Cardiac rehabilitation: A class 1 recommendation

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Cardiac rehabilitation, consisting of prescribed exercise and counseling for risk modification, has proven benefits for patients with cardiovascular disease. Nevertheless, rates of referral and use remain low. Efforts to increase program referral and participation are ongoing.


  • Cardiac rehabilitation should begin in the hospital after heart surgery or myocardial infarction, should continue with a hospital-centered 36-session program, and should be maintained independently by the patient for life.
  • Exercise in a cardiac rehabilitation program entails little risk and many proven benefits.
  • Cardiac rehabilitation is indicated and covered by the Centers for Medicare and Medicaid Services (CMS) for a number of cardiovascular conditions.
  • Utilization of cardiac rehabilitation could be improved through CMS reimbursement incentives, electronic medical record prompts, lower copayments for participation, and home-based programs for patients who live far from medical centers.



Cardiac rehabilitation has a class 1 indication (ie, strong recommendation) after heart surgery, myocardial infarction, or coronary intervention, and for stable angina or peripheral artery disease. It has a class 2a indication (ie, moderate recommendation) for stable systolic heart failure. Yet it is still under­utilized despite its demonstrated benefits, endorsement by most recognized cardiovascular societies, and coverage by the US Centers for Medicare and Medicaid Services (CMS).

Here, we review cardiac rehabilitation—its benefits, appropriate indications, barriers to referral and enrollment, and efforts to increase its use.


In 1772, William Heberden (also remembered today for describing swelling of the distal interphalangeal joints in osteoarthritis) described1 a patient with angina pectoris who “set himself a task of sawing wood for half an hour every day, and was nearly cured.”

Despite early clues, it would be some time before the medical community would recognize the benefits of exercise for cardiovascular health. Before the 1930s, immobilization and extended bedrest were encouraged for up to 6 weeks after a cardiovascular event, leading to significant deconditioning.2 Things slowly began to change in the 1940s with Levine’s introduction of up-to-chair therapy,3 and short daily walks were introduced in the 1950s. Over time, the link between a sedentary lifestyle and cardiovascular disease was studied and led to greater investigation into the benefits of exercise, propelling us into the modern era.4,5


The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) defines cardiac rehabilitation as the provision of comprehensive long-term services involving medical evaluation, prescriptive exercise, cardiac risk-factor modification, education, counseling, and behavioral interventions.6 CMS defines it as a physician-supervised program that furnishes physician-prescribed exercise, cardiac risk-factor modification (including education, counseling, and behavioral intervention), psychosocial assessment, outcomes assessment, and other items and services.7

In general, most cardiac rehabilitation programs provide medically supervised exercise and patient education designed to improve cardiac health and functional status. Risk factors are targeted to reduce disability and rates of morbidity and mortality, to improve functional capacity, and to alleviate activity-related symptoms.


Phases of cardiac rehabilitation
Cardiac rehabilitation traditionally consists of 3 phases: inpatient, outpatient, and independent maintenance (Table 1). No uniform nomenclature of the phases exists, which can lead to patient, provider, and payer confusion. Some programs have 4 phases (eg, phase 2 might be considered light activity at home before beginning a formal outpatient cardiac rehabilitation program). The 3 phases, as traditionally defined, are detailed below.

Phase 1: Inpatient rehabilitation

Phase 1 typically takes place in the inpatient setting, often after open heart surgery (eg, coronary artery bypass grafting, valve repair or replacement, heart transplant), myocardial infarction, or percutaneous coronary intervention. This phase may last only a few days, especially in the current era of short hospital stays.

During phase 1, patients discuss their health situation and goals with their primary provider or cardiologist and receive education about recovery and cardiovascular risk factors. Early mobilization to prepare for discharge and to resume simple activities of daily living is emphasized. Depending on the institution, phase 1 exercise may involve simple ambulation on the ward or using equipment such as a stationary bike or treadmill.6 Phase 2 enrollment ideally is set up before discharge.

Phase 2: Limited-time outpatient rehabilitation

Phase 2 traditionally takes place in a hospital-based outpatient facility and consists of a physician-supervised multidisciplinary program. Growing evidence shows that home-based cardiac rehabilitation may be as effective as a medical facility-based program and should be an option for patients who have difficulty getting access to a traditional program.8

A phase 2 program takes a threefold approach, consisting of exercise, aggressive risk-factor modification, and education classes. A Cochrane review9 included programs that also incorporated behavioral modification and psychosocial support as a means of secondary prevention, underscoring the evolving definition of cardiac rehabilitation.

During the initial phase 2 visit, an individualized treatment plan is developed, incorporating an exercise prescription and realistic goals for secondary prevention. Sessions typically take place 3 times a week for up to 36 sessions; usually, options are available for less frequent weekly attendance for a longer period to achieve a full course. In some cases, patients may qualify for up to 72 sessions, particularly if they have not progressed as expected.

Exercise. As part of the initial evaluation, AACVPR guidelines6 suggest an exercise test­—eg, a symptom-limited exercise stress test, a 6-minute walk test, or use of a Rating of Perceived Exertion scale. Prescribed exercise generally targets moderate activity in the range of 50% to 70% of peak estimated functional capacity. In the appropriate clinical context, high-functioning patients can be offered high-intensity interval training instead of moderate exercise, as they confer similar benefits.10

Risk-factor reduction. Comprehensive risk-factor reduction can address smoking, hypertension, high cholesterol, diabetes, obesity, and diet, as well as psychosocial issues such as stress, anxiety, depression, and alcohol use. Sexual activity counseling may also be included.

Education classes are aimed at helping patients understand cardiovascular disease and empowering them to manage their medical treatment and lifestyle modifications.6

Phase 3: Lifetime maintenance

In phase 3, patients independently continue risk-factor modification and physical activity without cardiac monitoring. Most cardiac rehabilitation programs offer transition-to-maintenance classes after completion of phase 2; this may be a welcome option, particularly for those who have developed a good routine and rapport with the staff and other participants. Others may opt for an independent program, using their own home equipment or a local health club.

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