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Concordant Evidence-Based Interventions in Cardiac and Pulmonary Rehabilitation Guidelines

Smith, Sheree M. S., PhD; Chaudhary, Katrina, BA; Blackstock, Felicity, PhD

Journal of Cardiopulmonary Rehabilitation and Prevention: January 2019 - Volume 39 - Issue 1 - p 9–18
doi: 10.1097/HCR.0000000000000359
Scientific Review

Chronic conditions such as chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) contribute to a significant burden to patients and many experience a reduction in physical functioning, psychological health, and quality of life. The sentinel symptom for COPD and CVD is breathlessness. Rehabilitation programs have been proven to reduce disease symptoms and increase levels of physical and psychological wellness. Pulmonary and cardiac rehabilitation programs have been recommended in international and national guidelines for managing COPD and CVD. Given that these programs seek to reduce breathlessness and improve the physical and psychological functioning of people with COPD and CVD, this review examines the concordant evidence-based interventions in rehabilitation guidelines. The findings of this review indicate that there was concordance in the program design, location of programs, types of health professionals involved in program delivery, assessments of patient at commencement and completion of program, and the delivery of educational topics with minor deviations that were related to disease-specific topics. Apart from disease-specific recommendations, the main divergence from rehabilitation guidelines was found to be dietary screening, inspiratory muscle training, and psychological assessments in evidence-based recommendations for cardiac and pulmonary programs.

Breathlessness is the cardinal symptom experienced by patients with cardiac and respiratory diseases. Rehabilitation has been proven to reduce symptoms such as breathlessness. A synergy between cardiac and pulmonary rehabilitation programs has not been investigated and any synergy between the 2 programs may prove useful in resourcelimited health environments.

Lung, Sleep and Heart Health Research Network, School of Nursing and Midwifery, Western Sydney University, Penrith, Australia (Dr Smith); Respiratory, Sleep and Environmental Health Research Academic Unit, Ingham Institute, South Western Sydney Local Health District, Liverpool, Australia (Dr Smith); Library Service, Western Sydney University, Penrith, Australia (Ms Chaudhary); and School of Health and Science, Western Sydney University, Penrith, Australia (Dr Blackstock).

Correspondence: Sheree M. S. Smith, PhD, Lung, Sleep and Heart Health Research Network, School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith Sydney, NSW 2751 Australia (sheree.smith@westernsydney.edu.au).

All authors reviewed the findings and contributed to the content, writing, drafting, and revision of the manuscript, and agreed to the final version.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com).

People with long-term conditions such as chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have significant morbidity and a reduced quality of life.1 , 2 In the United States, 27.6% of the adult population have a diagnosis of CVD, resulting in 12 million visits to a physician's office per year and 3.7 million hospital discharges recorded with an average stay of nearly 5 d.3 , 4 For COPD, an estimated 12.7 million adults are diagnosed with the disease in addition to current data that indicate that up to 24 million adults in the United States have impaired lung function.5 The most hospitalized COPD patient group are those older than 65 y who account for 65% of all COPD hospital discharges.5 The US annual estimated cost of COPD is approximately $50 billion (USD).6 Shortness of breath is a sentinel symptom for both CVD and COPD7 and may impact a person's physical8 and psychological functioning,9 and disease-specific rehabilitation has been proven useful in reducing the effects of this distressing symptom.

The symptom of breathlessness is complex.10 It is a common symptom that can be caused by many diseases and often is an interaction of physiological mechanisms and psychological and social factors.11 In lung disease, breathlessness may be experienced by patients with respiratory diseases when either dynamic hyperinflation or bronchospasm occurs.12 , 13 Recently, dynamic hyperinflation has been found to also affect the function of the heart during expiration resulting in worsening breathlessness.14 In chronic heart failure, Witte and Clark15 suggest, in addition to increased left ventricular filling pressure, that skeletal muscle receptors may become overactive and this response is intrinsically related to the ventilatory response to exercise and breathlessness. In both lung and cardiac diseases, it is important to ensure that patients receive optimal medical management to counteract the physiological responses to these diseases16 , 17 prior to commencing a rehabilitation program.

The concept of rehabilitation has been applied and integrated into disease-specific multifaceted programs that form part of CVD1 and COPD2 care. These rehabilitation programs often comprise core elements of exercise training,18 , 19 health behavior,20 , 21 and educational aspects of symptom self-management and are delivered in hospitals22 , 23 and the community19 , 24 over a variety of time frames.1 , 2 There is evidence that individual interventions1 , 21 within these programs are effective in improving quality of life and reducing morbidity, and both cardiac25 and pulmonary26 rehabilitation programs have been proven to be effective in reducing hospitalization.

