Cardiac rehabilitation (CR) is a multifaceted intervention that is directed toward improving healthy lifestyle characteristics (i.e., increased physical activity, healthy nutrition, smoking cessation counseling as needed, and attainment/maintenance of a healthy body weight) as well as key health metrics (i.e., optimal lipid, glucose, and blood pressure control). Simply stated, CR is a comprehensive healthy lifestyle intervention; the medical community is increasingly recognizing that formally helping individuals to lead a healthy lifestyle is medicine that should be prescribed to everyone.^1,2 Moreover, the longstanding objectives and goals of CR align very well with the American Heart Association's (AHA's) more recent definition of poor/intermediate/ideal cardiovascular health and the Life's Simple 7 initiative.^1,2

There is a wealth of literature in support of CR.³ Previous research clearly demonstrates CR significantly improves exercise capacity, quality of life, cardiovascular risk profile, and prognosis in patients diagnosed with cardiovascular disease (CVD), including those patients undergoing a percutaneous coronary intervention (PCI).^4-9 Moreover, CR services are viewed as a cost-effective intervention.^8,10 This robust supportive body of literature has led to the endorsement of CR in current clinical practice guidelines.¹¹ The case for CR has been made numerous times, and there is clear consensus that eligible patients should be referred to and participate in this well-established healthy lifestyle program.

Despite the body of original evidence and clinical practice guidelines in support of CR, referral and participation remain alarmingly low.^12-16 The reasons for poor referral and participation are complex and multifactorial. Certain groups diagnosed with CVD, including racial and ethnic minorities, those with advanced disease severity and comorbidities, the elderly, women, and those in lower socioeconomic classes and socioeconomic strata are even less likely to participate in CR; this is not an exhaustive list of individual characteristics associated with poor referral and participation in CR.¹² Not surprisingly, however, there is data to indicate that individuals with these characteristics derive comparable if not greater benefits from CR if they do participate.^5,7,17 Moreover, there are numerous health care system and provider factors that are associated with poor CR referral and participation, including lack of referral automation, local CR availability and capacity constraints, and poor communication on the importance of CR to patients.¹⁶ Collectively, these barriers and challenges result in CR participation rates being historically less than 50%,¹² even with new initiatives such as AHA's Get With the Guidelines.¹⁴ The data on CR referral and participation clearly indicate we are not meeting goals with respect to prescribing this important healthy lifestyle medicine and ensuring treatment compliance.

The preceding sections describe the paradox that currently exists in CR; although numerous benefits are clearly derived from participation, most do not participate. Moving forward, the CR paradox will only be rectified by: 1) improving processes that can be implemented in the currently available CR model; 2) creating and implementing novel CR models; and 3) capitalizing on technologic advances.

Improving Processes

For many patients post-PCI, the first opportunity to learn about CR is shortly after the procedure as an inpatient. While automated referral to CR during the inpatient stay has become more common, strong endorsement for CR participation from all health care providers of the interdisciplinary team (i.e., physician, nursing, physical therapy, and social work) is often a missing component. A recent AHA scientific advisory strongly advocated for such an approach; each inpatient health care professional caring for patients with CVD, post-PCI, as well as other diagnoses and procedures has a responsibility to stress the importance of CR to post-discharge care and to ensure that the patient understands this message; messaging to the patient should be planned and consistent amongst the members of the inpatient team.¹⁶ Health care professionals should also be cognizant of potential CR referral biases and ensure patients with characteristics that increase the likelihood of nonparticipation (e.g., women, minorities, and the elderly) are also given a strong and consistent message that they should participate. Another important improvement in current processes in the transition from CVD/post-PCI inpatient care to outpatient care is reducing the time commonly taken to begin CR. Currently, a delay of several weeks between inpatient discharge and contact by a CR program to schedule the initial appointment is common; there is no scientific basis warranting this delay. This gap in time is a critical lost opportunity during which the likelihood for CR participation, regardless of automated referral, precipitously drops in a number of patients. Research has shown that an early access clinic, in which the time from discharge to CR initiation is reduced from weeks to days, significantly increases CR participation and completion.¹⁸ These easily applicable changes in current processes, a consistent and strong of endorsement for CR from all health care professionals, and decreasing time from event/procedure to CR initiation have the potential to dramatically increase patient participation.

