improvement in lipid profiles. Optimal lipid management requires specifically directed dietary and, when medically indicated, pharmacologic management as a component of multifactorial cardiac rehabilitation. Reduction in Cigarette Smoking Multifactorial cardiac rehabilitation, with well-designed educational and behavioral components, reduces cigarette smoking. Sixteen to 26 percent of patients can be expected to stop smoking. These smoking cessation rates enhance the spontaneously high smoking cessation rates in most populations following a coronary event. Scientific evidence, consensus reports, and scientific reviews in the nonrehabilitation setting, including the Surgeon General's messages since 1965, lend strong support that education, counseling, and behavioral interventions are beneficial for smoking cessation. Improvement in Psychosocial Well-Being and Stress Reduction Exercise training enhances measures of psychological and social functioning, particularly as a component of multifactorial cardiac rehabilitation. Improvement in psychological status and functioning, including measures of emotional stress and reduction of the Type-A behavior pattern, is consistent with the improvement in psychosocial outcomes that occurs in nonrehabilitation settings. Reduction in Mortality A survival benefit for patients who participate in cardiac rehabilitation exercise training is suggested from the scientific data, but this cannot be attributed solely to exercise training because many studies involved multifactorial interventions. Meta-analysis of the randomized controlled trials of exercise rehabilitation in patients following myocardial infarction establishes a reduction in mortality approximating 25 percent at 3-year followup. This reduction in mortality approaches that resulting from pharmacologic management of patients following myocardial infarction with beta-blocking drugs or patients with left ventricular systolic dysfunction with angiotensin-converting enzyme (ACE) inhibitor therapy. The reduction in cardiovascular mortality was 26 percent in multifactorial randomized trials of cardiac rehabilitation and 15 percent in trials that involved only an exercise intervention. The panel concludes that multifactorial cardiac rehabilitation services can reduce mortality in patients following myocardial infarction. Safety The safety of cardiac rehabilitation exercise training is inferred from aggregate analysis of clinical experience. None of the more than three dozen randomized controlled trials of cardiac rehabilitation exercise training in patients with CHD, involving over 4,500 patients, described an increase in morbidity or mortality in rehabilitation compared with control patient groups. A survey of 142 cardiac rehabilitation programs in the United States, involving patients participating in exercise rehabilitation from 1980 to 1984, reported, based on aggregate data, a low rate of nonfatal myocardial infarction of 1 per 294,000 patient-hours; the cardiac mortality rate was 1 per 784,000 patient-hours. A total of 21 episodes of cardiac arrest occurred, with successful resuscitation of 17 patients. Thus, the safety of exercise rehabilitation is established by the very low rates of occurrence of myocardial infarction and cardiovascular complications during exercise training. Intake Assessment, Risk Stratification, and Transition Planning Authoritative, detailed documents addressing the organizational structure, delivery, and management approaches to cardiac rehabilitation services have been published by the American College of Cardiology (ACC), the American College of Physicians (ACP), the American Heart Association (AHA), and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). This Clinical Practice Guideline does not duplicate this information. The panel highlights the value of risk stratification of patients with CHD as a basis for individual prescription of exercise training and appropriate exercise supervision. Risk stratification is based on clinical assessment of functional capacity, myocardial ischemia, ventricular dysfunction, and arrhythmias. The panel agrees with a 1988 report of the U.S. Department of Health and Human Services (U.S. DHHS) regarding ECG monitoring during cardiac rehabilitation exercise training that "given the variable occurrence of arrhythmias and the fact that the safety of exercise regimens has only been documented by means of aggregate data, the use of continuous or intermittent monitoring for a specific patient remains a matter of clinical judgement." The initial assessment of a patient should incorporate the patient's educational and psychosocial status as a basis for recommending interventions. In recent years, alternate approaches to the delivery of cardiac rehabilitation services, other than traditional supervised group and individual programs, have been examined in carefully selected, clinically stable patients. These alternate approaches, often home-based, can be effectively and safely implemented for such patients. Transtelephonic and other means of monitoring and surveillance of low- and moderate-risk patients can extend cardiac rehabilitation services beyond the traditional supervised setting and broaden the availability of cardiac rehabilitation services. Conclusions On the basis of a comprehensive review of the scientific literature, the panel concludes that cardiac rehabilitation services are an essential component of the contemporary management of patients with multiple presentations of CHD and with heart failure. Cardiac