In the long term, most people with cardiac disease receive most or all of their care in primary care and the community. Once the process of short term recovery is complete, the emphasis of cardiac rehabilitation shifts to long term maintenance of physical activity and lifestyle change, with appropriate secondary prophylactic drug therapy. The boundaries between cardiac rehabilitation, secondary prevention and normal medical care are blurred. The overall aim is comprehensive cardiac care.

Although many patients make good recoveries, others have substantially impaired health.^176,177 People with coronary disease require frequent admissions to hospital^177,181 and have a high rate of infarction or reinfarction.^{178,179,180,181} A healthy lifestyle can reduce substantially the risk of further coronary events^1,2 but is difficult to achieve and maintain.^{147,156,182,183} Drug treatment is effective but uptake and compliance are often suboptimal.¹⁸⁴ Recommendations on lifestyle modification and secondary drug treatment from the SIGN guidelines on secondary prevention following MI¹ and stable angina² are summarised in Table 2. The recently completed Heart Protection Study seems likely to extend the indications for statin therapy to all patients with coronary disease irrespective of their serum cholesterol.¹⁸⁵

Table 2: Lifestyle modification and drug therapy for secondary prevention of CHD

5.1 Transition to primary care

The main responsibility for long term follow up in coronary disease lies with the individual and is facilitated by primary care. For patients who have been treated in hospital, care is transferred from secondary to primary care when it is evolving and complex. It also needs to be flexible and tailored to individual needs. There is plenty of opportunity for aspects of care to get lost during transfer, and plenty of evidence that this happens in practice.¹⁸³ Although there is little direct evidence about how best this transition can be improved,^190,191 good communication appears to be an essential first step.¹⁸⁶ In particular, tailored information should be provided with details of treatment and cardiac rehabilitation to date, ongoing monitoring required, and future treatment planned.

5.2 Follow up in primary care

A systematic review of 12 randomised trials of secondary prevention programmes in coronary heart disease found that structured disease management programmes improved risk factor profiles and increased secondary preventive treatment.¹⁸⁷ They also reduced hospital admissions and enhanced quality of life. Evidence level 1+

The programmes included in this review differed considerably - all were multi-faceted, with about half including medical and lifestyle treatments, and the rest being predominantly lifestyle and psychosocial. Most were based from hospitals, but two conducted in UK primary care suggest that a structured approach benefits health related quality of life and uptake of secondary prevention. Evidence level 1+

In the first study in Belfast, health visitors were trained to give health education on diet, exercise and smoking and how to monitor blood pressure levels.^17,156,157 After two years, they reported significantly more physical activity and better diet in the intervention group, but no changes in smoking, blood pressure or lipids. Participants reported less angina and scored better for physical mobility on the Nottingham Health Profile. Total mortality was reduced in the intervention group. However, three years after the intervention finished most of the benefits that had been present at two years had disappeared.¹⁷ Evidence level 1+

In the second study, in Grampian, nurse-led secondary prevention clinics were used to promote medical and lifestyle components of secondary prevention.^177,188 At one year, significantly more patients took aspirin, had better blood pressure treatment and lipid treatment, were moderately physically active and had low fat diets; but there were no differences in smoking. The clinics improved patients' health related quality of life, especially physical and functioning aspects (where they scored particularly poorly at baseline) and fewer patients required hospital admission. Evidence level 1+

In a third study, nurse-led clinics were compared to GP recall and audit with feedback.¹⁸⁹ Secondary prevention improved in all three groups and was best in the nurse-led group for aspirin prescribing. Two other interventions have been tested: cardiac liaison nurses¹⁹⁰ and postal prompts to patients and their GPs.¹⁹¹ Although the former increased follow up in primary care, neither showed benefit to secondary preventive drug prescribing or risk factors. These trials emphasise that structured follow up in primary care must be coupled to appropriate drug prescribing. Evidence level 1+

Structured care and follow up in primary care should be provided for patients with coronary heart disease.

