Cardiac Rehabilitation
Structured programme of exercise, education, and psychological support for patients recovering from cardiac events or procedures. Reduces cardiovascular mortality and hospital readmissions.
Key Facts
- Reduces cardiovascular mortality by ~25% and hospital readmissions by ~18-25% (Cochrane meta-analysis)
- NICE CG172: all patients should be offered cardiac rehabilitation after MI, CABG, PCI, heart failure, and stable angina
- Four phases: Phase 1 (inpatient), Phase 2 (early post-discharge), Phase 3 (structured outpatient programme), Phase 4 (long-term maintenance)
- Components: supervised exercise training, cardiovascular risk education, dietary advice, smoking cessation, psychological support, medication optimisation
- BACPR (British Association for Cardiovascular Prevention and Rehabilitation) sets standards for CR in the UK
- Uptake remains poor: only ~50% of eligible patients in the UK participate; lower in women, elderly, ethnic minorities
- Home-based CR: equivalent outcomes to centre-based (BRUM trial); improves access and uptake
- Exercise prescription: individualised, typically moderate intensity aerobic (60-80% max HR) + resistance training, 2-3 sessions/week for 6-12 weeks
Overview
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
Clinical Presentation
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
Differential Diagnosis
| Programme | Features | Suitability |
|---|---|---|
| Centre-based CR | Supervised, group, hospital/community | Standard; social support benefits |
| Home-based CR | Self-directed with support (Heart Manual, Activate Your Heart) | If centre-based unsuitable; equivalent outcomes |
| Digital/remote CR | App-based, telehealth monitoring | Emerging; COVID-19 accelerated adoption |
| Exercise-only programme | Supervised exercise without full CR components | Inferior to comprehensive CR |
Diagnosis / Investigation
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
Management
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
Prognosis
- 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
Other Relevant Information
BACPR Core Components of CR
| Component | Detail |
|---|---|
| Health behaviour change | Smoking, diet, physical activity, alcohol |
| Lifestyle risk factor management | BP, lipids, weight, diabetes |
| Psychosocial health | Anxiety, depression, stress management, return to work |
| Medical risk management | Medication optimisation, adherence |
| Long-term management | Self-management, maintenance strategies |
| Audit and evaluation | Outcome measurement, quality improvement |
Exercise Prescription in CR
| Parameter | Recommendation |
|---|---|
| Frequency | 2-3 sessions/week |
| Intensity | 60-80% peak HR or RPE 12-15 |
| Duration | 20-60 min per session |
| Type | Aerobic (walking, cycling) + resistance |
| Programme duration | 6-12 weeks (Phase 3) |
| Progression | Gradual, individualised |