The AHA Guidelines and Scientifi c Statements Handbook
Agency for Healthcare Policy and Research and
others [1,12,18–27] conclude that cardiac rehabilita-
tion programs should provided a multidisciplinary
approach to overall cardiovascular risk reduction
including but not limited to exercise training alone.
As such CR/SP programs provide an important and
effi cient venue for delivery of preventive care,
behavior medication, and the reduction of modifi -
able risk factors for CVD [1].
This chapter will review several recently published
statements describing CR/SP program core compon-
ents, program effi cacy, and performance measures
[1,28,29]. The chapter is intended to assist clinicians
and cardiac rehabilitation program staff in the
design and development of programs and to assist
healthcare providers, insurers and policy makers,
and consumers in the recognition of the compre-
hensive nature of such programs. It is not the intent
of this chapter to promote a rote approach or homo-
geneity among programs but rather to foster a foun-
dation of services on which each program can
establish its own specifi c strengths and identity and
effectively attain outcome goals for its target popula-
tion. The AHA encourages clinicians to implement
these program components and performance mea-
sures in order to provide for comprehensive cardiac
rehabilitation/secondary prevention programs.
Defi nition of cardiac rehabilitation/
secondary prevention
The term cardiac rehabilitation/secondary prevention
refers to coordinated, multifaceted interventions
designed to optimize cardiac patients’ physical, psy-
chological, and social functioning, in addition to
stabilizing, slowing, or even reversing the progres-
sion of the underlying atherosclerotic processes,
thereby reducing morbidity and mortality [17]. CR
is an integral component in the overall management
of patients with CVD, whereby the patient plays
a signifi cant role in the successful outcomes of
CR aimed at the secondary prevention of CVD
events [2,3,12].
Appropriate patients for cardiac
rehabilitation/secondary prevention
Candidates for CR/SP services historically were
patients who had suffered a myocardial infarction
(MI), undergone coronary artery bypass graft
(CABG) surgery, or had been diagnosed with stable
angina pectoris. However, more recently, candidacy
has been broadened to include patients who have
undergone percutaneous coronary intervention
(PCI), heart transplantation, or heart valve replace-
ment/repair [12]. Further, patients with stable
chronic heart failure, peripheral arterial disease
(PAD) with claudication, or other forms of CVD
including cardiac surgical procedures, also may be
eligible.CR/SP programming structure
Cardiac rehabilitation/secondary prevention pro-
grams are generally divided into three main phases:
(1) Inpatient CR (Phase 1 CR): a program that deliv-
ers preventive and rehabilitative services to hospital-
ized patients following an index CVD event, such as
an MI/acute coronary syndrome; (2) Early outpa-
tient CR (Phase 2 CR): a program generally begin-
ning within 1–3 weeks post-hospitalization that
delivers preventive and rehabilitative services, typi-
cally including electrocardiographic monitoring, to
patients in the outpatient setting early after a CVD
event, generally over the fi rst 3 to 6 months post-
hospitalization; (3) Long-term outpatient CR/SP
(Phase 3/Phase 4): a program that provides long-
term delivery of preventive and rehabilitative ser-
vices for patients in the outpatient setting. The CR
services are generally most benefi cial when delivered
soon after hospitalization. However, there are often
clinical, social, and logistical reasons which delay
enrollment in CR. For this reason, CR services may
begin up to 6 to 12 months following a cardiac
event. Because patients can be referred to CR at
varying times following a CVD event, parties respon-
sible for the referral of patients to CR include hos-
pitals and healthcare systems as well as physician
practices and other healthcare settings with prim-
ary responsibility for the care of patients after a
CVD event.Underutilization of cardiac rehabilitation/
secondary prevention services
Unfortunately, CR/SP programs remain underused
in the United States, with an estimated participation
rate of only 10–20% of the >2 million eligible