Pulmonary and cardiac rehabilitation programs for COPD and CVD patients, respectively, have been recommended in international and national guidelines that have been endorsed by professional societies and organizations. These evidenced-based rehabilitation programs encompass pharmacological and nonpharmacological approaches and interventions for the management of symptoms such as breathlessness. It would be reasonable to ascertain whether breathlessness reduction interventions are similar within these separate disease-focused rehabilitation programs. Second, it would be useful to examine the measurement of clinical and patient outcomes purported in these programs for similarities and differences in relation to the effectiveness of the breathlessness reduction interventions. Therefore, this review was conducted to identify concordant evidence-based interventions and outcomes within pulmonary and cardiac rehabilitation programs reported within international and national guidelines.

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METHODS

The aim of this systematic review was to identify and evaluate published national and international guidelines on cardiac and pulmonary rehabilitation. The central objective of this review was to identify concordant evidence-based breathlessness reduction interventions and outcome measures within these rehabilitation guidelines.

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SEARCH STRATEGY

An a priori protocol-driven and systematic search of peer-reviewed literature was performed in accordance with guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.27 , 28 The following electronic databases were searched for relevant citations: MEDLINE (OVID) including Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations, EMBASE (Ovid), and CINAHL (EBSCO). Search results were limited to English language and the search strategy pertained to citations published between January 2000 and July 2016 time frame to help ensure that the most recent guidelines were identified.

The search terms included “cardiac rehabilitation” and “pulmonary rehabilitation,” combined with “guideline” in the title and abstract fields. Search terms were abbreviated and adapted to relevant medical subject headings in each database, and the search strategy adapted for the MEDLINE database is presented in Table 1. In addition, we also conducted a search of specialty organizations and health professional and government websites including the American Thoracic Society, European Respiratory Society, The Thoracic Society of Australia & New Zealand, British Thoracic Society, Heart Foundation of Australia, European Society of Cardiology, British Heart Foundation, National Institute for Health and Care Excellence, Lung Foundation of Australia, British Lung Foundation, Heart and Stroke Foundation of Canada, Clinical Excellence Commission, and Agency for Clinical Innovation of New South Wales, Australia, for additional endorsed evidence-based guidelines.

Table 1

Table 1

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ELIGIBILITY CRITERIA

Practice or clinical guidelines were eligible for inclusion if they were a primary document that was endorsed or accredited by a national or international society or organization and detailed the evidence base for interventions. The guidelines of interest were required to incorporate either cardiac or pulmonary rehabilitation programs. Practice or clinical guidelines that either reported general opinion and description that were not substantiated with evidence or were not endorsed were excluded. The primary outcomes of interest for this review were concordant evidence-based interventions and outcomes measures. These review outcomes were evaluated through the detailing of rehabilitation interventions or outcome measurement to ensure that concordance could be determined.

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GUIDELINE AND STATEMENT SELECTION AND DATA EXTRACTION

After completing website and database searches, duplicates were removed. The titles and abstracts of the retrieved guidelines and statements were screened independently by 2 authors (S.M.S. and F.B.) using the inclusion criteria. Full-text guidelines were retrieved and further assessed for inclusion. Any disagreements regarding the inclusion of a guideline were discussed and consensus achieved. Extraction of data was undertaken and reviewed (F.B., S.M.S.) for completeness using a pre-designed spreadsheet.

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QUALITY ASSESSMENT

Two reviewers (F.B. and S.M.S.) assessed the quality of included guidelines using the “advancing guideline development, reporting and evaluation in healthcare (AGREE II)” guidance (see Supplemental Digital Content 1, available at: http://links.lww.com/JCRP/A85).29 The AGREE instrument has 23 items that are grouped into 6 domains which encompass scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence.29 (pE840) In addition to the quality assessment of guidelines, guideline recommendations were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).30

