Cardiac rehabilitation programs

INTRODUCTION — Outpatient cardiac rehabilitation programs provide supervised exercise training in conjunction with other secondary prevention interventions. They are designed to speed recovery from acute cardiovascular events, such as myocardial infarction, myocardial revascularization, heart transplantation, or hospitalization for heart failure, and to improve quality of life. In addition, patients with stable coronary heart disease and symptomatic peripheral arterial disease derive benefits. Despite the improvement in health outcomes associated with cardiac rehabilitation, only one in four cardiac-rehabilitation-eligible Medicare beneficiaries participate [1]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

This topic will discuss the organization and content of these programs. The indications for and the efficacy and safety of cardiac rehabilitation are discussed separately. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease".)

COMPONENTS — The components of cardiac rehabilitation programs are delivered by a dedicated team including a medical director, nurses, exercise specialists, nutritionists, and psychologists. These programs include provision of comprehensive long-term services involving the following core components (table 1A-B) [2-5]:

●Medical evaluation/baseline patient assessment.

●Exercise training and physical activity counseling.

●Coronary risk factor reduction/secondary prevention, including nutritional counseling and weight management.

●Psychosocial support.

●Education regarding diet, weight management, purpose of medications, medication side effects, effects on exercise tolerance, and re-enforcement for medication adherence. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Comprehensive risk factor intervention' and "Psychosocial factors in acute coronary syndrome" and "Psychosocial factors in sudden cardiac arrest".)

Most outpatient programs consist of three times weekly, electrocardiogram-monitored, hour-long exercise sessions for 8 to 12 weeks. The goals of these sessions are to develop and teach an individualized exercise prescription that is both safe and effective, to initiate interventions aimed at reducing coronary risk factors, and to identify and manage the psychosocial problems that commonly affect the cardiac patient [6]. Testing procedures to assess exercise capacity are discussed separately. (See "Exercise assessment and measurement of exercise capacity in patients with coronary heart disease".)

INITIATION OF REHABILITATION — Historically, a significant amount of cardiac rehabilitation intervention took place during hospitalization [7]. With the abbreviated length of hospital stays, the goal of caregivers during the hospital stay is to promote early ambulation, to introduce patients to the goals of cardiac rehabilitation, and to enroll individuals in outpatient programs.

The first visit at an outpatient cardiac rehabilitation program can be as early as the first week after hospitalization for an uncomplicated myocardial infarction or percutaneous coronary intervention. Patients with complicated hospital courses or cardiac surgery may have to wait longer before starting. For patients following percutaneous coronary intervention either by radial or femoral approach, cardiac rehabilitation should be delayed until access site discomfort or complications are resolved. Cardiac rehabilitation is typically ordered by cardiology health professionals who remain involved in the patient’s rehabilitation progress and can be contacted to make recommendations if patients have untoward responses to exercise. However, many primary care providers are comfortable prescribing cardiac rehabilitation services and monitoring a patient’s progress.

There is evidence that early enrollment improves subsequent attendance and outcomes [8-11]. In an observational study of 1241 patients hospitalized for a cardiac event or cardiac surgery, a delay in beginning cardiac rehabilitation by more than 30 days was an independent predictor of a decreased improvement in exercise performance [12].

A Cochrane systematic review and meta-analysis of 26 trials (5299 participants) assessed the effectiveness of interventions to increase cardiac rehabilitation utilization [13]. Meta-regression analysis showed that the intervention deliverer (nurse or allied healthcare provider) along with the delivery format (face-to-face) were effective in increasing enrollment. Many hospital centers have referral to cardiac rehabilitation as part of their discharge order set.

Although patients with fewer financial and social resources are less likely to participate in and complete rehabilitation, one study indicated that financial incentives may be an efficacious strategy for increasing cardiac rehabilitation participation and adherence among Medicaid (United States) patients [14].

EXERCISE TRAINING — The goals of a cardiac rehabilitation program are to [15]:

●Assess the patient’s baseline ability and limitations

●Develop an exercise prescription

●Observe the patient's response to that prescription

●Encourage long-term participation in regular unsupervised exercise

The components of an exercise prescription include the mode, frequency, duration, and intensity of exercise (table 2 and table 1A-B). Fear of movement (kinesiophobia) is present in a substantial proportion of patients referred for cardiac rehabilitation. A test modality can help identify this problem, which requires patient education by the cardiac rehabilitation staff [16].

