Cardiac rehabilitation: A class 1 recommendation

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Ades et al have defined cardiac rehabilitation referral as a combination of electronic medical records order, patient-physician discussion, and receipt of an order by a cardiac rehabilitation program.21

Ideally, referral for outpatient cardiac rehabilitation should take place at the time of hospital discharge. The AACVPR endorses a “cardiovascular continuum of care” model that emphasizes a smooth transition from inpatient to outpatient programs.6 Inpatient referral is a strong predictor of cardiac rehabilitation enrollment, and lack of referral in phase 1 negatively affects enrollment rates.

Depending on the diagnosis, US and Canadian guidelines recommend cardiac rehabilitation starting within 1 to 4 weeks of the index event, with acceptable wait times up to 60 days.6,22 In the United Kingdom, referral is recommended within 24 hours of patient eligibility; assessment for a cardiovascular prevention and rehabilitation program, with a defined pathway and individual goals, is expected to be completed within 10 working days of referral.23 Such a standard is difficult to meet in the United States, where the time from hospital discharge to cardiac rehabilitation program enrollment averages 35 days.24,25

After an uncomplicated myocardial infarction or percutaneous coronary intervention, patients with a normal or mildly reduced left ventricular ejection fraction should start outpatient cardiac rehabilitation within 14 days of the index event. For such cases, cardiac rehabilitation has been shown to be safe within 1 to 2 weeks of hospital discharge and is associated with increased participation rates.

When to start phase 2 cardiac rehabilitation
After a minimally invasive open-heart procedure, many patients could likely start cardiac rehabilitation within 4 weeks. For those who underwent sternotomy, some institutions require waiting at least 6 weeks before starting phase 2, allowing time for the incision to heal and the patient to be able to drive independently, although the inpatient phase 1 of cardiac rehabilitation could start within a few days of surgery (Table 3).26–30


Despite its significant benefits, cardiac rehabilitation is underused for many reasons.

Referral rates vary

A study using the 1997 Medicare claims data­base showed national referral rates of only 14% after myocardial infarction and 31% after coronary artery bypass grafting.31

Rates of referral to cardiac rehabilitation compared with other quality measures for acute myocardial infarction (MI)

Figure 1. Rates of referral to cardiac rehabilitation compared with other quality measures for acute myocardial infarction (MI) established by the Centers for Medicare and Medicaid Services (P < .001 for cardiac rehabilitation referral compared with other interventions).

A later study using the National Cardiovascular Data Registry between 2009 and 2017 found that the situation had improved, with a referral rate of about 60% for patients undergoing percutaneous coronary intervention.32 Nevertheless, referral rates for cardiac rehabilitation remain highly variable and still lag behind other CMS quality measures for optimal medical therapy after acute myocardial infarction (Figure 1). Factors associated with higher referral rates included ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, care in a high-volume center for percutaneous coronary intervention, and care in a private or community hospital in a Midwestern state. Small Midwestern hospitals generally had referral rates of over 80%, while major teaching hospitals and hospital systems on the East Coast and the West Coast had referral rates of less than 20%. Unlike some studies, this study found that insurance status had little bearing on referral rates.

Other studies found lower referral rates for women and patients with comorbidities such as previous coronary artery bypass grafting, diabetes, and heart failure.33,34

In the United Kingdom, patients with heart failure made up only 5% of patients in cardiac rehabilitation; only 7% to 20% of patients with a heart failure diagnosis were referred to cardiac rehabilitation from general and cardiology wards.35

Enrollment, completion rates even lower

Rates of referral for cardiac rehabilitation do not equate to rates of enrollment or participation. Enrollment was 50% in the United Kingdom in 2016.35 A 2015 US study evaluated 58,269 older patients eligible for cardiac rehabilitation after acute myocardial infarction; 62% were referred for cardiac rehabilitation at the time of discharge, but only 23% of the total attended at least 1 session, and just 5% of the total completed 36 or more sessions.36


The underuse of cardiac rehabilitation in the United States has led to an American Heart Association presidential advisory on the referral, enrollment, and delivery of cardiac rehabilitation.34 Dozens of barriers are mentioned, with several standing out as having the largest impact: lack of physician referral, weak endorsement by the prescribing provider, female sex of patients, lack of program availability, work-related hardship, low socioeconomic status, and lack of or limited healthcare insurance. Copayments have also become a major barrier, often ranging from $20 to $40 per session for patients with Medicare.

The Million Hearts Initiative has established a goal of 70% cardiac rehabilitation compliance for eligible patients by 2022, a goal they estimate could save 25,000 lives and prevent 180,000 hospitalizations annually.21

Lack of physician awareness and lack of referral may be the most modifiable factors with the capacity to have the largest impact. Increasing physician awareness is a top priority not only for primary care providers, but also for cardiologists. In 2014, CMS made referral for cardiac rehabilitation a quality measure that is trackable and reportable. CMS has also proposed models that would incentivize participation by increasing reimbursement for services provided, but these models have been halted.

Additional efforts to increase cardiac rehabilitation referral and participation include automated order sets, increased caregiver education, and early morning or late evening classes, single-sex classes, home or mobile-based exercise programs, and parking and transportation assistance.34 Grace et al37 reported that referral rates rose to 86% when a cardiac rehabilitation order was integrated into the electronic medical record and combined with a hospital liaison to educate patients about their need for cardiac rehabilitation. Lowering patient copayments would also be a good idea. We have recently seen some creative ways to reduce copayments, including philanthropy and grants.

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