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RESULTS

The combined database searches identified a total of 412 records, of which 170 were excluded as duplicates of records from another database. After the titles and abstracts were screened, a further 221 records were excluded, leaving 21 records that potentially directly addressed breathlessness through rehabilitation programs and were endorsed by international societies on respiratory or cardiac medicine. After the full text of these articles was reviewed, an additional 12 articles were excluded. The excluded publications comprised 2 articles that were duplicates published by journals of the collaborating societies,31 , 32 4 articles were retired guidelines that had since been updated,33–36 2 articles were guidelines on COPD management and not specific to pulmonary rehabilitation,17 , 37 2 articles were described as society statements and, therefore, did not meet the criteria of clinical practice guideline,38 , 39 and 1 article was a non–evidence-based tool kit on pulmonary rehabilitation40 and another article was an addendum. A total of 9 guideline publications were included and the Figure illustrates the flow for the selection of articles.28

Figure

Figure

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OVERVIEW OF INCLUDED GUIDELINES AND STATEMENTS

Of the included practice or clinical guidelines, 6 were related to cardiac rehabilitation16 , 41–45 and 3 were related to pulmonary rehabilitation.46–48 The guidelines were endorsed by societies in Europe and North America, and there was 1 guideline from Australia with multidisciplinary authorship. Table 2 summarizes the characteristics of these published guidelines.

Table 2

Table 2

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DESIGN FEATURES OF INTERVENTIONS

All guidelines described rehabilitation as being an individually tailored program that included exercise training and educational activities and had an assessment of the individual at commencement of rehabilitation along with formative assessment of the individual across the time frame of the program including the completion of the program. There was variability to the location of the rehabilitation programs although evidence existed in most practice guidelines for key health care settings such as hospital, community, or domiciliary care. The duration of programs was another inconsistency within pulmonary and cardiac guidelines. Program facilitation was equally variable, with guidelines describing personnel from medicine, nursing, and allied health disciplines involved in leading and managing rehabilitation programs.

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Location and Duration of Intervention

All practice guidelines that provided details on location of implementation referred to the rehabilitation program being conducted in hospital, community, or home setting,16 , 42 , 44–47 with all guidelines stating that location of program did not impact on outcomes. Choice of rehabilitation venue was recommended on the basis of phase of program, and 2 of the cardiac rehabilitation program guidelines16 , 45 specifically detailed phase 1 was hospital and phase 2 and 3 in community or home settings.

Duration of the program was described either in terms of the number of weeks or the number of sessions completed. The number of weeks ranged from 6 to 12 wk.16 , 45–48 A common theme across the guidelines was that longer programs were recommended, with Marciniuk et al47 proposing rehabilitation for up to 18 mo and the Japanese Cardiac Society44 advocating rehabilitation “for life.” Within the guidelines where sessions were prescribed, the number of sessions range between 16 and 24 and were based on a minimum of 2 sessions per week for 8 to 12 wk for an outpatient-based cardiac rehabilitation program.16

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Personnel

Four guidelines described the personnel involved in implementation of the rehabilitation programs.16 , 42 , 44 , 46 All articles described a multidisciplinary team being required for an optimal rehabilitation program design. Specifically, medical specialists, nurses, and physical therapist/physiotherapist/exercise physiologist were noted as central rehabilitation personnel. Other health professional disciplines involvement varied between the guidelines and included psychologist, dietician, pharmacist, occupational therapist, general practitioner, and social services experts.16 , 42 , 46

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Assessment of Patients

The majority of clinical practice guidelines indicated the importance of patient assessments before commencing any program for baseline health measurements relevant to disease-specific rehabilitation.16 , 42 , 43 , 45 , 46 Two cardiac rehabilitation guidelines also referred to interim assessments during the program42 , 45 and most guidelines suggested post-rehabilitation patient assessment.16 , 42 , 43 , 45 , 46 Interestingly, pulmonary rehabilitation guidelines appeared less focused on patient assessment than cardiac rehabilitation, with only 1 of 3 guideline documents recommending patient assessment.46 Guidelines that referred to the assessment of patients, all recommended detailed specific assessments such as interviewing the patient to determine health status and/or measurement of exercise capacity. Additional information beyond these parameters varied between cardiac and pulmonary rehabilitation and was contextual to the guideline-based patient population. For example, cardiac risk factors and psychological state were considered important outcomes to be measured in cardiac rehabilitation post–myocardial infarction. Table 3 summarizes the assessment processes recommended across clinical practice guidelines.

Table 3

Table 3

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Components of Interventions

The core components described by all practice or clinical guidelines were exercise training and education. The precise nature of the exercise training and education varied between guidelines and was in part specific to the patient population. Table 4 summarizes the exercise training interventions recommended and Table 5 summarizes the educational activities recommended. Concordant educational topics were smoking cessation, risk factors, stress management, self-management, diet, and exercise.

