The AHA Guidelines and Scientific Statements Handbook

Chapter 4 Cardiac Rehabilitation and Secondary Prevention Programs

patients per year [30]. Contributing to this poor
level of utilization are potential barriers to participa-
tion including those which are patient-oriented
(e.g., patient motivation), those that are provider-
oriented (e.g., low patient referral rate, particularly
of women, older adults, and ethnic minority
patients), and still others related to societal barriers
or the healthcare system (e.g., lack of insurance cov-
erage or absence of a CR program) [30–32]. In addi-
tion, there is a lack of “visibility” and recognition by
the public of the importance of cardiac rehabilita-
tion services. It should be noted, however, that even
though some persons may have signifi cant patient-
or provider-oriented barriers to CR referral, nearly
all patients with CVD can benefi t from at least some
components of a comprehensive, secondary pre-
vention CR program. To address these concerns
effectively, alternative models to the traditional
hospital- or community center-based setting for
outpatient programs have been developed. These
models include home-based and community-based
group programs that use nurses or other non-
physician healthcare providers, as well as electronic
media programs as an alternative for providing

risk-factor modifi cation education and instruction

for structured exercise [33–36].

Core components of cardiac

rehabilitation/secondary prevention

programs

All cardiac rehabilitation/secondary prevention pro-

grams should contain specifi c core components that

aim to optimize cardiovascular risk reduction, foster

healthy behaviors and compliance with these behav-

iors, reduce disability, and promote an active life-

style for patients with cardiovascular disease. The

AHA/AACVPR Core Components of Cardiac

Rehabilitation/Secondary Prevention Programs [28]

provide information on the evaluation, interven-

tions, and expected outcomes for such programs in

agreement with the 2006 update of the AHA/ACC

secondary prevention guidelines [37], including

baseline patient assessment, nutritional counseling,

risk factor management (lipids, blood pressure,

weight, diabetes mellitus, and smoking), psychoso-

cial interventions, and physical activity counseling

and exercise training (Table 4.1). Inherent in these

Table 4.1. Core components of cardiac rehabilitation/secondary prevention programs

Patient Assessment [17,36–39]
Evaluation

• Medical history: Review current and prior cardiovascular medical and surgical diagnoses and procedures (including assessment of left
  ventricular function); comorbidities (including peripheral arterial disease, cerebral vascular disease, pulmonary disease, kidney disease,
  diabetes mellitus, musculoskeletal and neuromuscular disorders, depression, and other pertinent diseases); symptoms of cardiovascular
  disease; medications (including dose, frequency, and compliance); date of most recent infl uenza vaccination; cardiovascular risk profi le; and
  educational barriers and preferences. Refer to each core component of care for relevant assessment measures.


• Physical examination: Assess cardiopulmonary systems (including pulse rate and regularity, blood pressure, auscultation of heart and
  lungs, palpation and inspection of lower extremities for edema and presence of arterial pulses); post-cardiovascular procedure wound sites;
  orthopedic and neuromuscular status; and cognitive function. Refer to each core component for respective additional physical measures.


• Testing: Obtain resting 12-lead ECG; assess patient’s perceived health-related quality of life or health status. Refer to each core component
  for additional specifi ed tests.

Interventions

• Document the patient assessment information that refl ects the patient’s current status and guides the development and implementation of
  (1) a patient treatment plan that prioritizes goals and outlines intervention strategies for risk reduction, and (2) a discharge/follow-up plan that
  refl ects progress toward goals and guides long-term secondary prevention plans.


• Interactively, communicate the treatment and follow-up plans with the patient and appropriate family members/domestic partners in
  collaboration with the primary healthcare provider.


• In concert with the primary care provider and/or cardiologist, ensure that the patient is taking appropriate doses of aspirin, clopidogrel,
  beta-blockers, lipid-lowering agents, and ACE inhibitors or angiotensin receptor blockers as per the ACC/AHA, and that the patient has had an
  annual infl uenza vaccination.