Risk stratification for exercise — The risk of cardiovascular complications from exercise training should be evaluated before starting an exercise program. The risk stratification guidelines published by the American Heart Association use four categories of risk according to clinical characteristics and include contraindications for exercise (table 3A-E) [6].

●Class A individuals are apparently healthy and have no clinical evidence of increased cardiovascular risk of exercise.

●Class B individuals have clinically stable coronary heart disease. These individuals are at low risk of cardiovascular complications of vigorous exercise.

●Class C individuals are at moderate or high risk of cardiac complications during exercise by virtue of a history of multiple myocardial infarctions (MIs) or cardiac arrest, New York Heart Association class III or IV (table 4), exercise capacity of less than six metabolic equivalents (METs), and significant ischemia on the exercise test. One MET is defined as 3.5 mL O₂ uptake/kg per min, which is the resting oxygen uptake in a sitting position. (See "Exercise assessment and measurement of exercise capacity in patients with coronary heart disease".)

●Class D patients are those with unstable disease who require restriction of activity and for whom exercise is contraindicated.

Patients referred for outpatient cardiac rehabilitation typically belong to class B or C. They require different degrees of monitoring or supervision during exercise. (See 'Supervision' below.)

Although generally beneficial in class B and C patients, supervised exercise rehabilitation is associated with a small risk of adverse events. The 2007 American Heart Association scientific statement on exercise and acute cardiovascular events estimated that the risk of any major cardiovascular complication (cardiac arrest, death, or MI) is one event in 60,000 to 80,000 hours of supervised exercise [17]. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Safety'.)

Although there are no contraindications to comprehensive secondary prevention programs, contraindications to outpatient cardiac rehabilitation generally focus on the unstable Class D patient for whom exercise training is not recommended (table 5). The American College of Sports Medicine lists specific contraindications to cardiac rehabilitation [18].

Mode — The mode of exercise should be one that requires the use of large muscle groups and aerobic exercise such as walking, jogging, cycling, rowing, machine stair climbing, and other endurance activities [19,20]. Low impact activities are recommended because of a lesser risk of physical injury. The mode or modes of exercise chosen should be enjoyable for the individual and simple to carry out to maximize compliance. Selected exercise modalities must take into account physical limitations and musculoskeletal issues of the participants. For example, rowing has both aerobic and resistive exercise components. It requires good technique and can result in overuse or back injuries for individuals with pre-existing problems. Among postsurgical patients, upper body strengthening and weight lifting should be assessed individually based on the patients' chest wall symptoms after sternotomy.

Frequency and duration — The recommended frequency of exercise is at least three times a week but preferably on most days of the week, which is necessary to achieve a significant improvement in functional capacity [6,20]. Programs vary in their duration but 12 weeks is common.

Content — Each exercise session includes three phases:

●Warm up for 5 to 10 minutes. Warm-up exercises consist of stretching, flexibility movements, and aerobic activity that gradually increases the heart rate into the target range. This gradual increment in oxygen demand minimizes the risk of exercise-related cardiovascular complications.

●Conditioning or training phase, which consists of at least 20 minutes and preferably 30 to 45 minutes of continuous or discontinuous aerobic activity.

●Cool down for 5 to 10 minutes. The cool-down period involves low-intensity exercise and permits a gradual recovery from the conditioning phase. Omission of cool-down can result in a transient decrease in venous return, reducing coronary blood flow when heart rate and myocardial oxygen consumption remain high. Adverse consequences can include hypotension, angina, ischemic ST-T changes, and ventricular arrhythmias.

Intensity — Intensity of exercise may range from 40 to 85 percent of functional capacity (VO₂max), which corresponds to 55 to 90 percent of maximal heart rate (estimated as 220 minus the age in years, or more accurately measured at the highest exercise intensity on the maximal exercise test). Estimated heart rate is inappropriate for patients using heart rate-limiting cardiac drugs or who are pacer-dependent. (See "Exercise physiology".)

