A Review Of Guidelines For Cardiac Rehabilitation Exercise .
EURO PEANSO CIETY O FCARDIOLOGY ReviewA review of guidelines for cardiacrehabilitation exercise programmes:Is there an international consensus?European Journal of PreventiveCardiology0(00) 1–19! The European Society ofCardiology 2016Reprints and OI: 10.1177/2047487316657669ejpc.sagepub.comKym Joanne Price1, Brett Ashley Gordon1,2,Stephen Richard Bird1 and Amanda Clare Benson1AbstractBackground: Cardiac rehabilitation is an important component in the continuum of care for individuals with cardiovascular disease, providing a multidisciplinary education and exercise programme to improve morbidity and mortalityrisk. Internationally, cardiac rehabilitation programmes are implemented through various models. This review comparedcardiac rehabilitation guidelines in order to identify any differences and/or consensus in exercise testing, prescription andmonitoring.Methods: Guidelines, position statements and policy documents for cardiac rehabilitation, available internationally in theEnglish language, were identified through a search of electronic databases and government and cardiology society websites.Information about programme delivery, exercise testing, prescription and monitoring were extracted and compared.Results: Leading cardiac rehabilitation societies in North America and Europe recommend that patients progress frommoderate- to vigorous-intensity aerobic endurance exercise over the course of the programme, with resistance trainingincluded as an important adjunct, for maintaining independence and quality of life. North American and Europeanguidelines also recommend electrocardiograph-monitored exercise stress tests. Guidelines for South America andindividual European nations typically include similar recommendations; however, those in the United Kingdom,Australia and New Zealand specify lower-intensity exercise and less technical assessment of functional capacity.Conclusion: Higher-intensity aerobic training programmes, supplemented by resistance training, have been recommended and deemed safe for cardiac rehabilitation patients by many authorities. Based on research evidence, thismay also provide superior outcomes for patients and should therefore be considered when developing an internationalconsensus for exercise prescription in cardiac rehabilitation.KeywordsCardiac rehabilitation, cardiovascular disease, guidelines, exercise therapy, exercise test, exerciseReceived 15 December 2015; accepted 11 June 2016IntroductionCardiovascular disease (CVD) is a leading contributorto global mortality and morbidity. Internationally, it isthe cause of approximately a third of total yearlydeaths,1 with mortality rates in high-income countriesranging from 20% to 50%.2,3 CVD is responsible forapproximately 20% of the worldwide disease burden.1Cardiac rehabilitation promotes secondary prevention of CVD and is an essential component of carefor all cardiac patients.4,5 It is a coordinated physical,social and psychological intervention that favourablyinfluences the underlying risk factors in order to stabilise, slow or reverse disease progression, and facilitatesthe ability of the patient to preserve or resume an activeand functional contribution to the community.6,7Cardiac rehabilitation promotes a healthy and active1Discipline of Exercise Sciences, School of Health and BiomedicalSciences, RMIT University, Melbourne, Victoria, Australia2Discipline of Exercise Physiology, La Trobe Rural Health School, LaTrobe University, Bendigo, Victoria, AustraliaCorresponding author:Kym Joanne Price, Discipline of Exercise Sciences, School of Health andBiomedical Sciences, RMIT University, PO Box 71, Bundoora, Victoria3083, Australia.Email: kym.price@rmit.edu.auDownloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016
2European Journal of Preventive Cardiology 0(00)lifestyle, with the aim of improving quality of lifethrough: increased cardiac function; increased exercisetolerance; decreased cardiovascular symptoms; reducedlevels of anxiety, depression and stress; return to work;and maintaining independence in activities of dailyliving.5,6,8 Structured exercise has been identified asbeing central to the success of cardiac rehabilitation.9–11Strong, consistent positive evidence exists for exercise-based cardiac rehabilitation for patients with stableangina pectoris,7,10 myocardial infarction (MI)7,10,12and coronary revascularisation.7,10 Cardiac rehabilitation is also recommended for patients who have undergone heart transplant13 or valvular surgery,14 inaddition to those suffering chronic heart failure.15Meta-analyses have shown significant reductions inboth all-cause and cardiac mortality from exercisebased rehabilitation compared to standard medicalcare without structured exercise training or advice,with the reduction associated with long-term ratherthan short-term follow-up.7,12 Exercise-based cardiacrehabilitation results in a significantly lower risk offatal and non-fatal re-infarction through improved cardiac and