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Chapter 49: Cardiac Rehabilitation

Matthew N. Bartels; David Prince

INTRODUCTION

Globally the prevalence of cardiovascular disease continues to rise with an increase in the aged population.1,2 This in turn increases the percentage of patients seen in physiatric practices with underlying cardiovascular conditions that affect patient function, participation with therapy, and recovery. Studies have demonstrated that cardiac rehabilitation is associated with substantial physiologic benefits in cardiovascular atherogenesis, inflammation, and function (Table 49–1).

Table 49–1Biologic Mechanisms of the Benefits of Exercise
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Table 49–1 Biologic Mechanisms of the Benefits of Exercise

  • Antiatherogenic effects

    • Reduction of elevated plasma triglyceride levels

    • Increase in high-density lipoprotein cholesterol levels

  • Anti-inflammatory effects

  • Effects on endothelial function

  • Autonomic functional changes

  • Anti-ischemic effects

  • Antiarrhythmic effects

  • Reduction in age-related disability

Reproduced with permission from McLaughlin M. Rehabilitation of the Patient with Coronary Heart Disease. In: Fuster V, Harrington RA, Narula J, Eapen ZJ, eds. Hurst's The Heart, 14e New York, NY: McGraw-Hill; 2017.

Research has clearly demonstrated decreased mortality rates in patients who have undergone cardiac rehabilitation when compared to those that who not.3 Cardiac rehabilitation is a class I indication for most patients with stable angina, acute MI within the last year, percutaneous coronary intervention, congestive heart failure, cardiac transplant or coronary artery bypass surgery.4

A meta-analysis of 63 trials of 14,486 cardiac patients with a history of myocardial infarction or revascularization demonstrated that exercise decreased CV mortality (relative risk [RR], 0.74; 95% confidence interval [CI], 0.64–0.86), decreased the risk of hospital admission (RR, 0.82; 95% CI, 0.70–0.96), and did not significantly increase the death.5 Other studies have indicated that cardiac rehabilitation improves heart rate recovery by 41%, as well as left ventricular remodeling.6,7

Interestingly, another study identified a dose dependent relationship, Medicare MI patients that attended 36 sessions over a period of 5 years decreased their likelihood of death by 14% (HR, 0.86; 95% CI, 0.77–0.97) when compared to those that only completed 24 sessions in the same time period.3

Despite clear evidence of efficacy, studies have estimated that only a minority of patients actually received such therapy.8 Poor socioeconomic status, lack of physician referral, and logistics have been cited as possible reasons for the underutilization of cardiac rehabilitation.9

It is critical that the practicing physiatrist have a basic understanding of cardiovascular conditions prior to prescribing a cardiac rehabilitation program to maximize its efficacy and minimize adverse events.

Common indications for cardiac rehabilitation are described in Table 49–2. Patients who have had revascularization procedures are also candidates for cardiac rehabilitation and may have slightly higher referral rates.6,10,11

Table 49–2Clinical Indications and Contraindications for Inpatient and Outpatient Cardiac Rehabilitation
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Table 49–2 Clinical Indications and Contraindications for ...

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