The target heart rate range may be determined by several methods. Selection of a fixed percentage of maximal heart rate is the method most commonly used to guide exercise intensity. A percentage range is calculated from the maximal heart rate (percent HRmax) reached at peak exercise during a symptom-limited exercise tolerance test [21]. Exercise intensity has been categorized using the percent HRmax as light (<60 percent), moderate (60 to 79 percent), and heavy (>80 percent).

Energy expenditure is related to both intensity and duration. In general, lower intensity exercise should be performed for a longer duration. Symptom-limited patients may begin with discontinuous exercise and progress to 20 to 30 minutes of continuous exercise. The duration is increased before increasing the intensity. It is common for cardiac rehabilitation patients to rotate among a variety of dynamic exercise modalities: treadmill, bicycle, Schwinn Aerodyne, arm ergometer, rowing machine, etc. Energy expenditure and heart rate response are related to the intensity of the activity and the amount of muscle mass used to perform the activity.

Beta blockers, which are administered to most patients after MI, reduce the cardiac output response to exercise predominantly by limiting heart rate. Although resting heart rate, submaximal, and maximal exercise heart rates are reduced by beta blockers, traditional heart rate methods may be used to prescribe exercise intensity based on the patient's maximal heart rate measured during an exercise test performed on medication.

Symptom-limited exercise test refers to a submaximal testing modality often conducted before initiating a cardiac rehabilitation program to establish a baseline fitness level, determine maximal heart rate, and assess the safety of exercise by observing symptoms and electrocardiographic indications of ischemia or cardiac arrhythmia [22]. A symptom-limited exercise test is terminated at the onset of symptoms related to coronary heart disease, usually chest pain or shortness of breath (or leg fatigue if it is severe and occurs before the patient reaches age-predicted functional capacity). This heart rate level becomes the maximal heart rate, and the exercise training heart rate is a given.

●Use of the heart rate maximum reserve (a percent of the difference between the maximal and resting heart rates). A table shows an example of an exercise prescription using the HRmax reserve method in a 40-year-old individual (HRmax of 180), with a resting heart rate of 60 and a desired exercise intensity of 60 to 80 percent capacity (table 6).

●Observation of the relationship between exercise heart rate and VO₂ or METs (figure 1). One MET is defined as 3.5 mL O₂ uptake/kg per min, which is the resting oxygen uptake in a sitting position. These methods require the monitoring of heart rate or pulse-taking.

A personalized exercise prescription can optimize a patient’s results from cardiac rehabilitation. Patients with decreased functional mobility and muscle strength, balance impairment, and physical frailty may require lower-intensity physical activity, whereas those with higher function may benefit from higher-intensity cardiac rehabilitation. Patient preference, safety, and suitability influence whether high- versus moderate-intensity exercise rehabilitation is appropriate.

Rating of perceived exertion (Borg scale) — Exercise intensity can also be prescribed using the rating of perceived exertion (RPE or Borg scale) (table 7). This is a validated method that most patients can learn and apply easily and is valuable with unsupervised exercise [23,24]. On the category scale (6 to 20), an RPE of 12 to 13 (somewhat hard) corresponds to 60 percent VO₂max and an RPE of 16 (hard to very hard) corresponds to 85 percent VO₂max. An individual's subjective response during graded exercise testing is employed in specifying the RPE level for exercise training. The rating of perceived exertion appeared equally effective in guiding exercise intensity of patients participating in cardiac rehabilitation whether in a supervised center-based setting or a self-care, home-based setting [25].

The exercise intensity for healthy adults is usually 60 to 70 percent of functional capacity (using VO₂max, maximal METs, or heart rate maximum reserve) or a 12 to 13 level on the RPE scale (table 7). The incremental benefit of very high intensity exercise (>90 percent of HRmax) is small and is not recommended; it leads to lactate accumulation, fatigue, and an increase in the risk of physical injury or cardiovascular complications [6,21]. A study of high- versus low-dose exercise training had only a small effect on all outcomes [26].

Individuals with a low baseline fitness level, which is often the case among patients with heart disease, should begin at a lower percentage of maximum capacity [27]. Patients with stable angina may have an exercise prescription based upon 60 to 70 percent of the heart rate at which ischemic ST segment changes or anginal symptoms appear.

