Author(s): Maricarmen Cruz, MD, Isabel Borras, MD, Molinary Marla, MD, Edgar A Perez-Curet, MD, MPH, Joanneth Padro, MD
Originally published: December 9, 2011 Last updated: May 23, 2024
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Disease/Disorder

Definition

Cardiac rehabilitation is a comprehensive rehabilitation program that seeks to restore and improve function, limit disability, minimize cardiac risk factors, and optimize cardiac conditioning through secondary prevention efforts. Th program is customized to the individuality of the patient, using an interdisciplinary approach that includes medical assessment and recommendations, lifestyle modifications, supervised and individualized exercise prescription, training counseling, education in risk factors and healthy living, and stress management counseling. The goal is to improve the quality of life by optimizing physical, psychological, and social functioning that allows resumption of normal daily activities minimizing cardiac symptoms.1

Etiology

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. Other causes of coronary heart disease include microvascular coronary damage, which is a more common etiology for coronary disease in women, and congestive heart failure secondarily related to coronary artery disease, ischemic injury, hypertension, valvular disease, arrhythmia, and toxic and metabolic effects.2,3

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. About 20.5 million US adults have coronary artery disease, making it the most common type of heart disease in the US according to the Center for Disease Control. They report that over 800,000 people die from cardiovascular disease each year, 1 in every 33 seconds or 1 out of every 3 deaths. Costs in the management of heart disease are high, and about $239.9 billion each year from 2018- 2019 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 inactivity, 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

Patho-anatomy/physiology                              

The heart is a major component of the cardiovascular system, pumping 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)

The coronary artery gets progressively narrowed in its lumen as fatty material gets deposited in the subendothelial tissue of the vessel. This deposit builds up plaques. Insults to the artery breaks the intima layer permitting monocytes migrate to this subendothelial space where they become macrophages. This triggers a series of events, including macrophages taking of the LDL, activation of T-cells, release of cytokines, and the activation of the smooth muscle which repeats the taking of LDL and deposit of foam cells. If no further insult occurs, the plaque stabilizes and gets calcified; if further insults occur, the cycle repeats. With time the growth of these plaques occludes the path for blood and ischemia occur, leading the acute coronary syndrome and the consequent symptomatology experienced in heart disease.

Symptoms presented in an acute coronary syndrome include sudden onset of chest pain or oppression; pain or pressure typically radiates to the neck, jaw or left arm. Associate to chest pain, patients report palpitations, shortness of breath, dizziness, nausea, vomits and/or cold sweats; atypical presentation may include abdominal pain. Other clinical manifestations may include syncope, cardiac arrest, and congestive heart failure.

Ischemic events may lead to myocardial infarct and new onset congestive heart failure. When heart failure is present (as primary or secondary etiology of heart disease), signs of clinical congestion must be observed as these will interfere with the heart’s ability to adjust to functional demands. In overall, the clinical progression of symptoms in heart disease will vary as the magnitude of the events and its residuals are managed and optimized.7,8

Table 1. Heart Failure Classification: disease progression and guide8
 Disease Severity  Activity GuidelinesElectrocardiogram/ Blood Pressure MonitoringSupervision Required
Class A: At high risk for HF but without structural heart disease or symptoms of HF (healthy individual)No restrictionNone requiredNone
Class B: Structural heart disease but without signs or symptoms of HF (known stable heart disease)Individualized exercise prescriptionOnly during prescriptive exerciseMedical supervision during prescriptive sessions and nonmedical supervision for other exercise
Class C: Structural heart disease with prior or current symptoms of HF (Known stable heart disease and unable to self-regulate activity level)Individualized exercise prescription and supervised by CPR- trained personOnly during prescriptive exerciseMedical supervision during prescriptive sessions and nonmedical supervision for other exercise
Class D: Refractory HF requiring specialized
interventions (Moderate
to high risk for
complications during
exercise)		Individualized exercise prescriptionContinuous during rehabilitation sessionsMedical supervision during all rehabilitation sessions

