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U.S. Department of Health and Human Services

Public Health Service

Agency for Health Care Policy and Research
National Heart, Lung, and Blood Institute

The Agency for Health Care Policy and Research (AHCPR) was established inj December 1989 under Public Law 101-239 (Omnibus Budget Reconciliation Act of 1989) to enhance the quality, appropriateness, and effectweness of health care services and access to these services. AHCPR carries out its mission by conducting and supporting general health services research, including medical effectiveness research, facilitating development of clinical practice guidelines, and disseminating research findings and guidelines to health care providers, policymakers, and the public.

The legislation also established within AHCPR the Office of the Forum for Quality and Effectiveness in Health Care (the Forum). The Forum has primary responsibility for facilitating the development, periodic review, and updating of clinical practice guidelines. The guidelines will assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.

The National Heart, Lung, and Blood Institute (NHLBI) supports biomedical research and patient and professional education on health care. NHLBI has coordinated development of several professionally oriented clinical guidelines, including ones on high blood pressure and high blood cholesterol, and collaborated with AHCPR in supporting a clinical practice guideline on unstable angina. Recognizing the importance of cardiac rehabilitation, NHLBI has again collaborated with AHCPR as a partner in the development of this clinical practice guideline.

Guidelines are available in formats suitable for health care practitioners, the scientific community, educators, and consumers. AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310. 6000 Executive Boulevard, Rockville, MD 20852. Number 17

Cardiac Rehabilitation

Cardiac Rehabilitation Guideline Panel

Nanette Kass Wenger, MD (Co-Chair)

Erika Sivarajan Froelicher, RN, PhD (Co-Chair)

L. Kent Smith, MD, MPH (Project Director)

Philip A. Ades, MD

Kathy Berra, BSN

James A. Blumenthal, PhD

Catherine M. E. Certo, ScD, PT

Anne M. Dattilo, PhD, RD

Dwight Davis, MD

Robert F. DeBusk, MD

Joseph P. Drozda, Jr., MD

Barbara J. Fletcher, RN, MN

Barry A. Franklin, PhD

Helen Gaston

Philip Greenland, MD

Patrick E. McBride, MD, MPH

Christopher G. A. McGregor, MB, FRCS

Neil B. Oldridge, PhD

Joseph C. Piscatella

Felix J. Rogers, DO

U.S. Department of Health and Human Services

Public Health Service

Agency for Health Care Policy and Research
National Heart, Lung, and Blood Institute

AHCPR Publication No. 96-0672
October 1995

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Guidelines are systematically developed statements to assist practitioner p ii and patient decisions about appropriate health care for specific clinical conditions. This guideline was developed by a private-sector panel convened by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung, and Blood Institute (NHLBI). The panel, assembled by the American Association of Cardiovascular and Pulmonary Rehabilitation, employed an explicit science-based methodology and expert clinical judgment to develop specific statements on management of cardiac rehabilitation.

Extensive literature searches were conducted, and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the reliability and utility of the guideline in clinical practice. The panel's recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants.

The guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done.

We believe that this AHCPR and NHLBI-assisted clinical practice guideline will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in the guideline. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner based on available resources and circumstances presented by individual patients.

Clifton R. Gaus, ScD Claude Lenfant, MD

Administrator Director
Agency for Health Care Policy National Heart, Lung,

and Research and Blood Institute

Publication of this guideline does not necessarily represent endorsement by the U.S. Department of Health and Human Services.

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Abstract

Coronary heart disease, heart failure, and cardiac transplantation are common cardiac problems of patients throughout the United States. The impact of these chronic conditions on patients, their families, and their communities represents both a major challenge and a major opportunity for providing optimal comprehensive management. Cardiac rehabilitation is defined by the World Health Organization as "the sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community." This guideline uses the U.S. Public Health Service definition of cardiac rehabilitation, namely "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 is designed for health professionals who provide care for cardiac patients, as well as for consumers, and is intended to optimize the quality, safety, effectiveness, and access to cardiac rehabilitation services.

The panel further defines cardiac rehabilitation as a multifactorial intervention process that follows a well-defined program structure. The process begins with assessments regarding all relevant aspects of the patient's status: medical, nutritional, psychosocial, educational, and vocational. The implementation of cardiac rehabilitation, based on these initial assessments, is designed to address the individual patient's needs as he or she works toward achieving optimal outcomes. This guideline addresses the relationship between identified patient needs and the provision of multifactorial services throughout the cardiac rehabilitation process to ensure optimal attention to these needs.

This guideline provides broad recommendations based on evaluation of the scientific evidence pertaining to the various components of cardiac rehabilitation. The key components of cardiac rehabilitation—exercise, education, counseling (about cardiac risk factor modification, development of psychosocial and motivational skills), and behavioral interventions—are each addressed.

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted, for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR appreciates citation as to source, and the suggested format is provided below:

Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute. AHCPR Publication No. 96-0672. October 1995.

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