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The Role of Cardiac Rehabilitation in the Treatment and Secondary Prevention of Cardiovascular Disease

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Abstract

One of the most striking developments in recent medical thinking has been the evolution of the philosophy of rehabilitation, or the ‘third phase of medical care’. The impact of this discipline on medical practice stems from the widespread intensification in contemporary medical teaching of the concept that delineates the patient’s relationship with himself, his family and work and also with the total community. Several observations have progressively led to cardiac rehabilitation being considered an important part of cardiovascular prevention and to the development of various educational programmes and clinical interventions to identify and modify major coronary risk factors and consequently to reduce morbidity and mortality in patients with established heart diseases.

In this article, the most recent studies on cardiac rehabilitation programmes are reviewed. We also highlight the need for additional studies in order to evaluate the risk of exercise for patients with diagnosed or occult cardiovascular disease and, especially, to evaluate the role of physical activity relative to other interventions on healthcare costs.

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References

  1. Benton J, Rusk H. The patient with cardiovascular disease and rehabilitation: the third phase of medical care. Circulation 1953 Sep; 8(3): 417–26

    Article  PubMed  CAS  Google Scholar 

  2. Cardiac rehabilitation programs: a statement for healthcare professionals from the American Heart Association. Circulation 1994; 90: 1602-10

    Google Scholar 

  3. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized trials. Am J Med 2004; 116: 682–97

    Article  PubMed  Google Scholar 

  4. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/ secondary prevention programs: a statement for healthcare professionals from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000; 102: 1069–73

    Article  PubMed  CAS  Google Scholar 

  5. Smith Jr SC, Blair SN, Bonow RO, et al. AHA/ACC Scientific Statement: AHA/ ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 2001; 104: 1577–9

    Article  PubMed  Google Scholar 

  6. Wenger NK, Froelicher ES, Smith LK, et al. Clinical practice guidelines No. 17: cardiac rehabilitation as secondary prevention. Rockville (MD): US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, National Heart, Lung and Blood Institute; 1995. AHCPR Publication 96–0672

  7. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for cardiac rehabilitation and secondary prevention programs. 4th ed. Champaign (IL): Human Kinetics, 2004

  8. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med 2001; 345: 892–902

    Article  PubMed  CAS  Google Scholar 

  9. Ades PA, Balady GJ, Berra K. Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative. J Cardiopulm Rehabil 2001; 21: 263–72

    Article  PubMed  CAS  Google Scholar 

  10. Pollock ML, Franklin BA, Balady GJ, et al. AHA Science Advisory. Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription: an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association; position paper endorsed by the American College of Sports Medicine. Circulation 2000; 101: 828–33

    Article  PubMed  CAS  Google Scholar 

  11. Leon AS. Exercise following myocardial infarction: current recommendations. Sports Med 2000; 29: 301–11

    Article  PubMed  CAS  Google Scholar 

  12. Miller NH, Haskell WL, Berra K, et al. Home versus group exercise training for increased functional capacity after myocardial infarction. Circulation 1984; 70: 645–9

    Article  PubMed  CAS  Google Scholar 

  13. Haskell WL. Cardiovascular disease prevention and lifestyle interventions: effectiveness and efficacy. J Cardiovasc Nurs 2003; 18: 245–55

    PubMed  Google Scholar 

  14. Harris DE, Record NB. Cardiac rehabilitation in community settings. J Cardiopulm Rehabil 2003; 23: 250–9

    Article  PubMed  Google Scholar 

  15. Southard BH, Southard DR, Nuckolls J. Clinical trials of an Internet-based case management system for secondary prevention of heart disease. J Cardiopulm Rehabil 2003; 23: 341–8

    Article  PubMed  Google Scholar 

  16. American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins, 2000

  17. Fletcher GF, Balady G, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104: 1694–740

    Article  PubMed  CAS  Google Scholar 

  18. Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation 1999; 99: 963–72

    Article  PubMed  CAS  Google Scholar 

  19. Lakka TA, Venalainen JM, Rauramaa R, et al. Relation of leisure-time physical activity and cardiorespiratory fitness to the risk of acute myocardial infarction. N Engl J Med 1994; 330: 1549–54

    Article  PubMed  CAS  Google Scholar 

  20. Tanasescu M, Leitzmann MF, Rimm EB, et al. Exercise type and intensity in relation to coronary heart disease in men. JAMA 2002; 288: 1994–2000

    Article  PubMed  Google Scholar 

  21. O’Connor GT, Buring JE, Yusuf S, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80: 234–44

    Article  PubMed  Google Scholar 

  22. Oldridge NB, Guyatt GH, Fischer ME, et al. Cardiac rehabilitation after myocardial infarction: combined experience of randomized clinical trials. JAMA 1988; 260: 945–50

