A Call to Arms: Efforts to Improve Outcomes Through Cardiac Rehabilitation

Despite substantial morbidity and mortality benefits, cardiac rehabilitation (CR) services are vastly underutilized. For example, CR is recommended for only 20% of eligible persons and referral rates are lower in women and the elderly, both of whom have been shown to benefit. Even in hospitals participating in the Get With The Guidelines program, Vera Bittner, MD, MSPH, and colleagues have shown that the overall referral rate was only 56%, with a wide variation between hospitals: in more than one-third of participating hospitals, the referral rate was <20%.1 Indeed, CR utilization is much lower than other secondary prevention measures, despite the fact that the comparative effectiveness is similar or greater for CR.

CR is a class I recommendation in most contemporary CV clinical practice guidelines2 and is recommended in a number of clinical settings, including:

  • post-MI or CABG;
  • following PCI;
  • heart or heart/lung transplantation recipients;
  • patients with stable angina or stable chronic HF;
  • peripheral arterial disease with claudication;
  • and following cardiac surgical procedures for heart valve repair or replacement.3

What about reimbursement? The Centers for Medicare and Medicaid Services (CMS) reimburse for CR related to many variants of CVD, including an acute MI within the preceding 12 months; revascularization (CABG or PCI); current stable angina pectoris; or heart valve repair or replacement. At the present time, however, despite the growing body of evidence, CMS does not reimburse for cardiac rehabilitation in patients with HF.

There is a significant dose-response relationship between the number of CR sessions attended and long-term outcomes.4 In an analysis of more than 30,000 Medicare claims for individuals participating in at least one CR session, those who attended ≥24 sessions had the lowest subsequent rate of MI, whereas patients who attended fewer than 12 CR sessions had the highest incidence of MI. Attending all 36 sessions that Medicare reimburses was associated with:

  • an 18% lower risk of death compared with attending 24 sessions;     
    a 29% lower risk compared with attending 12 sessions;
  • and a 58% lower risk compared with attending one session.

That’s in line with meta-analyses of randomized controlled trials that suggest participation in CR programs reduces all-cause mortality anywhere from 15-28% and cardiac morbidity from 26-31%, a level of benefit comparable to the use of statins, beta-blockers, and aspirin. Moreover, CR boosts physical strength and endurance by 20-50%, an improvement that could determine whether a patient is able to return to an active life—and a benefit not typically seen with other secondary prevention therapies.


The risk of CR is very low: one cardiac arrest for every 120,000 patient-hours of exercise and one death in every 750,000 patient-hours of exercise.5 Even individuals 65 years of age and older, as well as HF patients, typically respond well and can safely participate in regular exercise.

It is recommended that individuals at moderate or high risk for cardiac complications with exercise participate in a medically supervised program for at least 8 to 12 weeks after an acute event, until the safety of the prescribed exercise regimen has been established. Low-risk patients may initially benefit from medically supervised exercise, but self-monitored home-based exercise programs also have been documented to be effective and safe and potentially associated with better rates of adherence compared with group-based programs.

A Call to Arms

A number of medical societies specializing in cardiac care and rehabilitation have issued a “call to arms” with the publication of performance measures to make referral to cardiac rehab as automatic as giving aspirin during a heart attack. Recommendations include6,7:

  • Initiation of an automatic referral to appropriate inpatient health professional(s) to assess the readiness of all patients with a cardiac event for discharge home and for participation in an outpatient CR program
  • Educating all inpatient health professionals on the methods to implement that will result in greater patient participation in CR programs including:
    • referral to CR/secondary prevention program (SPP) in the hospital discharge plan;
    • automatically referring all eligible patients at the time of hospital discharge;
    • having ward clerks/office staff ensure that referrals are completed;
    • providing patients with a choice of CR/SPP to attend;
    • ensuring that patients are aware of and agree to the referral;
    • arranging personal visits from CR/SPP liaison;
    • providing written invitations and program brochures in multiple languages;
    • informing the CR/SPP of the referral and, when possible, establishing an appointment at the point of care;
    • making comprehensive interpreter service available if required;
    • providing transportation and parking assistance if required; and
    • following up with those referred but not yet enrolled.


  1. Brown TM, et al. J Am Coll Cardiol. 2009;54:515-21. http://content.onlinejacc.org/cgi/content/abstract/54/6/515 
  2. Thomas RJ, et al. J Am Coll Cardiol. 2007;50:1400-33. http://content.onlinejacc.org/cgi/content/full/50/14/1400
  3. Wenger NK. J Am Coll Cardiol. 2008;51:1619-31. http://
  4. Hammill BG, et al. Circulation. 2010;121:63-70.
  5. Thompson PD. Circulation 2005;112:2354-63.
  6. Balady GJ, et al. Circulation. 2011;124:2951-60. 
  7. Arena R, et al. Circulation. 2012;125:1321-9.

Keywords: Lung Transplantation, Myocardial Infarction, Societies, Medical, Angina, Stable, Transportation, Referral and Consultation, Centers for Medicare and Medicaid Services, U.S., Peripheral Arterial Disease, Heart Arrest, Inpatients, Pamphlets, Patient Discharge, Heart Diseases, Incidence, Secondary Prevention, Outpatients, Patient Participation, Cardiac Surgical Procedures

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