According to the World Heart Federation website, World Heart Day 2015 focused on creating healthy heart environments by ensuring that everyone has the chance to make healthy heart choices. One of these choices is cardiac rehabilitation (CR) and secondary prevention.
Cardiovascular diseases are the number one cause of mortality and morbidity worldwide.[1] The main reason of the decrease in mortality due to coronary artery disease is not just the advances in treatment of the acute coronary syndromes, but the advances in the secondary prevention methods as well. CR program is a cost-effective secondary prevention strategy used as an important part of treatment of cardiovascular diseases.[2] The benefits of CR include reduction in mortality, symptom relief, smoking cessation, improved physical fitness, risk factor modification, and improved overall psychosocial well-being.[3] The main key to CR effectiveness lies in its complete attendance by patients, usually consisting of a 24-session protocol, including hospital or home-based exercise, education, and social and emotional support.[4] In the Netherlands CR is a comprehensive multidisciplinary program with a typical duration of 6-12 weeks (2 or 3 sessions in the week), consisting of one or more group-based therapies (education, exercise training, relaxation therapy, and lifestyle modification therapy) supplemented by individual counseling when indicated (e.g., by a psychologist, a dietician, or a social worker).[3] According to the American Heart Association, CR sessions are limited to a maximum of two 1 h sessions per day up to 36 sessions furnished over a period of up to 36 weeks with the option for an additional 36 sessions and CR programs to include five components: Physician-prescribed exercise, cardiac risk factor modification (education, counseling, and behavioral intervention), psychosocial assessment, outcomes assessment, and individualized treatment plan.[5]
Incomplete participating in CR sessions may lead to the recurrence of cardiac events and its related rehospitalization, increased need for more medication, decreased quality of life, and an increased risk of comorbidity and even mortality. Last studies shows that participation in incomplete CR programs (24 sessions) is necessary to achieve optimal improvement in vital indices such as metabolic equivalents and resting heart rate and, therefore, incomplete CR sessions may not warrant this efficacy.[6] Despite its proven benefits, CR referral and participation rates have been very low compared with other evidence-based treatments.[7] In Iran, the lack of accessibility to program sites and lack of insurance coverage contributes to the vast underuse of CR services.[8] While the majority of insurance companies in the USA cover complete CR for cardiovascular patients,[9] major insurance companies in Iran cover only 70% of 10 sessions of hospital-based CR and patients pay the costs for the remaining sessions; a very small number of patients have complementary insurance that cover all rehabilitation sessions. One of the most inhibitive factors for participation of patients in these courses could be elimination by reviewing of insurance policies in the rehabilitation area and for all patients to have an opportunity for participating in these actions.
The importance of comprehensive CR should be strengthened in the future, because of the continuous changes in the population, the increasingly favorable effects obtainable by strict secondary prevention follow-up, and the increasing demand for a better quality of life in the modern society.[10]
REFERENCES
- 1.Mendis S, Alwan A, editors. Geneva: World Health Organization; 2011. Prioritized research agenda for prevention and control of noncommunicable diseases; pp. 1–50. [Google Scholar]
- 2.Basati F, Sadeghi M, Kargarfard M, Golabchi A, Yazdekhasti S. Effects of a cardiac rehabilitation program on systolic function and left ventricular mass in patients after myocardial infarction and revascularization. J Res Med Sci. 2012;17:S28–32. [Google Scholar]
- 3.Golabchi A, Basati F, Kargarfard M, Sadeghi M. Can cardiac rehabilitation programs improve functional capacity and left ventricular diastolic function in patients with mechanical reperfusion after ST elevation myocardial infarction. A double-blind clinical trial? ARYA Atheroscler. 2012;8:125–9. [PMC free article] [PubMed] [Google Scholar]
- 4.Suaya JA, Shepard DS, Normand ST, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116:1653–62. doi: 10.1161/CIRCULATIONAHA.107.701466. [DOI] [PubMed] [Google Scholar]
- 5.Hills LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;12:123–210. [Google Scholar]
- 6.Sarafzadeh J, Nejatian M, Saeb NS. The necessity for a complete cardiac rehabilitation program to achieve better improvement in physical function and cardiac parameters. J Cardiovasc Thorac Res. 2009;1:23–7. [Google Scholar]
- 7.Moradi B, Maleki M, Esmaeilzadeh M, Abkenar HB. Physician-related factors affecting cardiac rehabilitation referral. J Tehran Heart Cent. 2011;6:187–92. [PMC free article] [PubMed] [Google Scholar]
- 8.Leon AS, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, et al. ; American Heart Association; Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention); Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity); American association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation and secondary prevention of coronary heart disease: An American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111:369–76. doi: 10.1161/01.CIR.0000151788.08740.5C. [DOI] [PubMed] [Google Scholar]
- 9.Thirapatarapong W, Thomas RJ, Pack Q, Sharma S, Squires RW. Commercial insurance coverage for outpatient cardiac rehabilitation in patients with heart failure in the United States. J Cardiopulm Rehabil Prev. 2014;34:386–9. doi: 10.1097/HCR.0000000000000060. [DOI] [PubMed] [Google Scholar]
- 10.Mampuya WM. Cardiac rehabilitation past, present and future: An overview. Cardiovasc Diagn Ther. 2012;2:38–49. doi: 10.3978/j.issn.2223-3652.2012.01.02. [DOI] [PMC free article] [PubMed] [Google Scholar]