migdail, (301) 427-1855.