Chapter 4 Cardiac Rehabilitation and Secondary Prevention Programsdecrease the risk of sudden cardiac death due to
ventricular tachyarrhythmias [93,94].
Exercise training appears to alter hemostatic
effects, which can reduce the risk of a thrombotic
occlusion of a coronary artery after the disruption
of a vulnerable plaque. These antithrombotic effects
include increased plasma volume, reduced blood
viscosity, decreased platelet aggregation, and
enhanced thrombolytic ability [95,96]. Some studies
also have shown that exercise training may reduce
plasma levels of fi brinogen [96].
Psychosocial interventions
Psychosocial dysfunction is common in patients
participating in CR. These problems include depres-
sion, anger, anxiety disorders, and social isolation.
Observational studies have demonstrated associa-
tions between psychosocial disorders and the risk
of initial or recurrent cardiovascular events [97].
However, a large randomized multicenter trial
reported that cases of depression and social isolation
improved similarly in both the intervention and
control groups [98] with no improvement in event-
free survival. Nevertheless, even if psychosocial
interventions ultimately are shown not to alter the
prognosis of CHD patients, they remain an integral
part of cardiac rehabilitation services to improve the
psychological well-being and quality of life of cardiac
patients.
Performance measures
Using a previously published methodology [15,99],
the AHA, in conjunction with the AACVPR and the
ACC, has addressed performance measures for the
referral of eligible patients to a CR program and
the delivery of CR services through multidisciplinary
CR programs, focusing on processes of care that
have been documented to help improve patient out-
comes (Appendices A and B) [29]. The purpose of
these performance measure sets is to help improve
the delivery of CR in order to reduce cardiovascular
mortality and morbidity and optimize health in
persons with CVD, including acute MI, CABG
surgery, PCI, stable angina pectoris, and heart trans-
plant or heart valve surgery.
The rationale for developing and implementing
performance measure sets for referral to and deliv-
ery of CR services was based on several key factors:
- Despite the known benefi ts of CR and the wide-
spread endorsement of its use, CR is vastly under-
utilized [104–106]. Reasons for this gap in CR
participation are numerous, but the most critical
and potentially most correctable reasons revolve
around obstacles in the initial referral of patients to
CR programs. These obstacles can be reduced
through the systematic adoption of standing orders
and other similar tools for CR referral for appropri-
ate hospitalized patients [107]. Furthermore, physi-
cian accountability associated with the use of these
performance measures may lead to innovative
approaches to improve referral rates and improve
the outcome of patients with CVD. - The core components for CR have been published
[28] (Table 4.1) and systems for CR program certi-
fi cation exist [108]. However, since certifi cation is
not required in most instances for CR program
operation or for reimbursement purposes, CR
program certifi cation is obtained by a relatively
small portion of CR programs in the United
States [109]. - There is a need to reduce the gap in delivery of CR
services to persons with CVD. Improvement in CR
delivery will require better approaches in the referral
to, enrollment in, and completion of programs in
CR. It is anticipated that the implementation of CR
performance measure sets will stimulate changes in
the clinical practice of preventive and rehabilitative
care for persons with CVD. The performance mea-
sures are designed to help healthcare groups identify
potentially correctable and actionable sources of
suboptimal clinical care such as structure- and
process-based gaps in CR services.
1 Structure-based measures quantify the infra-
structure from which CR is provided and are based
upon the provision of appropriate personnel and
equipment to satisfy high quality standards of care
for CR services. For example, a structure-based per-
formance measure for a CR program is one that
specifi es that a CR program has appropriate person-
nel and equipment to provide rapid care in medical
emergencies that may occur during CR program
sessions.
2 Process-based measures quantify specifi c aspects
of care and are designed to capture all relevant
dimensions of CR care. For example, a process-
based performance measure for a CR program is one
that specifi es that all patients in a CR program