Exercise progression — Another important element of the exercise prescription is exercise progression. Although there is no standard format for exercise progression, progression should be individualized according to patient tolerance, motivation and goals, symptoms, baseline fitness level, and musculoskeletal limitations [28]. Patients exercising below 3.5 METs on exit from cardiac rehabilitation represent a high-risk group with one- and three-year event rates ≥7 and ≥18 percent, respectively. Thus, the MET level can be used to identify patients at increased risk for an event who may benefit from closer follow-up, extension of length of cardiac rehabilitation, etc [29].

Supervision — The level of available supervision influences the prescription for exercise in cardiac rehabilitation programs:

●Patients at moderate or high risk of cardiac complications from exercise (Class C) should participate in a medically supervised program with electrocardiogram (ECG) monitoring and personnel and equipment suitable for advanced cardiac life support. This level of medical supervision should be continued for 8 to 12 weeks until the safety of the prescribed exercise regimen has been established [6].

●Low-risk patients (class B) may initially benefit from medically supervised ECG-monitored exercise (6 to 12 sessions), which helps to reassure the patient of the program’s safety. Self-monitored, home-based exercise programs also have been shown to be effective and safe in these patients, and result in better rates of adherence when compared to group-based programs [30]. Patients may exercise without supervision when they understand how to monitor activity levels. They are taught to guide exercise intensity by heart rate and/or RPE. Low-level isometric (resistance) activities may be prescribed for low-risk patients to increase muscular strength.

Resistance training — Many cardiac rehabilitation programs incorporate resistance training along with aerobic exercise training once the aerobic exercise targets have been attained. The primary goals are to increase muscle strength, endurance, and mass, thereby enhancing a patient's ability to perform household and vocational tasks.

Resistance exercises are referenced to the individual's measured or estimated maximal strength or the "one-repetition maximum" (ie, the maximal weight a patient can lift once). A general recommendation for resistance training in cardiac patients includes 30 to 40 percent of the one-repetition maximum for upper body exercises and 40 to 50 percent of the one-repetition maximum for lower body exercises; there are 12 to 15 repetitions per set, performed two to three times weekly [27].

Long-term exercise — The goal of exercise training in the context of a cardiac rehabilitation program is to get patients to participate in regular physical activity long term. The benefits of long-term exercise are discussed separately. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

In a study, the functional improvement after outpatient cardiac rehabilitation in acute coronary syndrome patients did not appear related to an improvement in left ventricular ejection fraction [31]. Nonetheless, in a substudy of the OPTICARE trial, better exercise capacity was significantly associated with higher scores on the global and physical domains of health-related quality of life [32].

HEART FAILURE AND CARDIAC TRANSPLANTATION PATIENTS — The role of cardiac rehabilitation programs in patients with heart failure or in those who have undergone cardiac transplantation is discussed separately. (See "Cardiac rehabilitation in patients with heart failure" and "Heart transplantation in adults: Exercise-based rehabilitation for transplant recipients".)

EDUCATION — In addition to regular exercise training, cardiac rehabilitation programs typically address the traditional modifiable risk factors of smoking, hypertension, diabetes, and lipid abnormalities [19]. These have been referred to as “multifactorial” programs. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

The long-term success of any of the risk-factor reducing interventions depends largely upon patient compliance. As an example, compliance with exercise, diet, and smoking cessation should be assessed regularly by the rehabilitation nurses and physical therapists. When poor compliance is suspected, the cause should be identified and encouragement and alternatives should be provided.

In the SWEDEHEART Registry, patients attending exercise-based cardiac rehabilitation, compared with nonattenders, achieved significantly larger improvements in cardiovascular risk factors at one year post-myocardial infarction [33].

In a study of problem-based learning versus home-sent patient information after coronary heart disease, there were significant improvements in body mass index, body weight, and high-density lipoprotein cholesterol in the problem-based learning group [34].

Nutritional counseling and weight management — Nutritional counseling is aimed at achieving weight loss or control and an improved lipid profile and blood pressure level (table 1A-B) [35]. It is best offered by a registered dietitian who can spend enough time with the patient to discuss dietary habits, food choices, and how to implement an individualized dietary plan. (See "Healthy diet in adults".)

Sodium restriction and diabetes control may also be required.

