4 Organizational Issues Intake Assessment and Risk Stratification for Exercise Surveillance Authoritative, detailed publications addressing structure and organization of cardiac rehabilitation programs have been produced by the ACC,2 U.S. DHHS,7 ACP,5 AHA,300 AHCPR,8 AACVPR,34,35 and the WHO.6,67 In addition to these documents from national and international professional organizations, recent textbooks have reviewed the eligibility for and organization and conduct of cardiac rehabilitation services,301,302 Because of the availability of these authoritative materials on organizational issues pertaining to patient intake, risk stratification, and prescription of exercise training, this guideline does not detail the practices recommended for assessing patients at entry into cardiac rehabilitation, the stratification of patients by cardiovascular risk status, or the recommendations for exercise testing and/or exercise prescription. The references cited above provide uniform guidance for the intake evaluation of cardiac patients referred for cardiac rehabilitation services. The risk stratification developed by AACVPR35 is shown in Table 14. Recommendations regarding ECG monitoring of exercise training have been produced by the AHA,44 ACC,2 ACP,5 AACVPR,34,35 WHO,6,67 and ACSM.303 The ACC criteria for ECG monitoring of cardiac rehabilitation exercise training are shown in Table 15. Review of the scientific literature concerning ECG monitoring of rehabilitative exercise training does not permit a definitive recommendation. No study has compared the effect of continuous or intermittent ECG monitoring with no monitoring on the safety of cardiac rehabilitation exercise training. Descriptive information regarding cardiac arrest during outpatient cardiac rehabilitation exercise training is based on aggregate analysis from the United States.258 One hundred and forty-two randomly selected outpatient cardiac rehabilitation programs provided questionnaire-based information on cardiac arrests occurring between January 1980 and December 1984.65 Information was provided for 51,303 patients who collectively exercised for 2,351,916 hours. Twenty-one cardiac arrests occurred, and descriptive information was available for 20 patients. Eighteen patients were men, with an age range of 42-80 years; all patients had a primary diagnosis of CHD. Sixteen patients had prior myocardial infarction; four had prior CABG. Eleven patients experienced the cardiac arrest within the first 6 months of program participation, five within the first month. Nine cardiac arrests occurred in programs with continuous ECG monitoring, and 11 occurred in those with intermittent ECG monitoring. Twelve of the 20 cardiac arrests Table 14. Minimal guidelines for risk stratification Risk Level Low Intermediate High Characteristics No significant left ventricular dysfunction (i.e., ejection No resting or exercise-induced myocardial ischemia manifested No resting or exercise-induced complex arrhythmias Functional capacity ≥ 6 METs on graded exercise test 3 Mild to moderately depressed left ventricular function (ejection Functional capacity < 5-6 METs on graded exercise test 3 or more weeks after clinical event Failure to comply with exercise intensity prescription Exercise-induced myocardial ischemia (1-2 mm ST-segment depression) or reversible ischemic defects (echocardiographic or nuclear radiography) Severely depressed left ventricular function (ejection fraction < 30%) Complex ventricular arrhythmias at rest or appearing or Decrease in systolic blood pressure of > 15 mmHg during exercise or failure to rise with increasing exercise workloads Survivor of sudden cardiac death Myocardial infarction complicated by congestive heart failure, cardiogenic shock, and/or complex ventricular arrhythmias Severe coronary artery disease and marked exercise-induced myocardial ischemia (> 2 mm ST-segment depression) Note: MET = metabolic equivalent units. From Guidelines for Rehabilitation Programs (p. 14) by the American Association of Cardiovascular and Pulmonary Rehabilitation, Champaign, IL: Human Kinetics Books. Copyright 1995 by American Association of Cardiovascular and Pulmonary Rehabilitation. Reprinted by permission. occurred during exercise training, six within 30 minutes of completing exercise training, and two within 30-60 minutes of completing exercise training. Cardiac arrest rhythm was documented in 17 patients; ventricular tachycardia and/or fibrillation were demonstrated in 16 patients; and asystole occurred in 1 patient. Successful cardiopulmonary resuscitation occurred in 17 of the 20 patients (85 percent). Eighteen of the 20 patients were regarded as being adherent to the exercise prescription, and 1 patient was reported to overexert.65 The risk stratification status of the patients was documented by various measures. Eleven patients had high-risk status based on history: five had a prior cardiac arrest, four had heart failure, five had ventricular tachycardia, and two had a history of both heart failure and ventricular tachycardia. Ten of Table 15. Criteria for electrocardiographic monitoring 1. Severely depressed left ventricular function (ejection