Figures 1. Decision tree for cardiac rehabilitation services . . 3. Changes in lipid levels in 18 randomized controlled trials 22 43 63 Foreword Cardiovascular disease is the leading cause of morbidity and mortality in the United States, responsible for almost 50 percent of all deaths. Coronary disease, the major category of cardiovascular disease, is clinically manifest as stable angina pectoris, unstable angina pectoris, myocardial infarction, silent myocardial ischemia, and sudden death. More than 13.5 million Americans have a history of myocardial infarction or experience angina pectoris. Nearly 1.5 million Americans sustain myocardial infarction each year, of which almost 500,000 are fatal. Five percent of myocardial infarctions occur in people younger than age 40, and about 45 percent occur in people under age 65. About 55 percent of all acute myocardial infarctions occur in the Medicare age group. The almost 1 million survivors of myocardial infarction are potential candidates for cardiac rehabilitation services, as are the more than 7 million patients with stable angina pectoris and patients following revascularization with coronary artery bypass surgery (309,000 patients in 1993, 45 percent under age 65) and percutaneous transluminal coronary angioplasty and other transcatheter interventional procedures (362,000 in 1993, 54 percent under age 65). Of these several million patients with coronary disease who are candidates for cardiac rehabilitation services, only 11-38 percent of patients typically participate in cardiac rehabilitation programs. Another major cardiac problem-heart failure-is the most common discharge diagnosis for hospitalized Medicare patients and the fourth most common discharge diagnosis for all patients hospitalized in the United States. The prevalence of heart failure has increased steadily with aging of the U.S. population and with the improved rate of survival resulting from the use of newer therapies for cardiovascular diseases. Many patients with end-stage heart failure are candidates for cardiac transplantation surgery. As benefits and safety are documented, cardiac rehabilitation services for patients with heart failure and after cardiac transplantation have gained increasing acceptance. This Clinical Practice Guideline was developed under a contract from the Agency for Health Care Policy and Research with the support of the National Heart, Lung, and Blood Institute. The contract was awarded to the American Association of Cardiovascular and Pulmonary Rehabilitation, which convened a private-sector multidisciplinary panel of experts that included physicians (cardiologists, internists, family physicians, and cardiac surgeons), registered nurses, a clinical health psychologist, a registered dietitian, exercise physiologists, a physical therapist, and two consumer-patient members collectively referred to in this document as "the panel." The panel principally based the conclusions and recommendations in this guideline on scientific evidence from an extensive review of original research published in peer-reviewed medical and health sciences journals. This guideline addresses the role of cardiac rehabilitation services for adult patients with coronary disease, with heart failure, and after cardiac transplantation. This guideline is designed to assist health care practitioners and consumers in making more informed decisions about their choices and to inform them of the cost-effectiveness of cardiac rehabilitation services. Needs for additional research are also highlighted. Executive Summary Cardiovascular disease is the leading cause of morbidity and mortality in the United States, accounting for over 50 percent of all deaths. Coronary heart disease (CHD), with its clinical manifestations of stable angina pectoris, unstable angina, acute myocardial infarction, and sudden cardiac death, affects 13.5 million Americans. The almost 1 million survivors of myocardial infarction and the 7 million patients with stable angina pectoris are candidates for cardiac rehabilitation, as are the 309,000 patients who undergo coronary artery bypass graft (CABG) surgery and the 362,000 patients who undergo percutaneous transluminal coronary angioplasty (PTCA) and other transcatheter procedures each year. An estimated 4.7 million patients with heart failure may also be eligible. Although beneficial outcomes from cardiac rehabilitation services can be expected in most of these patients, few such patients currently participate in cardiac rehabilitation programs. The U.S. Public Health Service definition of cardiac rehabilitation, used by the panel, states that "cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients." This guideline provides recommendations for cardiac rehabilitation services for patients with CHD and with heart failure, including those awaiting or following cardiac transplantation. This guideline is designed for use by health practitioners who provide care to patients with cardiovascular disease. These include physicians (primary care, cardiologists, and cardiovascular surgeons), nurses, exercise physiologists, dietitians, behavioral medicine specialists, psychologists, and physical and occupational therapists. The information can guide clinical decisionmaking regarding referral and followup of patients for cardiac rehabilitation services as well as administrative decisions regarding the availability of and access to cardiac rehabilitation services. This guideline details the outcomes that result from cardiac rehabilitation services. The interventions examined involve two parallel applications: (1) exercise training and (2) education, counseling, and behavioral interventions. The panel emphasizes the added effectiveness of multifactorial cardiac rehabilitation services integrated in a comprehensive approach. Outcomes of Cardiac Rehabilitation Services The results of cardiac rehabilitation services, based on reports in the scientific literature, are summarized in this guideline. The most substantial benefits include: Improvement in exercise tolerance. Improvement in symptoms. Improvement in blood lipid levels. Reduction in cigarette smoking. Improvement in psychosocial well-being and reduction of stress. Reduction in mortality. Improvement in Exercise Tolerance Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients, with CHD and with heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes. Appropriately prescribed and conducted exercise training should be an integral component of cardiac rehabilitation services and particularly benefits patients with decreased exercise tolerance. Maintenance of exercise training is required to sustain improvement in exercise tolerance. Improvement in Symptoms Cardiac rehabilitation exercise training decreases symptoms of angina pectoris in patients with CHD and decreases symptoms of heart failure in patients with left ventricular systolic dysfunction. Improvement in clinical measures of myocardial ischemia, as identified by electrocardiographic (ECG) and nuclear cardiology techniques, following exercise rehabilitation provides objective support for the reported symptomatic improvement. Exercise training of patients with left ventricular systolic dysfunction provides added symptomatic improvement to that achieved by appropriate medication management. Improvement in Blood Lipid Levels Multifactorial cardiac rehabilitation in patients with CHD, including exercise training and education, results in improved lipid and lipoprotein levels. Exercise training as a sole intervention has not effected consistent |