and peak oxygen uptake in the high calorie, high expenditure
exercise group.
What are the risks of cardiac
rehabilitation?
A French observational study of more than 25 000 patients
undergoing cardiac rehabilitation reported one cardiac event for
50 000 hours of exercise training, equivalent to 1.3 cardiac
arrests per million patient-hours.
41
An earlier US study reported
one case of ventricular fibrillation per 111 996 patient-hours of
exercise and one myocardial infarction per 294 118
patient-hours.
42
Patients with unstable angina, uncontrolled ventricular
arrhythmia, and severe heart failure (New York Heart
Association (NYHA) level 3 or 4, ejection fraction <35%) have
been considered at high risk, with formal risk stratification (to
include factors such as a history of arrhythmias and functional
capacity) conducted by an experienced clinician before they
engage in the exercise component of cardiac rehabilitation.
1
However, the most recent Cochrane review found “no evidence
to suggest that exercise training programmes cause harm in
terms of an increase in the risk of all cause death in either the
short or longer term” in patients with stable chronic heart failure
(NYHA level 1–3).
22
Access to cardiac rehabilitation
For those who have difficulty accessing centre based cardiac
rehabilitation, or those who dislike groups, home based cardiac
rehabilitation programmes are sometimes available.
17 43
The
most widely used programme in the UK is the Heart
Manual
44
—a six week intervention that uses written material
and a relaxation CD and is delivered by a trained healthcare
facilitator who makes home visits and provides telephone
support—which has been shown to be just as effective as centre
based programmes.
45 46
Overcoming barriers to cardiac
rehabilitation
Despite robust evidence of clinical and cost effectiveness, uptake
of cardiac rehabilitation varies worldwide and by patient group,
with participation rates ranging from 20% to 50%.
1-48
Poor
uptake has been attributed to several factors, including
physicians’ reluctance to refer some patients, particularly women
and those from ethnic minorities or lower socioeconomic classes,
and lack of resources, capacity, and funding.
6-52
Adherence to
cardiac rehabilitation programmes is affected by factors such
as psychological wellbeing, geographical location, access to
transport, and a dislike of group based rehabilitation sessions
(box 3).
13-43
The most effective way to increase uptake and
optimise adherence and secondary prevention is for clinicians
to endorse cardiac rehabilitation by inviting patients still in
hospital after a recent diagnosis of coronary heart disease or
heart failure to participate and for nurse led prevention clinics
to be linked with primary care and cardiac rehabilitation
services.
2-56
Novel ways of providing cardiac rehabilitation are emerging
using the internet and mobile phones.
57 58
A recent systematic
review has evaluated alternative models of delivery
59
that can
be provided via secondary prevention clinics.
60
Offering patients
a choice of centre based, home, or online programmes on an
equitable basis is likely to improve uptake across all groups of
cardiac patients. Self management and collaboration with care
givers can also improve uptake and outcomes.
61-63
We thank Jemma Lough for help with technical editing of the manuscript,
and Tony Mourant, retired consultant cardiologist, and Jenny Wingham,
senior clinical researcher, for commenting on earlier drafts of this paper.
Contributors: HMD conceived of the article based on a clinical review
he co-authored for the BMJ in 2004. He contributed to the literature
review, drafting and revising the article, and approval of the final version.
RST provided details from the various Cochrane systematic reviews
that he has led and conducted. PD and RST also contributed to the
literature review and drafting, design, and revision of the article. All
authors approved the final manuscript.
Competing interests: We have read and understood the BMJ Group
policy on declaration of interests and declare the following interests.
HMD and PD have co-authored Cochrane reviews in cardiac
rehabilitation with RST. RST is an author on several other Cochrane
reviews of cardiac rehabilitation. HMD and RST are co-chief investigators
on the REACH-HF programme of research, which is developing and
evaluating a home based cardiac rehabilitation intervention for people
with heart failure and their carers (NIHR PGfAR RP-PG-0611-12004).
Patient consent: Patient consent obtained.
Provenance and peer review: Not commissioned; externally peer
reviewed.
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