Table 2.
Cardiac rehabilitation recommendations in international guidelines for CHD and HF
| Region (society) | Recommendations for rehabilitation | Class of recommendation | Level of evidence | Comments | Ref. |
|---|---|---|---|---|---|
| CHDa | |||||
| USA (AHA/ACC) | All eligible patients with ACS or whose status is immediately post-coronary artery bypass surgery or post-PCI should be referred to a comprehensive outpatient cardiovascular rehabilitation programme either before hospital discharge or during the first follow-up office visit | I | A | A home-based cardiac rehabilitation programme can be substituted for a supervised, centre-based programme for low-risk patients | 32 |
| All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery or PCI and/or peripheral artery disease within the past year should be referred to a comprehensive outpatient cardiovascular rehabilitation programme | I | A | |||
| All eligible outpatients with the diagnosis of chronic angina within the past year should be referred to a comprehensive outpatient cardiovascular rehabilitation programme | I | B | |||
| UK (NICEb) | All individuals after a myocardial infarction should be given advice and offered a cardiac rehabilitation programme with an exercise component | NA | NA | NA | 34 |
| Programmes should include physical activity (adapted to clinical condition and ability), lifestyle advice (including advice on driving, flying and sexual activity), stress management and health education | NA | NA | |||
| Australia and New Zealand (NHFA and CSANZ) | Attendance at cardiac rehabilitation or a structured secondary prevention service for all patients hospitalized with ACS | I | A | Individualization of cardiac rehabilitation or secondary prevention service referral. A wide variety of prevention programmes improve health outcomes in patients with coronary disease. After discharge from hospital, patients with ACS and, where appropriate, their companions should be referred to an individualized preventive intervention according to their personal preference and values and the available resources. Services can be based in the hospital, primary care, the local community or the home | 36 |
| Europe (ESC) | Exercise-based cardiac rehabilitation is recommended in patients with chronic coronary syndrome. For full details, see 10.1093/eurheartj/ehz425 | I | A | Benefits of cardiac rehabilitation occur both after an acute myocardial infarction and after revascularization | 30 |
| HFc | |||||
| USA (AHA/ACC) | Exercise training (or regular physical activity) is safe and effective for patients with HF who are able to participate to improve functional status | I | A | NA | 33 |
| Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL and mortality | IIa | B | |||
| UK (NICEb) | Recommends offering individuals with HF a personalized, exercise-based cardiac rehabilitation programme, unless their condition is unstable | NA | NA | Emphasis on specificity of, and improving access to, rehabilitation for the patients, including offering choice of venue for rehabilitation, delivering a comprehensive programme and being sensitive to the needs of the individual | 35 |
| The programme should be preceded by an assessment to ensure that it is suitable for the person, provided in a format and setting (at home, in the community or in the hospital) that is easily accessible for the person, include a psychological and educational component, may be incorporated within an existing cardiac rehabilitation programme and should be accompanied by information about support available from health-care professionals when the individual is participating in the programme | NA | NA | |||
| Australia and New Zealand (NHFA and CSANZ) | Regular performance of moderate intensity (that is, breathing more quickly but able to hold a conversation) continuous exercise is undertaken by patients with stable chronic HF, particularly in those with reduced LVEF, to improve physical functioning and quality of life, and to reduce hospitalizations | Strong | High | Exercise studies in HF have been largely conducted in patients with HFrEF aged <70 years. However, evidence has emerged for the benefits of exercise training in patients with HFpEF, which is more prevalent in older patients with HF and in women | 37 |
| Europe (ESC) | Regular aerobic exercise is encouraged in patients with HF. For full details, see: 10.1093/eurheartj/ehw128 | I | A | Most of the evidence available in the Cochrane review is from patients with HFrEF | 31 |
ACS, acute coronary syndrome; CCS, chronic coronary syndrome; CHD, coronary heart disease; CSANZ, Cardiac Society of Australia and New Zealand; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-related quality of life; LVEF, left ventricular ejection fraction; NHFA, National Heart Foundation of Australia; NICE, National Institute for Health and Care Excellence; PCI, percutaneous coronary intervention. aIncludes ACS, acute myocardial infraction, post-revascularization, stable angina and PCI. bUnlike other guidelines, evidence informing the UK NICE guidance is assessed based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and the class/level approach is not used. cIncludes HFrEF and HFpEF. AHA/ACC guidelines adapted with permission from refs32,33, Elsevier. NICE guidelines adapted with permission from refs34,35, NICE. NHFA/CSANZ guidelines adapted with permission from refs36,37, Wiley.