Novel CR Models

Currently, CR is commonly delivered in a singular, standardized fashion in the U.S.: 36 supervised sessions in an outpatient clinical setting over 12 weeks. A primary challenge associated with increased participation in the current standardized model is limited patient access to CR due to numerous factors including: 1) a long commute from the home to facility, 2) lack of consistent transportation regardless of commute distance, and 3) limited infrastructure and capacity for a given CR program to increase the number of patients seen. Simply stated, a "one size fits all" CR model will always negatively impact the number of patients who can undergo this valuable lifestyle intervention. There is a body of literature demonstrating that alternate CR models, for example one focused on home-based care, are equally effective in improving healthy lifestyle patterns compared to traditional center-based care.^10,19 Expanding settings and models in which CR can be delivered and costs can be reimbursed has the potential to greatly expand the number of individuals who can and will participate. Migrating from a "one size fits all" to an individually tailored CR model is an important vision for the future.

Technology

The potential for technology to greatly enhance the reach of CR, irrespective of setting and infrastructure, cannot be underestimated and should most certainly be capitalized upon. Use of mobile phones, the internet, and wearable devices provide opportunities to continually engage patients in healthy lifestyle messaging and deliver interventions. There is an ever-growing body of literature demonstrating the great promise of delivering healthy lifestyle interventions through technology.^20-24 Determination of optimal models for technology-based healthy lifestyle interventions should continue and be rapidly implemented into clinical care when proven effective.

While the focus of this article is on CR as a secondary prevention model, specifically in post-PCI patients, the future and true promise of healthy lifestyle interventions lies within downstream implementation (i.e., primordial and primary prevention). There is clear evidence indicating that leading a healthy lifestyle substantially reduces the risk of developing CVD.^2,25 Therefore, transforming what is now known as secondary prevention CR to a broader healthy lifestyle program that also heavily focuses on primordial and primary CVD prevention should be considered a future imperative.

In conclusion, there is a clear and undeniable body of scientific evidence describing the numerous clinical and economic benefits of CR in the CVD population, including those undergoing PCI. Based on this body of evidence, current clinical practice guidelines strongly advocate for CR participation by all eligible patients. Even so, there is clear evidence that we have fallen short on ensuring the majority of individuals in need of this intervention participate. Deficiencies in the current CR model that have resulted in this shortfall are multifactorial and complex. However, there are clear strategies that can improve CR participation if implemented. Redefining what constitutes CR and migrating efforts downstream to focus on primordial and primary CVD prevention also have the potential for a highly positive impact. Leading a healthier lifestyle, which has always been the primary focus of CR, is medicine that should be prescribed to everyone.

References

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15. Parashar S, Spertus JA, et al. Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction. Circulation 2012;126:1587-95.
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18. Parker K, Stone JA, Arena R, et al. An early cardiac access clinic significantly improves cardiac rehabilitation participation and completion rates in low-risk ST-elevation myocardial infarction patients. Can J Cardiol 2011;27:619-27.
19. Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2010;1:CD007130.
20. Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med 2015;128:337-43.
21. Franklin NC, Lavie CJ, Arena RA. Personal health technology: A new era in cardiovascular disease prevention. Postgrad Med 2015;127:150-8.
22. Pratt M, Sarmiento OL, Montes F, et al. The implications of megatrends in information and communication technology and transportation for changes in global physical activity. Lancet 2012;380:282-93.
23. Pfaeffli L, Maddison R, Whittaker R, et al. A mHealth cardiac rehabilitation exercise intervention: findings from content development studies. BMC Cardiovasc Disord 2012;12:36.
24. Beatty AL, Fukuoka Y, Whooley MA. Using mobile technology for cardiac rehabilitation: a review and framework for development and evaluation. J Am Heart Assoc 2013;2:e000568.
25. Akesson A, Larsson SC, Discacciati A, Wolk A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men: a population-based prospective cohort study. J Am Coll Cardiol 2014;64:1299-306.

Keywords: Aged, Ambulatory Care, Automation, Blood Pressure, Body Weight, Cardiovascular Diseases, Comorbidity, Consensus, Glucose, Health Personnel, Inpatients, Life Style, Lipids, Minority Groups, Motor Activity, Outpatients, Patient Compliance, Patient Participation, Percutaneous Coronary Intervention, Primary Prevention, Prognosis, Quality of Life, Risk Factors, Secondary Prevention, Smoking Cessation, Social Work, Angiography

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