Cardiac Rehabilitation – An Underutilized Level IA Recommendation

This post was authored by Marjorie King, MD, FACC, MAACVPR, past president and chair of the Professional Liaison Committee of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).


Updated clinical practice guidelines for secondary prevention of coronary artery disease and treatment following PCI and CABG published in 2011 provided a class IA level of recommendation for referral to cardiac rehabilitation (CR)/secondary prevention programs.  This was based on recent evidence that participation in cardiac rehabilitation for patients with angina or following PCI, CABG, or myocardial infarction improves five-year mortality by 25-46%, with a clear dose response effect, in addition to multiple studies demonstrating improvement in function, modifiable risk factors, and quality of life. Despite this, cardiac rehabilitation programs remain underutilized, especially among older patients, women, and minorities.

Under-appreciation of the benefits of cardiac rehabilitation by healthcare professionals is only one of the issues, but is easily corrected as referral to CR is incorporated into performance measure sets and guidelines, based on accumulating evidence.  Like other important, but easily forgotten, treatments, such as recommending aspirin use, referral to CR needs to become systematized into the thought processes, algorithms and systems we use to care for patients. This is beginning to happen as hospitals are incorporating referral to CR in discharge order sets and instruction sheets.  Unfortunately, several studies have shown that although this increases the referral rate, actual enrollment rates remain low (<35% of eligible patients).   This discrepancy can be attributed to multiple factors – including healthcare practitioners at acute care hospitals, physicians, practitioners and office staff in outpatient settings, and insurance company policy makers, as well as to patient barriers such as financial issues, belief systems, and motivation.

Fortunately, some of the provider-based barriers to CR participation are reversible with simple measures incorporated into daily practice.  Even brief endorsement of cardiac rehabilitation by a physician has been shown to improve participation, so adding CR referral to your mental algorithm that already includes aspirin, stains, beta blockers, ACEI, is a simple step to take. A brief script about the importance of cardiac rehabilitation that can be used by a medical practitioner during discharge planning is included in the AACVPR/ACCF/AHA referral to CR measure.

Partnering with local peer advocates, such as Mended Hearts and WomenHeart can help break down patients’ reluctance to enroll in cardiac rehabilitation and may support their participation.  Mended Hearts visitors are strong advocates of CR and are now trained to work with patients after PCI, as well as CABG or valve surgery. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recently developed printable PDF fact sheets for patients about CR and CardioSmart also has patient fact sheets available in both English and Spanish and videos about CR that can be used in office or hospital settings.  Finally, AACVPR has a Program Directory which can help locate programs close to patients’ homes.

Cardiac rehabilitation core components include not only individualized, medically supervised exercise, education about modifiable risk factors, psychosocial support, but also stress communication with healthcare providers about progress and barriers to meeting goals. Cardiac rehabilitation programs extend practitioners secondary prevention efforts beyond those provided during hospital and office visits. It’s unfortunate that cardiac rehabilitation referral may be inadvertently omitted, depriving patients of this effective therapy. However, just adding a few simple steps to your office or hospital practice to facilitate enrollment in CR may make a big difference to your patients’ health and quality of life.


Please note that statements or opinions expressed herein reflect the views of the contributor, and do not reflect the official views of the ACCF, unless otherwise noted.

For more information about Cardiac Rehabilitation visit CardioSource.

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