coronary vascular function, as well asimproved CVD risk factor profiles when compared tocardiac rehabilitation without an exercise component.12Cardiac rehabilitation services exist in fewer than40% of countries throughout the world, with programmes available in 68% of the countries defined ashigh income by the World Bank.8 This figure falls toonly 22% in low- and middle-income countries, wherethe majority of deaths due to CVD occur.16 The densityof cardiac rehabilitation programmes varies from theequivalent of one programme for every 0.1 millioninhabitants in the United States (US)8 to one programme for every 2.2 million inhabitants throughoutLatin America16 and one programme for 164 millioninhabitants in Bangladesh, where there is a single facility to service the entire population.8 Guidelines for theprovision of cardiac rehabilitation have not been established in many of the nations providing this service.The purpose of this review is to compare nationalguidelines for outpatient cardiac rehabilitation fromaround the world alongside those prepared by leadingcardiovascular scientific societies, and provide insightinto any differences and/or consensus in patient eligibility, programme delivery and exercise testing, prescription and monitoring that exist.MethodsNational guidelines, position statements and policydocuments for exercise-based outpatient cardiacrehabilitation were searched from the earliest dateavailable to July 2015 using PubMed and GoogleScholar databases. The search terms ‘‘cardiacrehabilitation’’, ‘‘guidelines’’, ‘‘policy’’ and ‘‘positionstatement’’ were combined and searched alone and bycountry. Government and cardiology society websitesfor countries that were known to have cardiac rehabilitation services were also examined, along with referencelists of identified guidelines and review articles. Onlythose guidelines, position statements and policy documents available in English were included. Only resistance training recommendations for Germany have beenpublished in English; however, guidelines covering allaspects of cardiac rehabilitation have been translatedand summarised in a review article published byKaroff et al.,17 and the information presented was utilised in the current review. Where non-Englishlanguage guidelines or position statements werelocated, the authors were contacted to confirm thatan English version was not available. Document analyses of the guidelines, position statements and policydocuments were undertaken to extract the relevantinformation for this review.ResultsGuidelines, position statements and policy documentsfor outpatient cardiac rehabilitation from 18 individualcountries or regions were identified in the English language and included for review. The American HeartAssociation (AHA) and the American Association ofCardiovascularandPulmonaryRehabilitation(AACVPR) have issued a joint scientific statementdetailing the core components of cardiac rehabilitationprogrammes,18 with more comprehensive guidelineshaving been published by the AACVPR (with AHAendorsement).19 The Canadian Association of CardiacRehabilitation (CACR) have also developed detailedguidelines.20 A position statement has been preparedby the European Association of CardiovascularPrevention and Rehabilitation (EACPR),21 with severalindividual European countries also producing theirown guidelines. In the Australasian region, Australiaand New Zealand each have their own guidelines, prepared by the respective National Heart Foundations, inconjunction with the Australian CardiovascularHealth and Rehabilitation Association (ACRA) inAustralia.22–24 A joint position statement by theSouth American Society of Cardiology and the InterAmerican Committee on Cardiovascular Preventionencompasses the whole of South America.25 In Asia,English-language cardiac rehabilitation guidelineshave only been published in Japan. The World tion after Cardiovascular Diseases preparedguidelines for the provision of cardiac rehabilitation in1993.4 This document has an emphasis on developingcountries, but still contains information that is relevantDownloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016
Price et al.3to high-income countries. Published guidelines werealso located for Brazil, Columbia, Cuba, Denmark,Estonia, Germany, Italy, Poland, Spain, Switzerland,Israel, and South Korea, but these have been excludedfrom this review as they were not available in Englishand funding was not available for translators.Cardiac rehabilitation throughout the world followsthe same progression from hospitalisation after anacute event through to recovery and on-going maintenance. Cardiac rehabilitation is commonly divided intoeither three or four phases, with the content of thesephases varying between nations, as detailed inSupplementary Table 1.Programme eligibility and deliveryAspects of programme delivery detailed in cardiacrehabilitation guidelines include patient eligibility,pre-participation medical assessment, required personnel and responsibility for prescription and