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Cardiac rehabilitation is a medically supervised comprehensive program that seeks to restore and improve function, limit disability, minimize cardiac risk factors, and optimize cardiac conditioning through secondary prevention efforts. The program is customized to the individuality of the patient, using a supervised exercise prescription that includes lifestyle modification, exercise and training counseling, education in risk factors and healthy living and stress management counseling. The goal is to optimize physical, psychological and social functioning that allows resumption of normal daily activities without significant cardiac symptoms.1


Coronary atherosclerosis results from plaque formation in the inside lining of the vessels of the heart which can lead to partial or full blood obstruction of the larger heart coronary arteries. Coronary heart disease may occur as well due to microvascular coronary damage.2   Other causes of heart disease is congestive heart failure secondary to other causes like coronary artery disease, ischemic injury, hypertension, valvular disease, arrhythmia, and toxic and metabolic effects.3 Ischemic heart disease is due to the prevalence of obesity, inactive lifestyle, and smoking.

Epidemiology including risk factors and primary prevention

Heart Disease, and specifically coronary artery disease (CAD) is the foremost leading cause of mortality in the United States, independent of race or ethnicity. The Center for Disease Control reports that About 655,000 Americans die from heart disease each year, 1 in every 36 seconds or 1 out of every 4 deaths. Costs in the management of heart disease are high, and about $219 billion each year from 2014 to 2015, including cost of health care services, medicines, and lost productivity due to death.4

Irreversible risk factors for developing cardiac disease include: age, male gender, history of vascular disease, and family history. Reversible risks include “metabolic syndrome,” with diabetes, hypertension, hypercholesterolemia, abdominal obesity, smoking, activity, stress, Type A personality, and diet.5

Cardiac rehabilitation impacts the risk factors associated to coronary artery disease by using a comprehensive approach that incorporates lifestyle changes.  Standard outpatient cardiac rehabilitation lasting 6-12 weeks and have shown to improve physical function in patients with CAD by up to 15%.6


The heart is a major component of the cardiovascular system. It pumps oxygenated blood to the systemic circulation. Cardiac disease entails either pump failure or ischemia to the cardiac muscle. Valvular heart disease decreases maximum cardiac output (CO), resulting in increased myocardial oxygen consumption (MVO2) and decreased maximal oxygen consumption (VO2 max), along with increased oxygen consumption during submaximal exercise. Myocardial infarction decreases ejection fraction, thereby reducing stroke volume and CO, while ischemic heart disease results in a lower maximal heart rate, resulting in lower VO2 max. Congestive heart failure results in decreased cardiac output with low stroke volume, which is associated with a lower VO2 max, higher resting HR, and a greater MVO2.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Specific secondary or associated conditions and complications

Often patients with cardiac disease have peripheral vascular disease and impaired respiratory function, which may also limit their mobility and exercise tolerance. Kidney and cerebral vascular disease are also prevalent in this population due to the same pathophysiology. The complications of cardiac disease and its associated conditions can increase the likelihood of mortality.

Essentials of Assessment


Symptoms depend on the type of cardiac dysfunction present (Table 2).

Physical examination

Heart rate [HR]‑ Decreased in persons on beta-blockers or with conduction block or a pacemaker. HR is elevated in post cardiac transplant secondary to disruption of vagal innervation and in persons with certain arrhythmias. Blood pressure ‑ extremes of blood pressure and orthostasis may be present. Goal blood pressure is <140/90.8

Edema and elevated jugular venous pulse may be present in persons with CHF. Post bypass surgery patients should have sternotomy wound examined to exclude infection.

Displaced point of maximum impulse (PMI) indicates cardiomegaly. The degree of edema should be evaluated and monitored. Vascular exam should include bilateral pulses of upper and lower limbs and capillary refill.

Lung exam may reveal crackles indicating pulmonary edema in CHF. Inspiratory: expiratory ratio and the presence of abnormal breath sounds should be assessed,
Heart sounds ‑ Arrhythmias, irregular rate or rhythm.
Murmurs indicate valvular pathology. Friction rub may be present in pericarditis.

Carotid artery for evaluation of bruits/stenosis. Musculoskeletal/Neurological: A basic musculoskeletal and neurological examination should be performed since it may interfere with tolerance to exercise routine. Joint range of motion, upper and lower limb muscle strength, sensory/balance/ gait abnormalities, as well as pain should be evaluated, treated and considered in the rehabilitation program.