Specific secondary or associated conditions and complications

Atherosclerosis is the deposit of fatty material and eventual plaque formation in medium sized and large sized arteries. As in coronary artery disease, the insult to these larger vessels lead to further damage to the artery and eventual growth of these fatty/calcified plaques that end up occluding the lumen. Patients will experience other symptoms and/or complications depending on the organs affected by these occluded arteries. Often patients with cardiac disease have peripheral vascular disease, kidney, and cerebrovascular disease. Complications of atherosclerosis may include hypertension, stroke, renal insufficiency, among some. Clinical symptomatology will vary by the organ affected and the deficit cause by an acute occlusion or insult.9

Essentials of Assessment

History

Heart disease symptoms vary by etiology, and these symptoms variation are influenced by the severity of the disease, sequels of acute event/exacerbations, the ability to manage the primary condition conservatively, and other accompanying comorbidities.

Table 2. Symptoms Associated with Specific Cardiac Dysfunctions
Cardiac DysfunctionSymptoms
Congestive heart failureDyspnea, orthopnea, edema, nocturia, fatigue
Valvular dysfunctionDyspnea, fatigue, syncope or pre-syncope, edema
Coronary artery diseaseAngina, (if ischemia, patient may complain of left- sided chest pain with radiation to left arm or jaw)
ArrhythmiasPalpitations, syncope, dizziness, fluttering in the chest, shortness of breath, lightheadedness, chest pain
Peripheral arterial diseaseClaudication
CardiomyopathyDyspnea, edema, fatigue, irregular heartbeats, dizziness, lightheadedness

Physical examination

Vitals:
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 <140/90.10

Inspection:
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.

Palpation:
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.

Auscultation:
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.11 The talk test and target heart rate are also used to assess exercise intensity.

The 6 min walk test is a simple test that can be performed easily, and it provides an objective assessment of functional exercise capacity.12 It can also be used to monitor the response to the medical interventions provided. Even though this instrument is used as a marker of disease severity in pulmonary diagnosis it has also been validated in cardiovascular disease. The minimal clinical important change for both patient population is anywhere from 14.0 to 30.5 meters.13

In patients with CHF and severe left ventricle dysfunction, the functional capacity can be evaluated more accurately using cardiopulmonary exercise (CPX) testing, although most cardiac rehabilitation facilities are not equipped for CPX.14

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. In addition, a complete blood count and a comprehensive metabolic profile should be evaluated to assure that there are no metabolic abnormalities or significant anemias/thrombocytopenia that may serve as a contraindication for participation in the cardiac rehabilitation program. A 12-lead electrocardiogram is necessary to evaluate for arrhythmias, conduction blocks, left/right heart strain, hypertrophy, and ischemia.

Imaging

Advances in technology provide the ability to evaluate the heart in a non-invasive manner and assist in decision making for further 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 directly evaluate 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 regarding 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.15

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 was previously mentioned, 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 (i.e., Persantine, adenosine, dobutamine).

Early predictions of outcomes            

Early enrollment of patients in cardiac rehabilitation programs impact the outcomes attained from participation, this includes (1) later program participation (2) improvements in the exercise capacity within the first 15 days after hospital discharge (3) higher educational level (4) stronger physician recommendation, higher level of functioning (5) stronger social support.16,17

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.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.  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.14,16,18

Poor predictors of outcome include (1) patients with diabetes and CAD show less improvement in physical function and are less likely to adhere to rehabilitation programs (2) patient suffering from clinical depression due to its variance in aerobic capacity and adherence to the rehabilitation program.19

Environmental

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, and this is particularly true for the women.20  On the other hand, patients may experience barriers to rehabilitation programs due to driving distance, geographical complexity, and support from caregivers which decreases the compliance or adherence to the program and which may lead to disparities.21  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.

Social role and social support system18

Social networks improve patient’s attendance and adherence to therapeutic programs. These social relationships help influence and sustain the behaviors associated with improved illness management, incorporation of healthy lifestyles and improved quality of life.22,23 Networking and communication between the patient’s primary physician and family members ensure medication adherence, lifestyle modification and exercise regimen.

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.

Professional issues

Even though participation in cardiac rehabilitation program have increased, still there is underutilization in the United States. In 2020, only 24% of eligible patients to cardiac rehabilitation programs got to participate.