supervision of exercise and educational interventions(Supplementary Table 2). Acute coronary conditionsthat are eligible for cardiac rehabilitation are listed inSupplementary Table 2, while patients with peripheralarterial disease (PAD) are additionally included in theeligible patient lists for Austria,26 Europe,21,27France,28 Ireland,5 Japan29 and South America.25Medical and physical evaluations are recommended inall guidelines, with measurement of heart rate, bloodpressure, body mass index and waist girth all beingcommon. Furthermore, resting 12-lead electrocardiograph (ECG) prior to the commencement of cardiacrehabilitation is specified for Austria,26 Canada,20Europe,21 England,30 France,28 Germany,31 Japan,29Scotland32 and the US.18,19Recommendations throughout the world are for amultidisciplinary involvement in the delivery of cardiacrehabilitation programmes. Australian guidelines additionally specify the inclusion of an Aboriginal healthworker within indigenous communities,22 while in NewZealand, a Maori disease state management nurse isincluded as a member of the cardiac rehabilitationteam.24 The AACVPR guidelines identify that exercisetraining be prescribed by a physician to obtainMedicare benefits, but there is no additional information to encompass non-Medicare da,20263124Austria,Germany,New Zealand,NorthernIreland,33 The Netherlands34 and the UnitedKingdom (UK)35 specify that exercise programmingand supervision are the responsibility of a physiotherapist or a staff member trained in exercise prescription,such as a sport scientist or exercise physiologist. TheAACVPR guidelines specify a minimum number of sessions during which each patient should be directlysupervised, depending on their assessed level of riskand their progress.19 This recommendation has alsobeen included in the Irish guidelines5 and adapted inthose for South America.25 Staff-to-patient ratios varythroughout the world, depending on the stage ofrehabilitation, the intensity of exercise programmingand the available staff.Psychological evaluation and counselling are recommended in all nations, with stress management andrelaxation interventions also common. Educationaltopics covered during cardiac rehabilitation programmes routinely include the management of cardiovascular risk factors, nutritional and physical activityadvice, smoking cessation and vocational counselling.The duration of outpatient rehabilitation programmes differs between nations (Tables 1 and 2), varying from a minimum of 3 weeks in Germany withextension only in exceptional circumstances17 to aslong as 12 months in Austria, depending on the statusof the participant.26Exercise and functional assessmentConsiderable variation exists in the specificity and technical skill of exercise testing recommended in cardiacrehabilitation guidelines internationally, as shown inTables 1 and 2. An ECG-monitored exercise stresstest is recommended by the AHA and AACVPR,18,19CACR20 and EACPR.21 Guidelines for Japan,29 SouthAmerica25 and the majority of the European countriesreviewed26–28,31,34 also include this recommendation forpre-programme exercise testing. Despite these recommendations by leading cardiovascular societies, lesstechnical exercise testing, in the form of either a6–minute walk test or shuttle walk test, form the standard for the determination of functional capacity inAustralasia and the UK.22,24,30,32,33,36 However, thesenations do acknowledge that an ECG-monitored exercise stress test should be performed for high-riskpatients (those with decompensated heart failure,uncontrolled arrhythmias or experiencing angina atrest or with minimal exertion)24,32 or for patientswishing to participate in a high-intensity exercise programme ( 75% maximal heart rate (HRmax)).32Monitoring during exercise training sessionsHeart rate monitoring and/or the Borg Rating ofPerceived Exertion Scale37 are frequently recommended, with the monitoring of blood pressureduring exercise and the observation of signs and symptoms, such as excessive breathlessness or fatigue, chestpain and light-headedness, also being widely specified.The AACVPR guidelines for the US have detailed aprogression from continuous to intermittent ECGDownloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016
Type of exerciseIntensity of exerciseCanada(Canadian Association ofCardiacRehabilitation)20Downloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016Flexibility trainingNot specifiedAerobic intervaltrainingResistance trainingNot specified30–40% 1RM forupper body50–60% 1RM for lowerbody40–85% HRRTo moderate fatigueAerobic endurancetrainingResistance trainingLeading cardiology and cardiac rehabilitation organizations50–80% VO2max (closeEuropeAerobic endurance(European Association oftrainingto anaerobicCardiovascular(e.g. walking, jogging,threshold)Prevention andcycling, swimming,50–80% HRpeak or 40–Rehabilitation)21,27rowing, stair climbing,60% HRRelliptical trainer,RPE 10–14aerobics)Country1–3 sets of 12–15 repsfor 6–10 differentexercise for bothupper and lowerbody2–3 