Should I participate in a cardiac rehabilitation program?

Cardiac rehabilitation (CR), or “cardiac rehab,” is a multifaceted, medically supervised program proven to improve heart health and outcomes in people with certain types of cardiovascular disease. CR revolves around three major components: an individualized exercise and training program, education on topics related to heart health, and stress reduction.

CR is currently recommended for the following diagnoses: angina (chest pain); heart attack with or without angioplasty or bypass surgery; heart failure with reduced ejection fraction (HFrEF); and heart surgery including heart valve procedures or heart or heart/lung transplant. Insurance typically covers CR for these conditions, though copayment, duration, and frequency of treatment may vary depending on the insurance plan.

Benefits of cardiac rehabilitation

The benefits of CR are well supported by long-standing evidence that showed a 20% reduction in heart-related death and illness, and a 28% lower risk for hospital admissions. The risk of nonfatal strokes, heart attacks, and worsening of heart failure symptoms were also reduced. Improvements in quality of life, the ability to carry out day-to-day activities, and measures of depression and anxiety have also been established.

Patient satisfaction with CR services is consistently high. And most patients trace positive lifestyle changes to their participation in a CR program.

What should I expect from CR?

CR is an outpatient program that usually takes place in a medical center or hospital-based facility. It typically includes up to 36 sessions over a three-month period. There is a clear benefit for consistent participation in a CR program: research has shown that people attending at least 25 sessions seem to derive clinically significant benefit compared to those who attended fewer than 25 sessions.

Following a referral by your treating physician, who may be a cardiologist, cardiac surgeon, or your primary care physician, you will contact the CR program to schedule your intake visit. An exercise test is often performed prior to starting CR, but it is not absolutely necessary.

The exercise test will help in the planning of your exercise program. Exercise is performed under monitored conditions where your heart rhythm and blood pressure are regularly checked. In addition to supervised exercise, these sessions also include education about heart-healthy lifestyle changes and counseling to relieve stress and anxiety. It is known that depression is often diagnosed following a heart attack and usually negatively impacts prognosis; data have shown that CR participation helps in diagnosis of depression and can help improve symptoms of depression.

During the intake visit, you will meet the entire program staff. This includes a nurse, a physical therapist or exercise physiologist, and a dietitian or nutritionist. Together, your team will develop an individualized treatment plan (ITP), which provides a baseline risk assessment and clear, specific exercise, lifestyle, and educational objectives (such as quitting smoking or controlling anxiety). If necessary, your CR team may suggest additional assessments or referrals, for example, to a sleep apnea specialist or mental health professional.

You’ll participate in two to three sessions per week, and your ITP will be re-evaluated and adjusted as needed every month. For example, your exercise threshold may be increased, or your diet recommendations may be adjusted to include less carbohydrates.

During your final visit, your team will assess your functional improvement, weight loss, smoking status, and improvements in your cholesterol levels and HbA1c (a measure of blood sugar), if you have diabetes.

CR participants are strongly encouraged to continue their exercise routine and new lifestyle habits on their own after “graduating” out of the CR program.

What if my doctor doesn’t refer me for cardiac rehabilitation?

Despite the proven benefits of CR, only approximately one in five eligible patients participates in a CR program. If you are eligible for CR — if you have been treated for a heart attack, have received a coronary stent, or have undergone cardiac surgery such as a bypass or valve procedure — make sure you talk to your doctor about the role that cardiac rehabilitation could play in your recovery.

Your cardiac surgeon might recommend waiting four weeks before you start exercising. While it is important to follow that recommendation, you can initiate the paperwork and enrollment process before then, so you’re ready to start your CR program as soon as you are cleared by your surgeon.

What about home-based CR?

The American Heart Association (AHA), American College of Cardiology (ACC), and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recently released a statement about home-based CR. Based on the data, they stated that for appropriate, low- to moderate-risk patients, home-based CR is equivalent to center-based programs. Carefully selecting appropriate candidates reduces the risk of at-home CR, which involves an unsupervised exercise component. At this time, only a few programs offer a home-based option, and those that do often require that initial risk assessment and development of an ITP happen at a medical center.

In the coming months and years, the development and spread of mobile technologies will allow remote monitoring and guidance of exercise and education sessions. Eligible patients will be able to communicate and do their cardiac rehab on their own schedule, without having to miss work or arrange for transportation. CR staff will be able to reach a larger group of patients, and home-based programs are likely to enroll an increasing number of patients.

Related Information: Harvard Heart Letter

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