rehabilitation is a multifactorial process that includes exercise training, education and counseling regarding risk reduction and lifestyle changes, and use of behavioral interventions; these services should be integrated into the comprehensive care of cardiac patients. The objectives of cardiac rehabilitation services are to improve both the physiologic and psychosocial status of cardiac patients. The physiologic outcomes targeted include improvement in exercise capacity and exercise habits and optimization of risk-factor status, including improvement in blood lipid and lipoprotein profiles, body weight, and blood glucose and blood pressure levels, and the cessation of smoking. Enhancement of myocardial perfusion and performance, as well as reduction in progression of the underlying atherosclerotic process, are additional goals. The psychosocial functioning of patients should be improved when needed, including reduction of stress, anxiety, and depression. Functional independence of patients, particularly the elderly, is an essential goal of cardiac rehabilitation services. Return to appropriate and satisfactory work could benefit both patients and society. Recommendations for Additional Research Further scientific studies should address the following: Evaluation of the effects of cardiac rehabilitation exercise training, education, counseling, and behavioral interventions on special populations. These populations include elderly patients, women of all ages, patients from different ethnic groups, and those with lower educational or socioeconomic levels. Examination of outcomes of cardiac rehabilitation services in patients following acute myocardial infarction treated with contemporary therapies, including coronary thrombolysis and acute angioplasty. Evaluation of the effects of cardiac rehabilitation on rates of return to work, specifically targeting vocational rehabilitation counseling as a cardiac rehabilitation service. Evaluation of cost-effectiveness and cost-outcomes resulting from the delivery of cardiac rehabilitation services. A comparison should be made between various modes of delivery of cardiac rehabilitation services. Evaluation of outcomes of exercise rehabilitation with and without supervision and with and without ECG monitoring and surveillance in patients from higher risk groups including those with heart failure, elderly patients, and those with complex cardiovascular disease. Identification of factors that enhance adherence to cardiac rehabilitation services, including risk reduction and behavioral interventions. Evaluation of the safety and efficacy of strength training in higher risk populations such as elderly patients, women, unfit cardiac patients, and others at moderate-to-high cardiovascular risk. Prospective evaluation of the safety and benefit of exercise rehabilitation in patients with compensated heart failure and impaired ventricular systolic function. Development of optimal education and counseling strategies for costeffective coronary risk reduction. Development and assessment of valid psychosocial measures to ascertain improvement in psychological functioning and quality of life in patients following participation in multifactorial cardiac rehabilitation. Development of behavioral interventions for lifestyle changes for use in large populations of coronary patients, with prospective evaluation of gender, age, and ethnic differences in outcomes. 1 Overview Incidence and Prevalence The central purpose of this Clinical Practice Guideline is to define the scientific basis for recommendations for provision of cardiac rehabilitation services. Recommendations in this Clinical Practice Guideline are intended for health professionals caring for patients who might be candidates for cardiac rehabilitation services as well as clinicians involved in the provision of cardiac rehabilitation services. In addition, the guideline is intended to provide information to patients, their families, and others with interest in cardiac rehabilitation. Definitions and Goals The panel reviewed a number of definitions of cardiac rehabilitation presented by authoritative groups: the World Health Organization (WHO) in 1964,1 the ACC in 19862 supplemented by Task Force Reports in 1990 and 1991,34 the ACP in 1988,5 and an updated WHO report in 1993.6 The definition of cardiac rehabilitation used by the panel is based on a 1988 assessment by the U.S. Public Health Service of cardiac rehabilitation, which stated the following: 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. Cardiac rehabilitation services are prescribed for patients who (1) have had a myocardial infarction; (2) have had coronary bypass surgery; or (3) have chronic stable angina pectoris. The services are in three phases beginning during hospitalization, followed by a supervised ambulatory outpatient program lasting 3–6 months, and continuing in a lifetime maintenance stage in which physical fitness and risk factor reduction are accomplished in a minimally supervised or unsupervised setting.7 This definition does not fully recognize the pivotal role of the patient. The panel also advocates active assistance to enable the patient's acquisition of the knowledge, skills, and behaviors that will optimize adherence. The U.S. Public Health Service assessment further noted that cardiac rehabilitation exercise training could be provided with little risk of complications or adverse events. A more recent Public Health Service document extended prior cardiac rehabilitation recommendations, stating that "the |