Functional assessment

Cardiac patients often have lower exercise tolerance and cannot perform activities that require increased energy expenditure, such as walking, climbing stairs, or activities of daily living. Functional capacity [FC] refers to the maximum ability of the heart and lungs to deliver oxygen and the ability of muscles to extract it. FC is measured by determining the maximal oxygen uptake (VO2max) during incremental exercise. The metabolic equivalent (MET) describes functional capacity [FC]. One MET equals 3.5 milliliters of oxygen consumed per kilogram of body weight per minute (3.5 mlO2/kg/min), equal to the amount of energy used at rest. Exercise testing can provide objective measures of exercise capacity and be helpful in exercise prescription. The Borg Perceived Exertion Scale, a linear scale from 6-20, may also be used to monitor exercise intensity. A score of 12-14 on this scale is typically considered a moderate level of activity.9 The talk test and target heart rate are also used to assess exercise intensity.

In patients with CHF and severe left ventricle dysfunction, the functional capacity can be evaluated more accurately using cardiopulmonary exercise (CPX) testing10, although most cardiac rehabilitation facilities are not equipped for CPX.

Factors that influence Functional Capacity are age, fluid volume, left ventricle dysfunction, residual myocardial ischemia, deconditioning, diabetic neuropathy, peripheral vascular status, pulmonary status, and orthopedic problems limiting locomotion.

Laboratory studies

It is important to assess for cardiac risk factors including cholesterol, diabetes, or renal disease. Labs that may be indicated include lipid panel, fasting blood glucose, hemoglobin A1C, basic metabolic panel, beta-natriuretic peptide. A 12-lead electrocardiogram is necessary to evaluate for arrhythmias, conduction blocks, left/right heart strain, hypertrophy, and ischemia.


Advances in technology provide the ability to evaluate the heart in a non-invasive manner and assist in decision making for furthermore invasive interventions. Some of these tools include but are not limited to echocardiography, myocardial perfusion imaging, magnetic resonance and computed tomography. Chest radiograph evaluates structures within the chest such as bones, heart and lungs. It may reveal abnormalities such as cardiomegaly or pulmonary edema.

Echocardiograms evaluate directly the heart, the size of its chambers, the thickness of the walls, structural abnormalities, contractility and left ventricular ejection fraction. There are different types of echocardiograms and each has its uniqueness and utility.  A transthoracic echocardiogram can assess for left ventricular function, pulmonary hypertension, valvular pathology, or wall motion abnormality.

A transesophageal echocardiogram permits a more accurate assessment of the cardiac valves and evaluates for any cardiac thrombus or vegetation.  It also provides visualization of the left atrial appendage. This modality plays a crucial role in the evaluation of aortic dissections in patients with renal dysfunction. Stress echocardiogram evaluates cardiac function during exercise and provides information in regard to myocardial ischemia.11

Cardiac Computed tomography (CT) provides a three-dimensional non-invasive visualization of the heart, and estimates calcium score, which serves as a marker for increased mortality. CT angiography provides a good and rapid evaluation of the vasculature of the heart especially in patients with normal renal function.

Gated cardiac MRI can assess cardiac function and coronary anatomy. and myocardial ischemia. Phase contrast and myocardial tagging sequences assist in valvular flow assessments.11

Multi-gated acquisition scan (MUGA) can assess left and right ventricular function.

Thallium scan can assess for myocardial ischemia.

Cardiac Catheterization is the gold standard for evaluation of coronary anatomy, severity of disease and at the same time allows for reperfusion treatment.11

Supplemental assessment tools

Cardiac stress testing may be necessary to evaluate exercise tolerance and ischemic threshold. Graded exercise testing assesses the patient’s ability to tolerate increased physical activity and helps establish appropriate limits for exercise therapy. The six-minute-walk test (6MWT) which is the distance walked over six minutes on a hard, flat surface, provides information about functional capacity, clinical improvements and prognosis.12  Functional capacity can be assessed in patients with lower extremity impairments by using an arm or wheelchair ergometer. An extra wide treadmill may accommodate patients requiring wheelchairs for mobility. For patients who cannot perform adequate exercise, a pharmacologic stress test can be used if no contraindications (ie, Persantine, adenosine, dobutamine).

Early predictions of outcomes

Patients with diabetes and CAD show less improvement in physical function and are less likely to adhere to rehabilitation programs. Patients who improve the most are those CAD patients whose baseline self-reports in physical function are the lowest.10à 13 Early cardiac rehabilitation also decreased total mortality and major adverse cardiac and cerebrovascular events during a 1 year follow up in patients with a history of ST-segment elevation myocardial infarction (STEMI) and non-STEMI.11à14 Exercise training improves heart rate recovery in patients with recent MI. Patients who had an increase in heart rate recovery by 12 beats per minute had better cardiac survival rates.12à15   Improvements in MET levels have been associated with a reduction of mortality risk as much as 10% and 25% for patients with and without cardiovascular disease.51à16

Patients with Class D heart failure are discouraged from participating in conditioning exercises since due to their unstable cardiac status are more likely to have poor outcomes.

