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AHA/AACVPR Scientific Statement

Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update: A Scientific Statement From the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation

Balady, Gary J. MD, FAHA, Chair; Williams, Mark A. PhD, Co-chair; Ades, Philip A. MD; Bittner, Vera MD, FAHA; Comoss, Patricia RN; Foody, Jo Anne M. MD, FAHA; Franklin, Barry PhD, FAHA; Sanderson, Bonnie RN, PhD; Southard, Douglas PhD, MPH, PA-C

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Journal of Cardiopulmonary Rehabilitation and Prevention: May-June 2007 - Volume 27 - Issue 3 - p 121-129
doi: 10.1097/01.HCR.0000270696.01635.aa
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Cardiac rehabilitation/secondary prevention programs are recognized as integral to the comprehensive care of patients with cardiovascular disease1,2 and as such are recommended as useful and effective (Class I) by the American Heart Association (AHA) and the American College of Cardiology in the treatment of patients with coronary artery disease3-5 and chronic heart failure.6 Consensus statements from the American Heart Association,1 the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR),7 and the Agency for Health Care Policy and Research2 conclude that cardiac rehabilitation programs should offer a multifaceted and multidisciplinary approach to overall cardiovascular risk reduction and that programs that consist of exercise training alone are not considered cardiac rehabilitation. The AHA and the AACVPR recognize that all cardiac rehabilitation/secondary prevention programs should contain specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular disease.8

This update to the previous statement8 aims to present current information on the evaluation, interventions, and expected outcomes in each of the core components of cardiac rehabilitation/secondary prevention programs in agreement with the 2006 update of the AHA/American College of Cardiology (ACC) secondary prevention guidelines,9 including baseline patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counseling and exercise training (Tables 1 and 2).2,7,9-25 The most notable updates in the present statement are the changes in lipid goals and strategies to attain them and a new emphasis on ensuring that patients are taking the appropriate medications that have been shown to be of substantial benefit in reducing subsequent adverse cardiovascular events. Inherent to these recommendations is the understanding that successful risk factor modification and the maintenance of a physically active lifestyle is a lifelong process. Hence, incorporation of strategies to optimize patient adherence to lifestyle and pharmacological therapies is integral to the attainment of sustained benefits. It is essential to the success of any program that each of these interventions is performed in concert with the patient's primary care provider and/or cardiologist, who will subsequently supervise and refine these interventions over the long term.10 These recommendations are intended to assist cardiac rehabilitation staff in the design and development of programs and to assist healthcare providers, insurers and policy makers, and consumers in the recognition of the comprehensive nature of such programs. In turn, insurance providers and third-party payers should provide adequate reimbursement for cardiac rehabilitation/secondary prevention programs such that comprehensive interventions delivered by a multidisciplinary team of professionals can be sustained. It is not the intent of this statement to promote a rote approach or homogeneity among programs but rather to foster a foundation of services on which each program can establish its own specific strengths and identity and effectively attain outcome goals for its target population. Presently, these core components are an integral part of the national program certification process established by the AACVPR (http://www.aacvpr.org/certification/). As such, programs certified by the AACVPR are recognized as meeting essential standards of care in keeping with the contemporary definition of cardiac rehabilitation as a secondary prevention program. The AHA and AACVPR encourage all cardiac rehabilitation/secondary prevention programs to meet the standards for AACVPR program certification.

TABLE 1
TABLE 1:
Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: Patient Assessment, Nutritional Counseling, and Weight Management
TABLE 1
TABLE 1:
Continued
TABLE 2
TABLE 2:
Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: Blood Pressure Management, Lipid Management, Diabetes Management, Tobacco Cessation, Psychosocial Management, Physical Activity Counseling, and Exercise Training
TABLE 2
TABLE 2:
Continued
TABLE 2
TABLE 2:
Continued
TABLE 2
TABLE 2:
Continued
TABLE 2
TABLE 2:
Continued
Disclosures
Disclosures:
Disclosures
Table
Table

Comprehensive and detailed guidelines on cardiac rehabilitation/secondary prevention programs have been published by the AACVPR7 and endorsed by the AHA. Detailed guidelines on specific risk factor modification are also available.9,11-20 Specific details on management of patients with heart failure, valvular disease, arrhythmias, and other cardiovascular diagnoses in such programs are beyond the scope of this document and can be found in the AACVPR guidelines.7

References

1. Leon S, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation [published correction appears in Circulation. 2005;111:1717]. Circulation. 2005;111:369-376.
2. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agencies for Health Care Policy and Research, and the National Heart, Lung, and Blood Institute. AHCPR publication No. 96-0672. October 1995.
3. Antman EM, Anbe ST, Armstrong PW, et al. American College of Cardiology; American Heart Association; Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction:executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) [published correction appears in J Am Coll Cardiol. 2005;45:1376]. J Am Coll Cardiol. 2004;44:671-719.
4. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366-1374.
5. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003;107:149-158.
6. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112:1825-1852.
7. American Association for Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, Ill: Human Kinetics Publishers; 2004.
8. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000;102:1069-1073.
9. Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute [published correction appears in Circulation. 2006;113:e-847]. Circulation. 2006;113:2363-2372.
10. King ML, Williams MA, Fletcher GF, et al. Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: a scientific statement from the American Heart Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;112:3354-3360.
11. Sanderson BK, Southard D, Oldridge N. AACVPR consensus statement: outcomes evaluation in cardiac rehabilitation/secondary prevention programs: improving patient care and program effectiveness. J Cardiopulm Rehabil. 2004;24:68-79.
12. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.
13. Grundy SM, Cleeman JI, Merz CN, et al. For the Coordinating Committee of the National Cholesterol Education Program, endorsed by the National Heart, Lung, and Blood Institute, American College of Cardiology Foundation, and American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines [published correction appears in Circulation. 2004;110:763]. Circulation. 2004;110:227-239.
14. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report [published correction appears in JAMA. 2003;290:197]. JAMA. 2003;289:2560-2572.
15. Fiore MC, Bailey WC, Cohen SJ, for expert panel. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
16. Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998;158:1855-1867.
17. American Diabetes Association. Standards of medical care for patients with diabetes mellitus [published correction appears in Diabetes Care. 2003;26:972]. Diabetes Care. 2003;26(suppl 1):S33-S50.
18. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. American Diabetes Association. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1433-1438.
19. Thompson PD, Buchner D, Piña IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107:3109-3116.
20. Grundy SM, Pasternak R, Greenland P, Smith S Jr, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 1999;100:1481-1492.
21. American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. 7th ed. Baltimore, Md: Williams & Wilkins; 2006.
22. Piña IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation. 2003;107:1210-1225.
23. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682-692.
24. Poirier P, Giles TD, Bray GA, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113:898-918.
25. US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136:760-764.
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AHA Scientific Statements prevention rehabilitation

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