Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low- to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low- to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide.
The Global Charter on cardiovascular rehabilitation (CR) and prevention brings together 14 national associations and documents consensus among these associations regarding the internationally common core elements and benefits of CR. The Charter calls for augmentation of CR services to ensure broad access.
York University and University Health Network, Toronto, Ontario, Canada (Dr Grace); Physical Activity Promotion and Chronic Disease Prevention Unit, University of British Columbia, Vancouver, Canada (Dr Warburton); Libin Cardiovascular Institute of Alberta and University of Calgary, Calagry, Alberta, Canada (Dr Stone); School of Nursing, Auburn University, Auburn, Alabama (Dr Sanderson); University of Wisconsin School of Medicine and Public Health and Aurora Cardiovascular Services, Aurora Medical Center, Milwaukee, Wisconsin (Dr Oldridge); Croí Heart and Stroke Centre, Galway, Ireland (Ms Jones); University of California, Irvine (Dr Wong); Department of Clinical Sciences, University of Chester, Chester, United Kingdom (Dr Buckley).
Correspondence: Sherry L. Grace, PhD, Faculty of Health, York University, 368 Bethune, 4700 Keele St, Toronto, ON M3J 1P3, Canada (firstname.lastname@example.org).
The authors declare no conflict of interest.
Cardiovascular disease remains the leading killer of adult women and men globally. However, as substantial gains in reducing acute cardiovascular mortality have been realized, the prevalence of persons living with cardiovascular disease has increased significantly. Without systematic access to formal and informal programs of chronic cardiovascular disease prevention such as cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and/or suffer unnecessarily premature death.
AIMS AND FOCUS
The 2 aims of this Charter are as follows:
* to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation; and
* to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation.
The focus of this Charter is secondary prevention, which has well-established models supported by a robust evidence base. This Charter is visualized to fit at the latter end of a continuum from primary prevention, which is also recognized as valuable.
The World Health Organization1 has defined CR as:
The sum of activities required to influence favourably the underlying cause of the disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume when lost as normal a place as possible in the community.(p5)
This process includes the facilitation and delivery of prevention strategies.
Cardiovascular prevention and rehabilitation programs are shown to significantly reduce mortality and repeat hospitalizations.2–4 These benefits are demonstrated in patients with acute coronary syndromes, stable chronic angina, and stable chronic heart failure and after percutaneous coronary intervention, coronary artery bypass surgery, cardiac valve surgery, cardiac transplantation, and cardiac resynchronization therapy.5 There is a growing evidence base on the same benefits of cardiovascular prevention and rehabilitation principles being applied to individuals at high risk but yet not diagnosed with cardiovascular disease.6
In addition to these improved clinical outcomes, cardiovascular prevention and rehabilitation is also cost effective.7,8 Furthermore, comprehensive programs of cardiovascular prevention and rehabilitation reach across the continuum of patient care between acute disease and chronic disease care, thus easing the transition of patients from life-threatening illness to lifelong productivity and well-being.
The only proven model that significantly and substantially reduces the mortality and morbidity (both physical and psychological) associated with cardiovascular disease is CR. Despite the proven clinical and economic benefits of cardiovascular prevention and rehabilitation, it remains a chronically underutilized resource.9,10 The strong evidence base for cardiovascular prevention and rehabilitation is such that any person diagnosed with cardiovascular disease should be offered a comprehensive program, which is in equal importance with respect to the medical or surgical interventions they receive following such a diagnosis. For these reasons, proven mechanisms to facilitate universal access for indicated and eligible patients across genders, age, and ethnocultural and socioeconomic diversity should be instituted, such as systematic referral strategies.11 Referral to cardiovascular prevention and rehabilitation as a performance measure provides a major step to help facilitate accountability for implementing this quality indicator within processes of care.12
Cardiac rehabilitation programs facilitate chronic cardiovascular disease care by specifically targeting patient cardiometabolic health and psychosocial well-being. The core components of contemporary cardiovascular prevention and rehabilitation programs are intended to mitigate the atherosclerotic disease processes that drive cardiovascular disease progression and the related effects this has on psychosocial health. These components include individualized programs of cardioprotective pharmacological therapies in conjunction with health behavior and education interventions of physical activity and exercise, nutrition, psychological health, and smoking cessation, which are sensitive to and reflective of the socioeconomic and cultural mosaic in which they are offered.5,13,14 Secondary prevention including blood pressure and cholesterol management and the prescription of cardioprotective medication also forms an integral part of effective cardiovascular prevention and rehabilitation.15 Likewise, defining the core competencies of professionals providing these core components help align health care providers, educators, students, and administrators, with defined expectations for knowledge and skills in providing cardiovascular prevention and rehabilitation services.16
Cardiovascular prevention and rehabilitation programs may be offered and are equally effective in institution-, community-, and home-based settings.2,6,17–19 The secondary prevention of coronary heart disease for all in need framework forwards a flexible model that can be adapted to diverse settings while ensuring a minimum care standard.20 These parameters, if appropriate, can be applied to primary prevention.
Both government and private organizations responsible for the provision of patient care services can no longer deny patients with cardiovascular disease the access to cardiovascular prevention and rehabilitation.
The Charter is to be a call for action to cardiovascular prevention and rehabilitation organizations and established associations around the world to partner and collaborate with those responsible for administering patient care
1. to establish cardiovascular prevention and rehabilitation as an essential, not optional service; and
2. to support countries to establish and augment programs of cardiovascular prevention and rehabilitation, adapted to local needs and conditions, to ensure broader access to these proven services.
With this Charter is the commitment to maintain and grow this consortium through partnership with international organizations to consider and communicate ongoing consensus on evidence-based standards for CR.
The Charter authors thank T. Briffa (Australia), M. Benetti (Brazil), S. Bredin (Canada), L. Carlyle (Canada), J. Chang (United States), C. Chessex (Canada), A. Clark (Canada), A. Contractor (India), C. Cyr (Canada), P. Doherty (United Kingdom), G. Melo-Ghisi (Brazil), J. Harris (Canada), S. Hinton (United Kingdom), R. Humphrey (United States), N. Jaha (Saudi Arabia), A. Jones (China), A.C. Kentner (Canada), R. Munoz-Sandoval (Mexico), N. Oldridge (United States), P. Oh (Canada), B. O'Neill (Canada), J. Redfern (Australia), B. Reid (Canada), N. Sarrafzadegan (Iran), S. Shanmugasegaram (Canada), N. Suskin (Canada), C. Terzic (United States), R. Thomas (United States), and L. Wilson (Canada) for their contributions.
This study was funded by the Canadian Institutes of Health Research.
This article is endorsed by the following organizations: American Association of Cardiovascular and Pulmonary Rehabilitation, American Society for Preventive Cardiology, Australian Cardiovascular Health and Rehabilitation Association, Brazilian Group of Cardiopulmonary and Metabolic Rehabilitation of the Brazilian Society of Cardiology, British Association for Cardiovascular Prevention and Rehabilitation, the Canadian Association of Cardiac Rehabilitation, the Canadian Cardiovascular Society, the Cardiac Rehabilitation Association of New Zealand, the Centre for East-meets-West in Rehabilitation Sciences, Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, the Cuban Society of Cardiology, the Iranian Heart Foundation, the Irish Association of Cardiac Rehabilitation, the National Society for Prevention of Heart Disease and Rehabilitation, India, and the Saudi Group for Cardiovascular Prevention and Rehabilitation of the Saudi Heart Association.
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cardiac rehabilitation; health care access; prevention; outcome and process assessment