Cessation of smoking — Effective smoking cessation is difficult to achieve because of the strong psychological and physiologic dependence that occurs (table 1A-B). Effective approaches for smoking cessation and maintenance of abstinence include patient education about the risks of continued smoking, referral to smoking cessation group programs, nicotine patch therapy, nicotine gum, varenicline, self-help literature, and encouragement by the primary care providers [19,36]. (See "Overview of smoking cessation management in adults".)

Diabetes management — The cardiac rehabilitation program and the long-term maintenance of interventions learned and reinforced in these programs can have a major beneficial impact on the long-term control of blood sugar and HbA1c levels in patients with diabetes. (See "Exercise guidance in adults with diabetes mellitus" and "Overview of general medical care in nonpregnant adults with diabetes mellitus".)

Management of hypertension and hyperlipidemia — The pharmacologic management of hypertension and dyslipidemia for patients with atherosclerotic cardiovascular disease (ASCVD) are usually instituted in parallel by the physician or advanced practice provider. In the absence of a contraindication, all patients with ASCVD are treated with high-intensity statin (table 1A-B).

The role of the cardiac rehabilitation program with regard to these is to continue the educational process, monitor compliance with recommended therapies, and monitor outcomes. After hospital discharge for myocardial infarction (MI), participation in cardiac rehabilitation was associated with continuing to take high-intensity statin therapy with high adherence at six months post-MI discharge and two years post-MI discharge [37]. (See "Goal blood pressure in adults with hypertension" and "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease" and "Mechanisms of benefit of lipid-lowering drugs in patients with coronary heart disease".)

PSYCHOSOCIAL SUPPORT — A major component of a cardiac rehabilitation program is the identification and management of the variety of psychosocial and vocational problems that arise after a cardiac event or cardiac diagnosis (table 1A-B) [36,38]. Depression, anxiety, and denial are common in patients following myocardial infarction, occurring in up to 20 percent of patients. Depression is associated with lower exercise capacity, less energy, more fatigue, and a reduced quality of life and sense of well-being. Women, and in particular younger women, are at increased risk for depression [39,40]. (See "Psychosocial factors in acute coronary syndrome".)

In a randomized trial of coronary patients aged 36 to 84 years assigned to comprehensive cardiac rehabilitation versus comprehensive cardiac rehabilitation combined with stress management training, the addition of stress management training produced significant reductions in stress and greater improvements in medical outcomes. These data indicate that stress management training may provide incremental benefit when combined with comprehensive cardiac rehabilitation [41]. Regular exercise also leads to better adaptiveness to stress; this is true for both aerobic or resistance exercise [42].

Social vulnerability is associated with low use of cardiac rehabilitation following acute myocardial infarction [43]. Thus, identifying social risk factors may help improve access to care among vulnerable populations.

Psychosocial symptoms often translate into problems within the family, marriage, and the workplace and may lead to low rates of return to work, job loss, or disability. Individual or group psychotherapy and sometimes pharmacotherapy can be beneficial. Trained personnel including psychologists, psychiatrists, and social workers should be available within the rehabilitation program or on a referral basis to best manage these issues. This issue is discussed in detail elsewhere. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Psychosocial intervention'.) Cardiac rehabilitation and occupational counseling played an important role in worker recovery and subsequent reintegration into the workplace, particularly for clerical workers [44].

SUPPLEMENTAL APPROACHES — Most cardiac rehabilitation programs have a fixed duration, after which the benefits of structured rehabilitation may decline. It is possible that additional referral to other community-based lifestyle intervention programs that provide assistance with lifestyle modification may improve long-term outcomes. This approach was evaluated in a study of 824 patients with recent acute coronary syndrome or coronary artery revascularization procedure who had one or more of the following lifestyle risk factors (LRFs): body mass index >27 kg/m², self-reported physical inactivity, or smoking [45]. Among 824 patients who were randomly assigned to usual care or usual care plus nurse-coordinated referral to community-based lifestyle programs for weight reduction, increasing physical activity, and smoking cessation, 711 completed the program. The primary outcome of the proportion of success at 12 months was defined as improvement in ≥1 LRF using weight (≥5 percent reduction), six-minute-walking distance (≥10 percent improvement), and urinary cotinine (200 mg/mL detection limit) without deterioration in the other two. Most of the benefit was achieved through weight reduction.