    Article  PubMed  CAS  Google Scholar 

  23. Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001; (1): CD001800

    PubMed  Google Scholar 

  24. Niebauer J, Hambrecht R, Velich T, et al. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Circulation 1997; 96: 2534–41

    Article  PubMed  CAS  Google Scholar 

  25. Haskell WL, Alderman EL, Fair JM, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease: the Stanford Coronary Risk Intervention Prevention Project (SCRIP). Circulation 1994; 89: 975–90

    Article  PubMed  CAS  Google Scholar 

  26. Niebauer J, Cooke JP. Cardiovascular effects of exercise: role of endothelial shear stress. J Am Coll Cardiol 1996; 28: 1652–60

    Article  PubMed  CAS  Google Scholar 

  27. Dimmeler S, Zeiher AM. Exercise and cardiovascular health: get active to “AKTivate” your endothelial nitric oxide synthase. Circulation 2003; 107: 3118–20

    Article  PubMed  Google Scholar 

  28. Hambrecht R, Adams V, Erbs S, et al. Regular physical activity improves endothelial function in patients with coronary artery disease by increasing phosphorylation of endothelial nitric oxide synthase. Circulation 2003; 107: 3152–8

    Article  PubMed  CAS  Google Scholar 

  29. Fukai T, Siegfred MR, Ushio-Fukai M, et al. Regulation of the vascular extracellular superoxide dismutase by nitric oxide and exercise training. J Clin Invest 2000; 105: 1631–9

    Article  PubMed  CAS  Google Scholar 

  30. Hambrecht R, Wolf A, Gielen S, et al. Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000; 342: 454–60

    Article  PubMed  CAS  Google Scholar 

  31. Maseri A. Inflammation, atherosclerosis, and ischemic events: exploring the hidden side of the moon. N Engl J Med 1997; 336: 1014–6

    Article  PubMed  CAS  Google Scholar 

  32. Ross R, Janssen I. Physical activity, total and regional obesity: dose-response considerations. Med Sci Sports Exerc 2001; 33: S521–7

    Article  PubMed  CAS  Google Scholar 

  33. Jakicic JM, Clark K, Coleman E, et al. American College of Sports Medicine. American College of Sports Medicine position stand: appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2001; 33: 2145–56

    Article  PubMed  CAS  Google Scholar 

  34. Leon AS, Rice T, Mandel S, et al. Blood lipid response to 20 weeks of supervised exercise in a large biracial population: the HERITAGE Family Study. Metabolism 2000; 49: 513–20

    Article  PubMed  CAS  Google Scholar 

  35. Leon AS, Sanchez OA. Response of blood lipids to exercise training alone or combined with dietary intervention. Med Sci Sports Exerc 2001; 33: S502–15

    Article  PubMed  CAS  Google Scholar 

  36. Durstine JL, Grandjean PW, Davis PG, et al. Blood lipid and lipoprotein adaptations to exercise: a quantitative analysis. Sports Med 2001; 31: 1033–62

    Article  PubMed  CAS  Google Scholar 

  37. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002; 347: 1483–92

    Article  PubMed  CAS  Google Scholar 

  38. Kelley DE, Goodpaster BH. Effects of exercise on glucose homeostasis in type 2 diabetes mellitus. Med Sci Sports Exerc 2001; 33: S495–S501, S528–9

    Article  PubMed  CAS  Google Scholar 

  39. Tuomilehto J, Lindstrom J, Eriksson JG, Finnish Diabetes Prevention Study Group, et al. Prevention of type 2 diabetes mellitus by change in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: 1343–50

    Article  PubMed  CAS  Google Scholar 

  40. Knowler WC, Barrett-Connor E, Fowler SE, Diabetes Prevention Program Research Group, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403

    Article  PubMed  CAS  Google Scholar 

  41. Grundy SM, BrewerJr HB, Cleeman JI, American Heart Association; National Heart, Lung, and Blood Institute, et al. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109: 433–8

    Article  PubMed  Google Scholar 

  42. Grundy SM, Hansen B, Smith Jr SC, et al. Clinical management of metabolic syndrome: report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation 2004; 109: 551–6

    Article  PubMed  Google Scholar 

  43. Stewart KJ. Exercise training and the cardiovascular consequences of type 2 diabetes and hypertension: plausible mechanisms for improving cardiovascular health. JAMA 2002; 288: 1622–31

    Article  PubMed  Google Scholar 

  44. Tanaka H, Dinenno FA, Monahan KD, et al. Aging, habitual exercise, and dynamic arterial compliance. Circulation 2000; 102: 1270–5

    Article  PubMed  CAS  Google Scholar 

  45. Joyner MJ. Effect of exercise on arterial compliance. Circulation 2000; 102: 1214–5

    Article  PubMed  CAS  Google Scholar 

  46. Laughlin MH, Oltman C, Bowles DK. Exercise training-induced adaptations in the coronary circulation. Med Sci Sports Exerc 1998; 30: 352–60

