1.1 Remit and definitions

This guideline provides evidence-based recommendations for best practice in cardiac rehabilitation. It is primarily concerned with rehabilitation following myocardial infarction (MI) or coronary revascularisation, but also addresses the rehabilitation needs of patients with angina or heart failure. Cardiac rehabilitation has much in common with secondary prevention. To appreciate the difference, it may be considered that cardiac rehabilitation facilitates recovery whereas secondary prevention prevents further illness. This guideline complements the existing SIGN guidelines on secondary prevention following MI,¹ stable angina,² and heart failure.³

There are many definitions of cardiac rehabilitation.^4,5 The guideline development group felt that the following definition contained the key elements of cardiac rehabilitation: Cardiac rehabilitation is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health. The involvement of partners, other family members and carers is also important.

This guideline will be of interest to patients, general practitioners, cardiologists, physicians, primary and secondary care nurses, physiotherapists, physiologists, clinical psychologists, dietitians, occupational therapists, health service managers, and other health care professionals working with patients with cardiac disease.

1.2 The four phases of cardiac rehabilitation

It is useful to consider four phases of cardiac rehabilitation as each represents a different component of the journey of care: inpatient care, the early post discharge period, exercise training, and finally long term follow up. Some countries recognise three phases only, by calling the early post discharge period Phase 2A and exercise training Phase 2B. Common to each phase, and irrespective of which model of cardiac rehabilitation is chosen, is the need to tailor interventions to the individual and the importance of good communication with specialist cardiac services, primary and community care. There is evidence that treatment plans are not carried out in the community because doctors and nurses wait for patients to consult. A proactive approach to patient participation and monitoring is therefore recommended.

Phase 1 occurs during the inpatient stage or after a 'step change' in the patient's cardiac condition (defined as any myocardial infarction, onset of angina, any emergency hospital admission for coronary heart disease (CHD), cardiac surgery or angioplasty, or first diagnosis of heart failure). During this phase medical evaluation, reassurance and education, correction of cardiac misconceptions, risk factor assessment, mobilisation and discharge planning are the key elements.⁶ It is customary to involve family and partners from this early stage. A nurse counsellor can improve both the patient's and the partner's knowledge of heart disease and reduce anxiety and depression compared with those receiving routine care.⁷

Phase 2 is the early post discharge period, a time when many patients feel isolated and insecure. Support can be provided by home visiting, telephone contact,^{8,9,10,11,12,13} and by supervised use of the Heart Manual.¹⁴ This manual is a self-help programme for patients recovering from a heart attack that has been shown to reduce anxiety, depression and hospital readmission rate.

Phase 3 has historically taken the form of a structured exercise programme in a hospital setting with educational and psychological support and advice on risk factors. Increasingly it is recognised that both components can be undertaken safely and successfully in the community.^15,16 A menu-based approach recognises the need to tailor the delivery of services to the individual,^6,7 and is likely to include specific education to reduce cardiac misconceptions and encourage smoking cessation and weight management; vocational rehabilitation to assist return to work or retirement; and referral to a psychologist, cardiologist, or exercise physiologist.

Phase 4 involves the long term maintenance of physical activity and lifestyle change. Available evidence suggests that both must be sustained for benefits to continue.^17,18 Membership of a local cardiac support group, which involves exercise in a community centre such as a gym or leisure centre, may help maintain physical activity and behavioural change.

1.3 The need for a guideline

Compared with the rest of the UK, Scotland has a disproportionately high incidence and prevalence of CHD.¹⁹ Every year, the estimated 8,000 Scots surviving a myocardial infarction, 13,000 angina patients requiring admission to hospital, and 6,000 patients who undergo coronary bypass surgery or angioplasty are potential candidates for cardiac rehabilitation. Around 6,000 patients with heart failure may also be eligible.²⁰ Some patients, for example those who experience a myocardial infarction and then go on to be revascularised, may require cardiac rehabilitation on more than one occasion.

1.4 Current provision

The provision of exercise-based cardiac rehabilitation in the UK has increased since a British Cardiac Society Working Party Report showed just 99 programmes in 1989.²¹ 151 programmes were identified in 1992,²² 273 in 1996,²³ and most recently 300 in 1997.²⁴ Unfortunately, the growth in quantity has not been matched by improvements in quality. Programmes tend to be inadequately resourced and do not adhere to national guidelines.²⁵ A survey of Scottish outpatient cardiac rehabilitation programmes in 1994 found that although most offered exercise, relaxation and education, only a small proportion did so in a manner likely to reproduce the benefits found in randomised trials.²⁶ Later surveys suggest that the measurement of exercise, psychological and quality of life parameters remains patchy,²⁴ and that psychosocial factors are still poorly assessed.²³

The CHD Task Force identified 44 secondary care cardiac rehabilitation programmes in Scotland during the year 2000.²⁷ Two thirds of Phase 3 programmes were hospital-based at that time. One half used the Heart Manual either alone or in combination with Phase 3 exercise. 71% of patients attending a Phase 3 programme had survived a myocardial infarction, while 20% were post coronary bypass. Only small numbers of angioplasty, angina or heart failure patients attended such programmes. Median values for duration and frequency of exercise programmes were 11 weeks and twice per week respectively. Education programmes were often provided at separate times from exercise classes, depending on facilities available and lasted a median of six weeks. Most programmes offered psychological interventions, but only 16% had access to a clinical psychologist. 83% of programmes were co-ordinated by nurses and physiotherapists.

1.5 Uptake

Although beneficial outcomes from cardiac rehabilitation can be expected in most of these patients, only a minority participate.²⁸ A recent UK survey found that 14-23% of infarct patients, 33-56% of coronary bypass patients, and 6-10% of angioplasty patients were enrolled into cardiac rehabilitation programmes.²⁹ Reported rates of uptake of cardiac rehabilitation nevertheless underestimate the true level of activity because inpatient rehabilitation and the contribution made by home-based programmes such as the Heart Manual are not included in the figures.³⁰ The shortfall in Phase 3 uptake relates to ease of access to services.³¹ Women and elderly patients are less likely to be invited to attend cardiac rehabilitation programmes.^32,33,34 Uptake and completion of Phase 3 cardiac rehabilitation is also predicted by social deprivation,²⁸ level of education³³ and negative attitudes towards rehabilitation from partner and family.³⁵ The provision of outreach classes in health and community centres is likely to increase uptake in rural areas.³⁶

1.6 Review and updating

This guideline was issued in January 2002 and will be considered for review in 2005, or sooner if new evidence becomes available. Any updates to the guideline will be noted on the SIGN website: http://www.sign.ac.uk.