ALTERNATE APPROACHES — Alternative approaches to the delivery of supervised cardiac rehabilitation include home-based programs with monitoring of exercise using transtelephonic transmission of ECGs, computer-assisted interventions delivered by exercise physiologists in community-based settings, disease management and lifestyle health coaching interventions delivered by nurses and other health professionals using the telephone, and internet-based case management systems [46-51]. Interventions delivered by mail plus phone can increase the completion of cardiac rehabilitation [52,53] but not adherence to medication [52]. Alternatives to traditional cardiac rehabilitation include community-based group programs with guidance by nurses or other nonphysician healthcare providers, and electronic media programs for home-based comprehensive risk modification, education, and instruction, as well as for guidance of a structured exercise regimen [46-49]. Use of mobile health technologies may further expand cardiac rehabilitation availability [54,55].

The long-term assessment of the effectiveness of these approaches and the optimal mode of their delivery remain unknown. The attractiveness of these models is the potential to provide cardiac rehabilitation to low- and moderate-risk coronary patients who comprise the majority of contemporary postinfarction patients, most of whom do not participate in structured, supervised cardiac rehabilitation.

Home-based programs — Home-based cardiac rehabilitation programs, if appropriately structured and monitored, may be as safe and effective as center-based programs [56]. A Cochrane review including data through 2016 supports the previous conclusions that home- and center-based cardiac rehabilitation are similarly effective in improving clinical and health-related quality-of-life outcomes in patients after myocardial infarction, myocardial revascularization, or heart failure hospitalization [57]. After this meta-analysis was published, several randomized trials were published that also suggest similar outcomes after home-based versus center-based rehabilitation [58-63].

Local availability and individual patient preference may guide the choice for participation. According to Veterans' Health Administration data [64], patients are more likely to participate in cardiac rehabilitation when home-based rehabilitation programs are available after a hospitalization for ischemic heart disease. Home-based rehabilitation has also been shown to improve quality of life, aerobic capacity, and readmission rates in patients with chronic heart failure [65].

Telehealth exercise cardiac rehabilitation appears to be at least as effective as center-based cardiac rehabilitation in improving modifiable cardiovascular risk factors and functional capacity. It identifies the option of telehealth and the technologic advances to provide more comprehensive, responsive, and interactive interventions for individuals for whom center-based rehabilitation is not feasible [66]. The self-elected type of physical exercise in telemonitored cardiac rehabilitation improved all short- and long-term outcome measures [67]. A virtual rehabilitation-based video game program as an adjunct to cardiac rehabilitation showed improvement in ergometry, metabolic equivalents, resistance to fatigue, and health-related quality of life [68].

Virtual cardiac rehabilitation with aerobic exercise training, implemented during the COVID-19 era, offers an alternate mechanism of care delivery capable of providing similar patient outcomes and safety compared with facility-based programs. However, it remains uncertain whether the current recommendations for resistance exercise training in cardiac rehabilitation can be conducted safely in the setting of remote cardiac rehabilitation [69]. This requires the development of sustainable virtual cardiac rehabilitation solutions to fill gaps and disparities that existed before COVID-19 [70-73].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Primary prevention of cardiovascular disease" and "Society guideline links: Secondary prevention of cardiovascular disease" and "Society guideline links: Lifestyle management and cardiac rehabilitation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Heart attack recovery (The Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (The Basics)")

●Beyond the Basics topics (see "Patient education: Heart attack recovery (Beyond the Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)")

SUMMARY

●All patients with a qualifying diagnosis should be referred to an outpatient cardiac rehabilitation program.

●Exercise training is safe and effective for most patients with cardiovascular disease. However, individuals should be stratified for the risk of a cardiac-related event during exercise training. (See 'Exercise training' above.)

●Multifactorial rehabilitation programs consist of a baseline patient assessment, nutritional counseling and weight management, aggressive coronary risk-factor management, psychosocial management, physical activity counseling, and exercise training. (See 'Education' above.)

●Alternate approaches to traditional supervised group interventions, including community- and home-based programs, appear to be safe and effective for stable coronary patients. (See 'Alternate approaches' above.)