sessions per weekStatic stretching: 4reps per exercise,15–60 seconds perstretchPNF stretching: 6second contractionfollowed by 10–30second assistedstretch10–15 reps per set2 sessions per week20–40 minutes persession3–5 sessions per week 20–30 minutes persession 3 sessions per week(preferably 6–7)Duration andfrequencyof sessions 12 weeks2–16 weeksProgramme lengthExercise testingGraded exercise test(Bruce protocol)with ECG monitoringMonitoringHR monitoringBP monitoringRPEECG monitoring atdiscretion of medical director (progress fromcontinuous monitoring to intermittent as appropriatefor risk level ofpatient)Respiratory rate ifindicatedArterial oxygensaturationExercise testingSymptom-limited exercise testMonitoringObservation of symptomsHR monitoringBP monitoringECG monitoringduring initial stagesor for patients withnew symptomsExercise testingand monitoring(continued)Encouraged to engagein lighter forms ofphysical activity ondays when notattending a formalexercise session inorder to accumulate30–60 minutes ofmoderate- to vigorous-intensity onmost days of theweekEquivalent of 30 minutes of moderateintensity walkingper dayExpectations foradditional activityTable 1. Recommendations for exercise testing, prescription and monitoring in outpatient cardiac rehabilitation programs for independent regions and nations, including leadingcardiac rehabilitation organisations.4European Journal of Preventive Cardiology 0(00)
Aerobic endurancetraining(e.g. walking, treadmill,cycling, steps, rowing)United States(American HeartAssociation, AmericanAssociation ofCardiovascular andPulmonaryRehabilitation)18,19,70Independent nations and regionsJapanAerobic endurance(Japanese CirculationtrainingSociety)29(e.g. aerobics, cycling)Flexibility training(static stretching withemphasis on lowerback and thigh)Resistance training(e.g. calisthenics, handweights, pulleys, dumbbells, free weights,machine weights)Type of exerciseCountryTable 1. ContinuedAt anaerobic threshold(40–60% VO2peak,40–60% HRR, RPE12–13)To point of milddiscomfort40–80% VO2peak orHRmax based onmaximal exercisetestRPE 11–16To moderate fatigue(RPE 11–13)50% 1RM progressingto 60–70% 1RMIntensity of exercise15–60 minutes persessions1–3 sessions per week1–3 sets of 10–15 repsfor 8–10 differentexercises2–3 sessions per week(non-consecutivedays)3–5 reps per exercise,30–90 seconds foreach stretch as tolerable2–3 sessions per week(non-consecutivedays)20–60 minutes persession3–5 sessions per weekDuration andfrequencyof sessions5 months (first 5months following treatment) 36 sessionsProgramme lengthExercise testingExercise stress testMonitoringHR monitoringBP monitoringRPEECG monitoring recommended if chestpain is experiencedExercise testingSymptom-limited exercise test stronglyrecommendedMonitoringObservation of symptomsHR monitoringBP monitoringRPEECG (progress fromcontinuous monitoring to intermittent as appropriatefor risk level ofpatient)Exercise testingand monitoringDownloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016(continued)3–4 days per week ofhome-based trainingprescribed throughthe programmeHome-based physicalactivity to achieve30–60 minutes perday of moderateintensity activity onat least 5 days of theweekExpectations foradditional activityPrice et al.5
40–75% VO2maxLow intensity and highrepsResistance training30–45 minutes persession3–5 sessions per weekNot specifiedAs appropriateAerobic endurancetrainingNot specifiedLow- to moderateintensity physicalactivityAerobic endurancetraining(e.g. walking, cycling,treadmill, dancing)Resistance trainingAustralia(National HeartFoundation ofAustralia, AustralianCardiovascular Healthand RehabilitationAssociation)6,22,23,42New Zealand(New Zealand GuidelinesGroup, National HeartFoundation of NewZealand)2430–60 minutes persession (NSW)1–2 sessions per weekIntensity of exerciseType of exerciseDuration andfrequencyof sessionsCountryTable 1. Continued6–12 weeks3–12 weeksProgramme lengthExercise testing6-minute walk test(NSW)Symptom-limited maximal exercise stresstest recommendedprior to high-intensity programme orfor high-riskpatientsMonitoringObservation of symptomsHR monitoringBP monitoringRPEECG monitoring forhigh-intensity programmes or highrisk patients (VIC)Respiratory rate ifindicatedExercise testingExercise stress test(not necessary forlow-risk patientsundertaking supervised low- to moderate-intensity exercise training)MonitoringObservation of symptomsHR monitoringExercise testingand monitoringDownloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016(continued)At least 30 minutes ofmoderate physicalactivity on mostdays of the weekAt least 30 minutes oflight- to moderateintensit
Cardiac rehabilitation promotes secondary preven-tion of CVD and is an essential component of care for all cardiac patients.4,5 It is a coordinated physical, social and psychological intervention that favourably influences the underlying risk factors in order to stabil-ise, slow or reverse disease progression, and facilitates
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