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A Review of Guidelines for Cardiac Rehabilitation Exercise Programmes: Is There an International Consensus?

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A Review of Guidelines for Cardiac Rehabilitation Exercise Programmes: Is There an International Consensus? EU RO PEAN SOCIETY OF Review CARDIOLOGY ® European Journal of Preventive Cardiology 0(00) 1–19 A review of guidelines for cardiac ! The European Society of Cardiology 2016 rehabilitation exercise programmes: Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Is there an international consensus? DOI: 10.1177/2047487316657669 ejpc.sagepub.com Kym Joanne Price1, Brett Ashley Gordon1,2, Stephen Richard Bird1 and Amanda Clare Benson1 Abstract Background: Cardiac rehabilitation is an important component in the continuum of care for individuals with cardio- vascular disease, providing a multidisciplinary education and exercise programme to improve morbidity and mortality risk. Internationally, cardiac rehabilitation programmes are implemented through various models. This review compared cardiac rehabilitation guidelines in order to identify any differences and/or consensus in exercise testing, prescription and monitoring. Methods: Guidelines, position statements and policy documents for cardiac rehabilitation, available internationally in the English 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 from moderate- to vigorous-intensity aerobic endurance exercise over the course of the programme, with resistance training included as an important adjunct, for maintaining independence and quality of life. North American and European guidelines also recommend electrocardiograph-monitored exercise stress tests. Guidelines for South America and individual 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 recom- mended and deemed safe for cardiac rehabilitation patients by many authorities. Based on research evidence, this may also provide superior outcomes for patients and should therefore be considered when developing an international consensus for exercise prescription in cardiac rehabilitation. Keywords Cardiac rehabilitation, cardiovascular disease, guidelines, exercise therapy, exercise test, exercise Received 15 December 2015; accepted 11 June 2016 Introduction the ability of the patient to preserve or resume an active Cardiovascular disease (CVD) is a leading contributor and functional contribution to the community.6,7 to global mortality and morbidity. Internationally, it is Cardiac rehabilitation promotes a healthy and active the cause of approximately a third of total yearly deaths,1 with mortality rates in high-income countries 1Discipline of Exercise Sciences, School of Health and Biomedical ranging from 20% to 50%.2,3 CVD is responsible for 1 Sciences, RMIT University, Melbourne, Victoria, Australia approximately 20% of the worldwide disease burden. 2Discipline of Exercise Physiology, La Trobe Rural Health School, La Cardiac rehabilitation promotes secondary preven- Trobe University, Bendigo, Victoria, Australia tion of CVD and is an essential component of care for all cardiac patients.4,5 It is a coordinated physical, Corresponding author: Kym Joanne Price, Discipline of Exercise Sciences, School of Health and social and psychological intervention that favourably Biomedical Sciences, RMIT University, PO Box 71, Bundoora, Victoria influences the underlying risk factors in order to stabil- 3083, Australia. ise, slow or reverse disease progression, and facilitates Email: [email protected] Downloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016 2 European Journal of Preventive Cardiology 0(00) lifestyle, with the aim of improving quality of life rehabilitation’’, ‘‘guidelines’’, ‘‘policy’’ and ‘‘position through: increased cardiac function; increased exercise statement’’ were combined and searched alone and by tolerance; decreased cardiovascular symptoms; reduced country. Government and cardiology society websites levels of anxiety, depression and stress; return to work; for countries that were known to have cardiac rehabili- and maintaining independence in activities of daily tation services were also examined, along with reference living.5,6,8 Structured exercise has been identified as lists of identified guidelines and review articles. Only being central to the success of cardiac rehabilitation.9–11 those guidelines, position statements and policy docu- Strong, consistent positive evidence exists for exer- ments available in English were included. Only resist- cise-based cardiac rehabilitation for patients with stable ance training recommendations for Germany have been angina pectoris,7,10 myocardial infarction (MI)7,10,12 published in English; however, guidelines covering all and coronary revascularisation.7,10 Cardiac rehabilita- aspects of cardiac rehabilitation have been translated tion is also recommended for patients who have under- and summarised in a review article published by gone heart transplant13 or valvular surgery,14 in Karoff et al.,17 and the information presented was uti- addition to those suffering chronic heart failure.15 lised in the current review. Where non-English- Meta-analyses have shown significant reductions in language guidelines or position statements were both all-cause and cardiac mortality from exercise- located, the authors were contacted to confirm that based rehabilitation compared to standard medical an English version was not available. Document ana- care without structured exercise training or advice, lyses of the guidelines, position statements and policy with the reduction associated with long-term rather documents were undertaken to extract the relevant than short-term follow-up.7,12 Exercise-based cardiac information for this review. rehabilitation results in a significantly lower risk of fatal and non-fatal re-infarction through improved car- Results diac and coronary vascular function, as well as improved CVD risk factor profiles when compared to Guidelines, position statements and policy documents cardiac rehabilitation without an exercise component.12 for outpatient cardiac rehabilitation from 18 individual Cardiac rehabilitation services exist in fewer than countries or regions were identified in the English lan- 40% of countries throughout the world, with pro- guage and included for review. The American Heart grammes available in 68% of the countries defined as Association (AHA) and the American Association of high income by the World Bank.8 This figure falls to Cardiovascular and Pulmonary Rehabilitation only 22% in low- and middle-income countries, where (AACVPR) have issued a joint scientific statement the majority of deaths due to CVD occur.16 The density detailing the core components of cardiac rehabilitation of cardiac rehabilitation programmes varies from the programmes,18 with more comprehensive guidelines equivalent of one programme for every 0.1 million having been published by the AACVPR (with AHA inhabitants in the United States (US)8 to one pro- endorsement).19 The Canadian Association of Cardiac gramme for every 2.2 million inhabitants throughout Rehabilitation (CACR) have also developed detailed Latin America16 and one programme for 164 million guidelines.20 A position statement has been prepared inhabitants in Bangladesh, where there is a single facil- by the European Association of Cardiovascular ity to service the entire population.8 Guidelines for the Prevention and Rehabilitation (EACPR),21 with several provision of cardiac rehabilitation have not been estab- individual European countries also producing their lished in many of the nations providing this service. own guidelines. In the Australasian region, Australia The purpose of this review is to compare national and New Zealand each have their own guidelines, pre- guidelines for outpatient cardiac rehabilitation from pared by the respective National Heart Foundations, in around the world alongside those prepared by leading conjunction with the Australian Cardiovascular cardiovascular scientific societies, and provide insight Health and Rehabilitation Association (ACRA) in into any differences and/or consensus in patient eligi- Australia.22–24 A joint position statement by the bility, programme delivery and exercise testing, pre- South American Society of Cardiology and the Inter- scription and monitoring that exist. American Committee on Cardiovascular Prevention encompasses the whole of South America.25 In Asia, Methods English-language cardiac rehabilitation guidelines have only been published in Japan. The World Health National guidelines, position statements and policy Organization (WHO) Expert Committee on documents for exercise-based outpatient cardiac Rehabilitation after Cardiovascular Diseases prepared rehabilitation were searched from the earliest date guidelines for the provision of cardiac rehabilitation in available to July 2015 using PubMed and Google 1993.4 This document has an emphasis on developing Scholar databases. The search terms ‘‘cardiac countries, but still contains information that is relevant Downloaded from cpr.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on June 27, 2016 Price et al. 3 to high-income countries. Published guidelines were supervised, depending on their assessed level of risk also located
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