    Article  PubMed  CAS  Google Scholar 

  47. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 1986; 74: 1124–36

    Article  PubMed  CAS  Google Scholar 

  48. Bolli R. The late phase of preconditioning. Circ Res 2000; 87: 972–83

    Article  PubMed  CAS  Google Scholar 

  49. Leitch JW, Newling RP, Basta M, et al. Randomized trial of a hospital-based exercise training program after acute myocardial infarction: cardiac autonomic effects. J Am Coll Cardiol 1997; 29: 1263–8

    Article  PubMed  CAS  Google Scholar 

  50. Iellamo F, Legramante JM, Massaro MA, et al. Effects of residential exercise training on baroreflex sensitivity and heart rate variability in patients with coronary artery disease: a randomized, controlled study. Circulation 2000; 102: 2588–92

    Article  PubMed  CAS  Google Scholar 

  51. Kingwell BA, Dart AM, Jennings GL, et al. Exercise training reduces the sympathetic component of the blood pressure-heart rate baroreflex in man. Clin Sci 1992; 82: 357–62

    PubMed  CAS  Google Scholar 

  52. Church TS, Lavie CJ, Milani RV, et al. Improvements in blood rheology after cardiac rehabilitation and exercise training in patients with coronary heart disease. Am Heart J 2002; 143: 349–55

    Article  PubMed  Google Scholar 

  53. Rauramaa R, Li G, Vaisanen SB. Dose-response and coagulation and hemostatic factors. Med Sci Sports Exerc 2001; 33: S516–20, S528–9

    Article  PubMed  CAS  Google Scholar 

  54. Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sport Exerc 2001; 33: S484–92

    Article  CAS  Google Scholar 

  55. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine. American College of Sports Medicine position stand: exercise and hypertension. Med Sci Sports Exerc 2004; 36: 533–53

    Article  PubMed  Google Scholar 

  56. Kris-Etherton P, Harris WS, Appel LJ. American Heart Association. Nutrition Committee. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002; 106: 2747–57

    Article  PubMed  Google Scholar 

  57. Kris-Etherton P, Eckel RH, Howard BV, Nutrition Committee Population Science Committee and Clinical Science Committee of the American Heart Association, et al. AHA Science Advisory: Lyon Diet Heart Study: benefits of a Mediterranean-style, National Cholesterol Education Program/American Heart Association Step I dietary pattern on cardiovascular disease. Circulation 2001; 103: 1823–5

    Article  PubMed  CAS  Google Scholar 

  58. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143-421

    Google Scholar 

  59. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324: 71-86

    Google Scholar 

  60. Vaughan CJ, Gotto Jr AM, Basson CT. The evolving role of statins in the management of atherosclerosis. J Am Coll Cardiol 2000; 35: 1–10

    Article  PubMed  CAS  Google Scholar 

  61. Maron DJ, Fazio S, Linton MF. Current perspectives on statins. Circulation 2000; 101: 207–13

    Article  PubMed  CAS  Google Scholar 

  62. Libby P, Aikawa M. Mechanisms of plaque stabilization with statins. Am J Cardiol 2003;91: 4B–8B

    Article  PubMed  CAS  Google Scholar 

  63. Scandinavian Simvastatin Survival Study Group. Randomized trial of cholesterol lowering in 4444 patients with CHD. Lancet 1994; 344: 1383-9

    Google Scholar 

  64. Rubino HB, Robins SJ, Collins D. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of HDL cholesterol. N Engl J Med 1999; 341: 410–8

    Article  Google Scholar 

  65. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC7 Report [published erratum appears in JAMA 2003; 290: 197] JAMA 2003; 289: 2560–72

    Article  PubMed  CAS  Google Scholar 

  66. NHLBI Obesity Education Initial Expert Panel. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Rockville (MD): National Heart, Lung and Blood Institute in cooperation with the National Institutes of Diabetes and Digestive and Kidney Diseases, 1998 Sep. NIH Publication 98-4083

  67. American Diabetes Association. Clinical practice recommendations 2004. Diabetes Care 2004; 27: S1-S145

  68. Murray EW. Smoking cessation clinical practice guideline update: Agency for Healthcare Research and Quality Tobacco Resources. Tobacco Control 2000; 9Suppl. 1: I72–3

    Article  PubMed  Google Scholar 

  69. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999; 99: 2192–217

    Article  PubMed  CAS  Google Scholar 

  70. Berkman LF, Blumenthal J, Burg M, et al. ENhancing Recovery In Coronary Heart Disease (ENRICHD) patients investigators. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the ENhancing Recovery In Coronary Heart Disease patients (ENRICHD) randomized trial. JAMA 2003; 289: 3106–16