Another important predictor of negative outcome in cardiac rehabilitation is clinical depression. This has been associated to variance in aerobic capacity and adherence to the rehabilitation program.17


Cardiac patients may require environmental modifications and adaptive devices to compensate for their decreased tolerance for activity.  Feeling physically and socially safe in the rehabilitation setting increased compliance with treatment.18  On the other hand, patients that live far away, that do not have transportation or do not drive, have decreased the compliance or adherence to the program.19  Other factors to consider that might interfere or pose a challenge to patients with cardiovascular disease are the air quality, pollution, altitude, sunlight exposure and temperature. In addition, COVID 19 pandemic has led to structural and protocol adjustments within the rehabilitation facilities/programs due to the need for social distancing and masks requirements.

Social role and social support system

Patients who enjoy large social networks are more likely to attend and adhere to rehabilitation programs and sustain the behaviors associated with improved quality of life.20 Communication with the patient’s primary physician and family members is essential in order to help ensure medication adherence, lifestyle modification and exercise regimen. Patients must be committed to their rehabilitation program in order to succeed. Barriers to successfully completing a cardiac rehabilitation program include lack of employment, widowed status, and comorbidities such as arthritis.  Approximately 20-25% of patients with acute myocardial infarction present with depression, which, is associated with lower exercise capacity, less energy, more fatigue, and a reduced quality of life and sense of well-being.21,22

Professional Issues

Cardiac rehabilitation is underutilized in the United States.23  It is estimated that only 10%-20% of the eligible patients actually participate in cardiac rehabilitation each year.24 Women are significantly less likely than men to be referred for cardiac rehabilitation, and women with lower income are even less likely to be referred. Hispanic and black patients are less likely to be referred for cardiac rehabilitation than whites.

Rehabilitation Management and Treatments

Available or current treatment guidelines

The American Heart Association and the American Association of Cardiopulmonary Rehabilitation have delineated core components that all cardiac rehabilitation programs should provide as a secondary prevention program.6 These components aim to minimize cardiovascular risks, promote healthy behavior, patient adherence, and an active lifestyle for patients with cardiovascular disease.

Cardiac rehabilitation improves symptoms of angina, decreases symptoms of heart failure, lowers cholesterol levels, decreases mortality and reduces stress. Standard outpatient cardiac rehabilitation lasting 6-12 weeks is shown to improve physical function in patients with CAD by up to 15%.

At different disease stages19

new onset/acute:
The acute rehabilitation phase (phase 1), characterized by early mobilization with cardiac monitoring, is initiated in the hospital by trained therapists. Patients are encouraged to sit at the edge of bed or in a chair once medically stable. The goal of the acute, phase 1 program is for the patient to perform activities up to 4 METS and be discharged home on a home exercise program within 1-4 days.

Phase 1b uses inpatient rehabilitation (IRF, subacute setting) for patients of advanced age with multiple comorbidities who may have a difficult time with early mobilization and may progress more slowly. Typically, these services last up to 2 weeks.

Phase 2 is the outpatient, training, phase of cardiac rehabilitation, supervised by trained therapists. Typically, the cardiac training program is 3 sessions weekly for up to 8 weeks. This program initially includes aerobic exercises that progresses in duration and intensity, with subsequent addition of resistive exercises.

Phase 3, the maintenance phase of cardiac conditioning, is essential to the success of the program. This program is a lifelong lifestyle modification program.

Coordination of care

A cardiac rehabilitation program requires coordinated care among the patient, cardiologist, pneumologist and rehabilitation team (physiatrist, physical therapists, occupational therapists, social workers and nutritionist). The commitment to an active lifestyle, healthy diet, and adherence to pharmacologic treatment is a lifelong process requiring support of all involved in the patient’s care.25

Patient & family education

Patients and family members require instruction in regard to risk factor modification. Patients and family members should be educated on how to maintain a heart healthy diet, as well as any other recommended dietary restrictions (ie, diabetes, renal, heart failure). Patients should learn how to monitor their blood pressure, blood glucose, weight, and recognize the symptoms of heart failure, hypo/hyperglycemia, and hypo/hypertension. Motivational letters, telephone calls and home visits increase adherence to cardiac rehabilitation programs. Family support is essential so that patients achieve and adhere to those lifestyle changes.

Emerging/unique interventions

From an interventional cardiology point of view, Transcatheter Mitral and Tricuspid Valve replacement interventions have evolved to become a new standard of care in valve replacement. Virtual and augmented reality for surgery and cath labs are also taking a bigger role and may eventually become common practice.

Advances such as wearable technology aid in patient monitoring, such as smartphones, smart rings, stick on EKG monitors, wireless scales and blood pressure monitors that interface with smartphone apps to track their rehabilitation.