Disparities continue affecting special populations affected by heart disease and who could benefit from cardiac rehabilitation interventions. Among those groups are women, racial minorities including Black and Hispanics, older populations, and patients from lower socioeconomic groups.16

Rehabilitation Management and Treatments

Available or current treatment guidelines16,24

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%. In congestive heart failure, cardiac rehabilitation programs have shown to reduce hospitalization due to heart failure exacerbations and all-cause hospitalization.25

At different disease stages21,26,27

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. This phase may aid in the transition to outpatient care; these services may last up to 2 weeks.

subacute:
Phase 2 is the outpatient phase of cardiac rehabilitation that lasts between 12-18 weeks. At this stage the program is supervised by a trained therapist; it incorporates aerobic exercises that progresses in duration and intensity, first using large muscles, and later incorporating resistive training. Although all stages of cardiac rehabilitation use patient education as a core component for their engagement and clinical improvement, this stage is key in preparing the patient in observing symptoms experienced during training and in modifying the training intensity using the heart rate and/or the Borg Scale. Empowerment of the patient at this stage helps preparing the transition to the next stage of the program and/or the transition to unsupervised training.

chronic/stable:
Phase 3 is the maintenance phase of cardiac rehabilitation programs where the patient continues incorporating the learned lifestyle changes, risk factors modifications, and unsupervised exercise recommendations into his/her life as a lifelong modification.

Coordination of care

Coordination of care in cardiac rehabilitation programs seek to address a facilitated referral and/or enrollment into a rehabilitation program when transitioning from an inpatient to an outpatient setting. Coordination of care facilitates communication between the providers involved (cardiologist, pneumologist, rehabilitation team [physiatrist, physical therapists, occupational therapists] social workers and nutritionist) caring for the patient, and helps the patient understand the rehabilitation journey and the steps needed to navigate the process. Care coordinators support the patient’s adherence to healthy lifestyles including physical activity, nutrition, and adherence to pharmacologic treatment.28

Patient & family education

Patients and family members require instruction regarding risk factors modification. Patients and family members should be educated on how to maintain a heart healthy diet, as well as any other recommended dietary restrictions (i.e., 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                     

Home – based cardiac rehabilitation programs continue presenting as a mean to expand access to care, overcoming the barriers to reach underserved groups, distant locations, and patient’s preferences. Advances such as video connections, 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.16

Magnetic Resonance Imaging (MRI) is 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.29

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

The identification and assessment of risk factors continue being fundamental for the secondary prevention in heart disease and outcomes modification in cardiac rehabilitation interventions. Still, practice improvement in cardiac rehabilitation demands reflecting on the clinical competencies of physicians and other providers who should be referring patients to the program and are not doing so. From the healthcare disparity perspective, barriers influencing clinicians’ attitudes are unconscious bias, skills in cultural humility, cultural competence, and clinical curiosity, all which combined may lead to inability to deepen the understanding about the patient’s social context, which may interfere with enrollment, compliance and adherence to rehabilitation programs. These competencies may equally affect patients located at rural and urban areas.30

Cutting Edge/Emerging and Unique Concepts and Practice

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.

The COVID-19 pandemic led to the closure of multiple cardiac rehabilitation programs, accelerating the transition to the use of telehealth modalities to reach out to patients. 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.31,33 In addition, virtual modalities of care adapt to patient’s preference, and overcomes geographical barriers. The future will continue be influenced by the adaptation of newer delivery methods that incorporate technology.

Gaps in the Evidence-Based Knowledge

Despite the demonstrated benefits of cardiac rehabilitation on the secondary prevention of heart disease, its morbidity and mortality, this program is still considered underutilized.16,31 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.34,35 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.36 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.37,38

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.39,40

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.41 Despite knowledge gaps, there is evidence that patients with obstructive sleep apnea (OLA) may benefit and improve their OSA symptoms after completing two months of cardiac rehabilitation.42

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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. Cardiac Rehabilitation. 4/21/2016.

Maricarmen Cruz, MD, Isabel Borras, MD. Cardiac Rehabilitation. 6/8/2021

Author Disclosure

Maricarmen Cruz, MD
Nothing to Disclose

Isabel Borras, MD
Nothing to Disclose

Molinary Marla, MD
Nothing to Disclose

Edgar A Perez-Curet, MD, MPH
Nothing to Disclose

Joanneth Padro, MD
Nothing to Disclose