The role of cardiac rehabilitation in improving cardiovascular outcomes

Abstract

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.

Abstract

In this Review, Taylor and colleagues provide a summary of the current evidence base supporting the use of cardiac rehabilitation, an overview of international guidelines for cardiac rehabilitation and a discussion of major contemporary issues facing cardiac rehabilitation delivery around the world.

Key points

• Cardiac rehabilitation is a complex, multicomponent intervention that includes exercise training and physical activity promotion, health education, cardiovascular risk management and psychological support, personalized to the individual needs of patients with heart disease.

• Data from randomized, controlled trials support cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization.

• Despite this robust evidence base and strong guideline recommendations, global access to cardiac rehabilitation is persistently poor, with scarce cardiac rehabilitation provision in low-income and middle-income settings.

• Home-based and technology-based models of cardiac rehabilitation with appropriate quality assurance as an alternative or adjunct to traditional, centre-based programmes are needed to improve access to cardiac rehabilitation.

• Cardiac rehabilitation programmes need to cater for and manage the needs of the increasing number of patients with heart disease who present with two or more chronic diseases.

• Further research needs to strengthen the evidence base for cardiac rehabilitation in patients with heart failure with preserved ejection fraction, atrial fibrillation or congenital heart disease and after cardiac valve surgery or heart transplantation.