    Article  PubMed  Google Scholar 

  71. Franklin BA, Bonzheim K, Gordon S, et al. Safety of medically supervised cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest 1998; 114: 902–6

    Article  PubMed  CAS  Google Scholar 

  72. Mark DB, Lauer MS. Exercise capacity: the prognostic variable that doesn’t get enough respect. Circulation 2003; 108: 1534–6

    Article  PubMed  Google Scholar 

  73. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality of men referred for exercise testing. N Engl J Med 2002; 346: 793–801

    Article  PubMed  Google Scholar 

  74. Kavanagh T, Mertens DJ, Hamm LF, et al. Prediction of long-term prognosis in 12 169 men referred for cardiac rehabilitation. Circulation 2002; 106: 666–71

    Article  PubMed  Google Scholar 

  75. Kavanagh T, Mertens DJ, Hamm LF, et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol 2003; 42: 2139–43

    Article  PubMed  Google Scholar 

  76. Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004; 116: 693–706

    Article  PubMed  Google Scholar 

  77. Levin LA, Perk J. Cardiac rehabilitation: a cost analysis. J Intern Med 1991; 230: 230427-34

    Article  Google Scholar 

  78. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J 1992; 123: 916–21

    Article  PubMed  CAS  Google Scholar 

  79. Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997; 17: 222–31

    Article  PubMed  CAS  Google Scholar 

  80. Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. Am Heart J 2006 Feb; 151(2): 249–56

    Article  PubMed  Google Scholar 

  81. Roblin D, Diseker III RA, Orenstein D, et al. Delivery of outpatient cardiac rehabilitation in a managed care organization. J Cardioplum Rehabil 2004; 24: 157–64

    Article  Google Scholar 

  82. Johnson N, Fisher J, Nagle A, et al. Factors associated with referral to outpatient cardiac rehabilitation services. J Cardiopulm Rehabil 2004 May-Jun; 24(3): 165–70

    Article  PubMed  Google Scholar 

  83. Grace SL, Evindar A, Kung T, et al. Increasing access to cardiac rehabilitation: automatic referral to the program nearest home. J Cardiopulm Rehabil 2004 May-Jun; 24(3): 171–4

    Article  PubMed  Google Scholar 

  84. Scott IA, Lindsay KA, Harden HE. Utilisation of outpatient cardiac rehabilitation in Queensland. Med J Aust 2003 Oct 6; 179(7): 341–5

    PubMed  Google Scholar 

  85. Grace SL, Abbey SE, Shnek ZM, et al. Cardiac rehabilitation II: referral and participation. Gen Hosp Psychiatry 2002 May-Jun; 24(3): 127–34

    Article  PubMed  Google Scholar 

  86. Spencer FA, Salami B, Yarzebski J, et al. Temporal trends and associated factors of inpatient cardiac rehabilitation in patients with acute myocardial infarction: a community-wide perspective. J Cardiopulm Rehabil 2001 Nov-Dec; 21(6): 377–84

    Article  PubMed  CAS  Google Scholar 

  87. Barber K, Stommel M, Kroll J, et al. Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation. J Clin Epidemiol 2001 Oct; 54(10): 1025–30

    Article  PubMed  CAS  Google Scholar 

  88. Blackburn GG, Foody JM, Sprecher DL, et al. Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias. J Cardiopulm Rehabil 2000 May-Jun; 20(3): 189–95

    Article  PubMed  CAS  Google Scholar 

  89. Bittner V, Sanderson B, Breland J, et al. Referral patterns to a University-based cardiac rehabilitation program. Am J Cardiol 1999 Jan 15; 83(2): 252–5, A5

    Article  PubMed  CAS  Google Scholar 

  90. King KM, Humen DP, Teo KK. Cardiac rehabilitation: the forgotten intervention. Can J Cardiol 1999 Sep; 15(9): 979–85

    PubMed  CAS  Google Scholar 

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The authors received no funding to assist with the preparation of this manuscript and have no conflicts of interest directly relevant to its contents.

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  1. Division of Cardiology, II Faculty of Medicine, University of Rome “La Sapienza”, Sant’Andrea Hospital, Via di Grottarossa, 1035-39, 00189, Roma, Italy

    Francesca Giovannelli &  Speranza Rubattu

  2. IRCCS Neuromed, Pozzilli (IS), Italy

    Speranza Rubattu

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  1. Francesca Giovannelli
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  2. Speranza Rubattu
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Correspondence to Speranza Rubattu.

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Giovannelli, F., Rubattu, S. The Role of Cardiac Rehabilitation in the Treatment and Secondary Prevention of Cardiovascular Disease. High Blood Press Cardiovasc Prev 13, 21–27 (2006). https://doi.org/10.2165/00151642-200613010-00004

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