fraction below 30%) 2. Resting complex ventricular arrhythmia 3. Ventricular arrhythmias appearing or increasing with exercise 4. Decrease in systolic blood pressure with exercise 5. Survivors of sudden cardiac death 6. Survivors of myocardial infarction complicated by congestive heart failure, cardiogenic shock, serious ventricular arrhythmias, or some combination of the three 7. Severe coronary artery disease and marked exercise-induced ischemia (ST-segment depression > 2 mm) 8. Inability to self-monitor heart rate because of physical or intellectual impairment Note: From "Position report on cardiac rehabilitation: Recommendations of the American College of Cardiology on cardiovascular rehabilitation" by W.W. Parmley. Copyright 1986 by American College of Cardiology. Reprinted by permission from the American College of Cardiology. (Journal of the American College of Cardiology, 1986;7:451-3). the 18 patients (56 percent) had markedly abnormal baseline exercise ECG test responses, that is, high-risk exercise test data. Specifically, five had an exercise capacity of less than five METS, two had ST-segment depression at heart rates less than 120 beats per minute, two had peak systolic blood pressures of less than 130 mmHg, three had ventricular tachycardia, and one had exertional hypotension. Ten patients had had cardiac catheterization prior to the cardiac arrest; adequate data were available for nine of these patients, and six of the nine patients had high-risk findings at cardiac catheterization. Specifically, four patients had triple-vessel coronary artery disease, and one had left main coronary artery narrowing of 60 percent. Three patients had a left ventricular ejection fraction of less than 40 percent, and two had both triple-vessel coronary disease and a left ventricular ejection fraction of less than 40 percent. Four of the 20 cardiac arrest patients did not have classic criteria for high-risk status. One patient with Wolff-Parkinson-White syndrome had increasing angina 2 days prior to cardiac arrest. Another patient had multiform ventricular arrhythmia, and one patient had a 20-year history of vasovagal syncope and bradycardia (this patient had the asystolic arrest). The fourth patient experienced a fatal cardiac arrest while changing a tire within an hour after completing exercise training.65 The panel concurred with the statement of the U.S. DHHS Technology Assessment 1987 Report that electrocardiographic monitoring appears to provide a degree of safety during exercise therapy. Its utilization tends to be linked inversely with the cardiac stability of the patient, but no firm predictors exist which precisely identify those who might completely dispense with its use. Given the variable occurrence of arrhythmias and the fact that the safety of exercise regimens has only been determined by means of aggregate data, the use of continuous or intermittent monitoring for a specific patient remains a matter of clinical judgment. There are insufficient data to resolve the issue at this time. The reader is referred to the authoritative position papers, publications, and textbooks regarding staffing requirements, record keeping, documentation, facilities and equipment, and management of emergencies, including guidelines published by AACVPR.34,35 The remainder of this chapter addresses alternate approaches to the delivery of cardiac rehabilitation services and provides an overview of the pivotal issue of adherence. Alternate Approaches to the Delivery of Cardiac Rehabilitation Services RECOMMENDATION Alternate approaches to the delivery of cardiac rehabilitation services, other than traditional supervised group interventions, can be implemented effectively and safely for carefully selected clinically stable patients. Transtelephonic and other means of monitoring and surveillance of patients can extend cardiac rehabilitation services beyond the setting of supervised, structured, group-based rehabilitation. These alternate approaches have the potential to provide cardiac rehabilitation services to low- and moderate-risk patients who comprise the majority of patients with stable coronary disease, most of whom do not currently participate in supervised, structured rehabilitation. Scientific Evidence (Strength of Evidence = A) Eleven studies addressed program structure and surveillance. These included seven randomized controlled trials and four nonrandomized controlled studies. Each controlled study included a group of coronary patients who participated in home-based exercise training. The results of the home-based rehabilitation were compared with supervised rehabilitation or with a no-rehabilitation control group (or combinations of all three). Details regarding the randomized and nonrandomized controlled trials are provided in Tables 16 and 17. Two of the seven randomized controlled trials reported data from the same study,62,101 which compared patients after myocardial infarction randomly assigned to gymnasium training versus home-based exercise training versus a no-training control group. Both the gymnasium- and home-based exercise groups showed statistically significant (p < .05) improvement in their |