Key Facts

Cardiac rehabilitation (CR) is a comprehensive, evidence-based programme of exercise, education, risk factor modification, and psychological support designed to improve outcomes and quality of life after cardiac events or procedures.

Epidemiology

• ~350,000 eligible patients per year in the UK
• Uptake: ~50% of eligible patients (improving but still suboptimal)
• Lower participation among women (~40%), elderly, ethnic minorities, and socioeconomically deprived populations
• NACR (National Audit of Cardiac Rehabilitation) monitors outcomes and quality

Indications (NICE CG172)

• Post-MI (STEMI/NSTEMI)
• Post-PCI
• Post-CABG
• Stable angina
• Heart failure (HFrEF and HFpEF)
• Post-cardiac surgery (valve replacement)
• Post-ICD/CRT implantation
• Post-cardiac transplant
• Stable PAD

Who Should Be Referred

• All patients after acute coronary syndrome (STEMI, NSTEMI, UA)
• All patients after coronary revascularisation (PCI, CABG)
• All patients with heart failure
• Patients with stable angina
• Post-cardiac surgery patients
• Post-cardiac device implantation

Assessment Before Starting CR

• Exercise tolerance assessment (functional capacity)
• Cardiovascular risk factor assessment
• Psychological screening (anxiety, depression — PHQ-9, GAD-7)
• Medication review
• Comorbidity assessment
• Goal setting with patient

Barriers to Participation

• Lack of awareness/referral
• Transport difficulties
• Work commitments
• Comorbidities (musculoskeletal, respiratory)
• Psychological factors: anxiety about exercise, depression
• Cultural and language barriers
• Perceived lack of benefit

Pre-CR Assessment

• 12-lead ECG: baseline rhythm, evidence of ischaemia
• Exercise tolerance test (or 6MWT/ISWT): assess functional capacity, exercise prescription
• Echocardiography: LV function (important for exercise prescription in HF)
• Blood pressure: resting and exercise response
• Blood glucose/HbA1c: diabetes management
• Lipid profile: cardiovascular risk
• PHQ-9/GAD-7: psychological screening
• EQ-5D or Dartmouth COOP: quality of life baseline

Outcome Measures (NACR Standards)

• Exercise capacity (ISWT, 6MWT, or VO₂ max)
• Physical activity levels
• Smoking status
• BMI
• Blood pressure
• Cholesterol
• HbA1c
• Psychological wellbeing (PHQ-9, GAD-7)
• Medication adherence

Phase 1: Inpatient (Days 1-5)

• Early mobilisation after acute event
• Education: cardiac event understanding, medication, risk factors
• Psychological support: reassurance, screen for distress
• Discharge planning: referral to Phase 2/3

Phase 2: Early Post-Discharge (Weeks 1-6)

• Telephone/home visit follow-up
• Ongoing education and psychological support
• Heart Manual (home-based CR): evidence-based self-management programme
• Gradual increase in physical activity
• Medication optimisation
• Smoking cessation support

Phase 3: Structured Outpatient Programme (Weeks 6-12+)

• Supervised exercise training: 2-3 sessions/week for 6-12 weeks
  • Moderate intensity aerobic: 60-80% peak heart rate or RPE 12-15 (Borg scale)
  • Duration: 20-60 minutes per session
  • Modes: walking, cycling, circuit training, resistance exercises
• Education: diet (Mediterranean), weight management, stress management, sexual activity advice
• Psychological support: CBT for anxiety/depression, relaxation techniques, peer support
• Risk factor management: BP, lipids, diabetes, smoking cessation
• Medication review: optimisation of secondary prevention medications
• Return to work advice
• Driving advice (per DVLA regulations)

Phase 4: Long-Term Maintenance

• Community exercise programmes
• Self-management
• Ongoing risk factor monitoring
• Annual cardiovascular review
• Support groups

Pharmacological (Optimised During CR)

• Dual antiplatelet therapy (post-ACS)
• High-intensity statin
• Beta-blocker
• ACEi/ARB
• MRA (if HF)
• SGLT2 inhibitor (if HF or diabetes)

Referral Criteria

• All eligible patients: automatic referral at discharge or clinic
• Heart failure: referral to HF-specific CR programmes (exercise training in HFrEF: ExTraMATCH meta-analysis)
• High-risk patients: supervised setting with monitoring
• Home-based CR: for patients unable/unwilling to attend centre-based programme

• CR reduces cardiovascular mortality by ~25% (Cochrane meta-analysis)
• Reduces hospital readmissions by ~18-25%
• Improves exercise capacity by ~15-25%
• Improves quality of life (EQ-5D improvement)
• Psychological benefits: reduces anxiety and depression scores by 20-30%
• Smoking cessation rates: ~40-50% with CR support
• Cost-effective: estimated £2,000-3,000 per QALY gained
• Benefits maintained if long-term lifestyle changes sustained

BACPR Core Components of CR

Exercise Prescription in CR