5.3 Shared care

There is some evidence that patients with more complicated heart disease benefit from hospital-based clinics or a shared care approach. Comprehensive heart failure disease management clinics have been found to improve quality of life, functional capacity, patient satisfaction and compliance with medications, and to reduce hospital admissions in patients with heart failure.¹⁶⁰ These clinics were run in secondary care by staff with high levels of expertise. There is evidence from one RCT that similar benefits were not achieved by increasing less specialist follow up in primary care.¹⁹² However, all of these studies were conducted overseas, and more research is needed in the United Kingdom. Evidence level 1+

There are also benefits to patients with angina from courses of intensive and specialist hospital-based interventions. In particular, symptoms in patients with angina can be improved.⁷³ Hospital-based or shared care programmes for patients awaiting coronary revascularisation have been shown to reduce risk factors, improve quality of life, and shorten length of stay in hospital. ^73,155,193 Evidence level 1+

Coronary heart disease patients with limiting symptoms or awaiting coronary revascularisation should be considered for further comprehensive cardiac rehabilitation.

5.4 Self-help groups

In Scotland, there is a long history of self-help groups for patients with cardiac disease. Nineteen self-help groups were identified in 1994, located in sports and community centres, schools and universities, hospitals and church halls, and providing care following hospital-based programmes.^30,194 In 2001, there were over 30 cardiac support groups in Scotland.¹⁹⁵ The structure and content of programmes varied widely and included exercise sessions, relaxation sessions, invited speakers, and group discussions. Many of the exercise programmes were professionally supervised by physiotherapists, nurses, or fitness instructors; but none were equipped with defibrillators. Evidence level 3

There is no direct evidence about the effectiveness of self-help groups in cardiac rehabilitation. An important aspect of self help groups is the interaction between people and the opportunity to share experiences. Many patients value this, although others strongly dislike the idea.³⁰ Indirect evidence about group interaction from professionally-led programmes is mixed: some studies reported improvements in psychosocial functioning and others deterioration.^{75,196,197,198,199,200} Self help groups depend entirely on the small numbers of dedicated people who organise them and the enthusiasm of their members. Their main limitation is that only a minority of patients with coronary disease attend them. Evidence level 2+, 3, 4

Self help groups should be encouraged and enabled to use the same evidence-based approach to cardiac rehabilitation advocated for professionally led programmes.

5.5 Long term exercise programmes

Meta analysis of exercise-based cardiac rehabilitation trials has shown that the greatest benefit is associated with exercising for 12 weeks or longer.¹³⁵ If the benefits of exercise are to be sustained, moderate physical activity should continue long term, but this proves difficult for most people with coronary disease once supervision is withdrawn.¹⁴⁷ Some people may devise their own exercise programmes, return to previous sports, join a self help group or a sports centre, or use walking-based home exercise programmes.²⁰¹ Others prefer formal, class-based cardiac exercise programmes.³¹ There is no good evidence that any one of these options is better than any other, so the choice should be determined by patient preference. Clearly it is helpful if as many options as possible are available locally. Evidence level 1+, 2+, 3, 4

People with stable coronary disease should be encouraged to continue regular moderate intensity aerobic exercise.

The British Association for Cardiac Rehabilitation has made the following recommendations for those who have completed a Phase 3 exercise programme and wish to undertake supervised long term exercise. Patients should:

• be clinically stable
• understand their symptoms (and if they have angina know how to use sublingual nitrates)
• be able to self monitor and regulate their exercise
• be able to achieve an exercise capacity of more than 5 METS (equivalent to three minutes of a Bruce Protocol).²⁰²
  Evidence level 4

Referral for supervised long term exercise should include the following information (with consent):

• details of the cardiac event and other relevant medical history
• subsequent progress including complications and/or interventions
• the Phase 3 exercise prescription and summary of functional capacity
• results of exercise tolerance test if available
• details of the patient's medication.
  Evidence level 4

Fitness instructors delivering maintenance exercise programmes should be on the Exercise and Fitness Register and hold an S/NVQ Level 3 Instructor qualification.

If more than five years has elapsed since the individual's last assessment, if cardiac symptoms have recurred, or if the patient is beginning long term supervised exercise without having first completed a Phase 3 programme, (re)assessment by clinical risk stratification and a test of functional capacity with or without a formal exercise test is recommended (see section 3).