Chapter 4 Cardiac Rehabilitation and Secondary Prevention ProgramsComparison with other national
guidelines
Many individual countries throughout the world have
published guidelines for cardiac rehabilitation/second-
ary prevention programs. These include those from
Canada, several countries in Europe, Australia, and
South Africa. While each of these may differ slightly,
the overriding theme is that the comprehensive nature
of cardiac rehabilitation extends beyond exercise train-
ing alone. Emphasis is placed on the importance of the
identifi cation and treatment of modifi able risk factors
for cardiovascular disease. The AHA/AACVPR state-
ments and guidelines for cardiac rehabilitation/
secondary prevention programs are derived in concert
with the other national guidelines that address pre-
vention, including the JNC 7 [43], NCEP-ATP3 [40],
and the AHA/ACC Secondary Prevention Guidelines
[37]. The remarkable pace of scientifi c discovery chal-
lenges the provision of recommendations that refl ect
the most current science. Accordingly, the guidelines
on cardiac rehabilitation/secondary prevention pro-
grams are consistent with the best scientifi c knowledge
base available at the time of the writing of the docu-
ment, and may at times provide treatment targets and
strategies that differ from other prevention-focused
guidelines that were published several years earlier. It
is therefore both reasonable and appropriate that
medical directors of cardiac rehabilitation/secondary
prevention programs remain keenly aware of advances
in the broad fi eld of prevention, and implement pro-
grammatic changes relative to the most recent scientifi c
consensus regarding a particular area (e.g., lipid
management).
The recently published European Guidelines on
Cardiovascular Disease Prevention in Clinical Prac-
tice [110] promote the use of global risk scores, and
establish treatment targets that are nearly identical
to those of the American guidelines. They emphasize
the importance of behavior and behavioral change
strategies that foster the adoption and maintenance
of healthy lifestyles, as this is fundamental to the
attainment of individual risk factor modifi cation
and treatment goals.
Future research
As cardiac rehabilitation/secondary prevention pro-
grams encompass a very broad fi eld that ranges from
management of individual risk factors to behavior/
adherence strategies, there are many opportunities for
future research. Some specifi c areas are as follows [1]:1 Evaluations to determine the effectiveness and
safety of a variety of approaches designed to increase
patient referrals, accessibility, and delivery of car-
diac rehabilitation and secondary prevention ser-
vices and to promote adherence to program
components.
2 Comparisons of the cost-effectiveness of tradi-
tional supervised programs versus home-based exer-
cise and educational services with regard to improving
functional capacity, self-effi cacy, independent living,
risk factor modifi cation, long-term compliance,
rehospitalization rates, and quality of life.
3 Evaluation of the contributions of endurance and
resistance exercise for the modifi cation of risk factors
and their effects on pathophysiological mechanisms
involved in atherogenesis, myocardial ischemia, coro-
nary thrombosis, and ventricular tachyarrhythmias.
4 Randomized trials to better defi ne the role of
exercise therapy for safely improving functional
capacity, reducing cardiovascular symptoms, and
enhancing the quality of life among specifi c
subgroups of patients with cardiovascular disease,
particularly older, female, and ethnic minority
patients.
5 Feasibility of defi nitive randomized multicenter
clinical trials to assess the independent contribution
of exercise training to the morbidity and mortality
of patients after myocardial infarction or coronary
artery revascularization procedures and of patients
with stable angina pectoris or silent myocardial isch-
emia. These trials should include older, female, and
ethnic minority patients.
6 Studies to clarify the independent and additive
benefi ts of lifestyle modifi cation (i.e. beyond coro-
nary revascularization and effective pharmacothera-
pies) individually or in combination with other
interventions in preventing recurrent cardiovascular
events.
7 Evaluation of the use of cardiac rehabilitation
programs as centers for intensive lifestyle manage-
ment for weight loss, physical activity, nutrition, and
psychosocial support for people with additional
chronic medical conditions, such as type 2 diabetes
mellitus, the metabolic syndrome, and other insulin
resistant states.