Magnetic Resonance Imaging (MRI) is being used to provide complementary information on LV function, regional perfusion, angiogenesis, myocardial viability and orientations of myocytes.  When used with contrast, images can better enhance myocardial perfusion and angiogenesis. Imaging with combined MRI and Positron Emission Tomography is underdeveloped.26

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Risk factor modification can be adjusted for any patient population. It is particularly important in persons who are physically handicapped since their condition can often lead to accelerated cardiovascular disease. Physical challenges in this population may include weakness, spasticity, amputation, and balance problems. Training can be accomplished by modifying individualized conditioning programs and using adaptive equipment. Examples are arm crank ergometer, supine bicycle ergometer, and wheelchair ergometer for exercise testing. This equipment is available in many cardiopulmonary rehabilitation facilities. Exercise routines can also be adjusted to initiating with active repetitive exercises of one limb at a time sitting down and slowly progressing to bilateral limb, standing and resistive exercises as tolerated.

Cutting Edge/ Emerging and Unique Concepts and Practice

Cutting edge concepts and practice27,28

A ventricular assist device (VAD) is a mechanical circulatory apparatus designed to assist the right ventricle (RVAD), left ventricle (LVAD), or both (BiVAD). These VAD devices are often used as a bridge to heart transplant or for those not eligible for transplant.

Recent emerging techniques include trans-catheter aortic valve implantation for valvular disorders, mitral valve clips and fractionate flow reserve measurements for atherosclerotic lesion evaluation in PCI.

The recent COVID 19 pandemic has led to closure of multiple cardiac rehabilitation programs and in other instances virtual delivery has taken an integral role. Rawstorn et al. have previously demonstrated that telehealth delivered exercised-based cardiac rehabilitation was at least as effective as center based cardiac rehabilitation in improving cardiovascular risk factors, improving physical activity levels/functional capacity/diastolic blood pressure and reducing cholesterol levels. 29 Thus, future transformation of current delivery methods for cardiac rehab will probably continue to evolve to take a more technology/virtual based approach.

High-intensity interval training may improve the availability of services, permit more rapid improvement in exercise capacity, and facilitate better patient adherence.

Gaps in the Evidence- Based Knowledge

In spite of published research demonstrating the impact of cardiac rehabilitation on the secondary prevention of heart disease, its morbidity and mortality, this program is still considered underutilized.  There are multiple contributors to low referral and/or utilization: physicians understanding of the program’s benefit, patients’ interest, insurance coverage and hospital level barriers are considered influencing reasons for this gap.30,31 For vulnerable populations, sex and gender disparities (women, Black, Hispanic, and Asian ethnicity) make this difference more significant. Of patients who could benefit from cardiac rehabilitation, only 12% of those are women, 20% are black, 36% are Hispanic, and 50% are Asian, when compared to whites.32  

Although more evidence has been learned on ischemic microvascular disease versus obstructive heart disease in women, there are still gaps in understanding how rehabilitation should be tailored for this specific population and its benefits, including the psycho-emotional stressors and the necessary psychosocial interventions.33,34

Some studies suggest a polymorphism of genes that can influence the known risk factors that lead to coronary heart disease. A stronger effect is seen in genes regulating the cholesterol mechanism and the predisposition to plaque adhesions. This lipoprotein gene polymorphism may influence the ability to see lipid changes after cardiac rehabilitation, weight loss, and potential long-term benefits of exercise. The mechanism is unknown. More studies are required to understand the interplay between genes and the environmental factors.35,36

Sleep disordered breathing (SBD) is considered another risk factor for coronary artery disease that is characterized as repetitive apneas, arousals from sleep, and intermittent hypoxia.  It has been identified that those with SBD and who suffer an acute myocardial infarct have prolonged ischemia, and therefore a higher risk for ventricular dysfunction. It is not clear what is the relation between SBD and heart disease; neither the role that conventional therapy for SBD would have in a vulnerable heart.37  Even with this knowledge gap, there is evidence that patients with obstructive sleep apnea (OLA) may benefit and improve their OSA symptoms after completing two months of cardiac rehabilitation.38


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  38. Hupin D, Pichot V, Berger M, Sforza E, Raffin J, Lietar C, Poyzar E, Maudoux D, Barthelemy JC, Roche F.  Obstructive Sleep Apnea in Cardiac Rehabilitation Patients.  Journal of Clinical Sleep Medicine, 2018. Vol. 14, No. 7  https://doi.org/10.5664/jcsm.7206

Original Version of the Topic:  

Anna-Christina Bevelaqua, MD, Matthew Bartels, MD, Annemarie Gallagher, MD. Cardiac Rehabilitation. 12/9/2011.

Previous Revision(s) of the Topic:  

Maricarmen Cruz, MD, Isabel Borras, MD, Jose Cumba, MD. 4/21/2016.

Author Disclosure

Maricarmen Cruz, MD
Nothing to Disclose

Isabel Borras, MD
Nothing to Disclose