Table 4

Table 4

Table 5

Table 5

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Additional Program Components

Other rehabilitation components that were incorporated into many practice guidelines comprised dietary screening and nutritional interventions, psychological interventions, social support, smoking cessation interventions, noninvasive ventilation (NIV), and inspiratory muscle training.

Dietary screening and nutritional intervention were recommended by 4 cardiac rehabilitation practice guidelines.16 , 41–43 In contrast, only 1 of the 3 pulmonary rehabilitation guidelines46 recommended a nutritional component while a second guideline48 reported insufficient evidence to make such a recommendation. Guidelines that recommended a nutritional component, information on how to screen for nutritional status, were limited, with self-report estimates of calorie intake and diet reported as the common approach utilized. Objective measures described included body mass index and waist circumference and only 1 guideline43 described the use of a validated screening tool to measure caffeine and alcohol intake. In cardiac rehabilitation guidelines, nutritional interventions included education, behavior change interventions, diet diaries, goal setting on weight loss, and lipid management (dietary and pharmacotherapy). Bolton et al46 were not specific on recommendations for pulmonary rehabilitation nutritional interventions, other than to state that patients in the under- or overweight body mass index should be considered for specific dietetic support.

Psychological screening and/or interventions were recommended by all cardiac rehabilitation practice or clinical guidelines but not specifically referred to within pulmonary rehabilitation guidelines aside to include anxiety management, relaxation, and self-management confidence as educational topics.46 Other interventions that were discussed without specific levels of evidence included screening for anxiety, depression, quality of life, self-efficacy, counseling, the use of psychologist review, pharmacotherapy, cognitive behavioral therapy, interpersonal psychotherapy, relaxation therapy, problem-solving therapy, and psychoeducational interventions. Primarily, guideline-based activities were recommended to be small group or individual and to include family members. Only 1 practice guideline mentioned specific time frames for the duration of a psychosocial intervention and stated 8 to 10 sessions of relaxation therapy with each session being 60 to 90 min.45 Social support was discussed in 2 cardiac rehabilitation practice guidelines; however, the reference was to the culture of the program or embedding within psychological interventions rather than specific social support programs.16 , 41 The evidence for such activities was low and recommendations limited.

Smoking cessation was recommended by 5 practice guidelines, 2 directly stated specific interventions16 , 43 while 2 of the other guidelines designate smoking cessation as part of the rehabilitation educational activities.44 , 46 The specific guideline-based interventions encompass screening and/or assessment of smoking status, nicotine replacement therapy, behavior change interventions, education, hypnosis, acupuncture, and individual or small group counseling.

Other interventions discussed in cardiac and pulmonary guidelines were inspiratory muscle training, oxygen therapy, and NIV. Inspiratory muscle training was recommended by 1 cardiac rehabilitation practice guideline45 and not advocated in a pulmonary rehabilitation practice guideline.46 Specific needs of particular groups of patients formed recommendations such as oxygen therapy for people with severe exercise-induced hypoxemia,48 and the use of NIV in patients already using domiciliary NIV for chronic respiratory failure was recommended during exercise training; however, the use of NIV in other patient groups during exercise was not recommended in pulmonary rehabilitation guideline.46

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QUALITY ASSESSMENT OF GUIDELINES AND STATEMENTS

The quality of the guidelines included in this review was assessed and only 3 guidelines16 , 46 , 47 were found to meet all 23 criteria across the 6 domains of the AGREE II checklist. The criteria that were poorly reported in cardiac and pulmonary clinical guidelines were predominately in the domains of rigor, guideline development, and applicability. In this domain, criteria such as search methods, evidence selection criteria, and transparent link between recommendations and evidence were lacking. The domain for editorial independence also had limited reporting in the included guidelines. For assessing the quality of guideline recommendations, the GRADE criteria were utilized and 4 guidelines were found to meet all criteria.16 , 44 , 46 , 47

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DISCUSSION

The results for this systematic review demonstrate concordance in design principles between cardiac and pulmonary rehabilitation clinical practice guidelines, focusing on addressing the symptom of breathlessness. The design principles aligned in terms of the programs being described as an individually tailored intervention, a program duration of between 6 and 12 wk, located in comparable settings, facilitated by comparable multidisciplinary personnel, included assessment of patients prior to and following the program, and were constructed to include exercise training and education. As the focus of rehabilitation is on improving health outcomes through education, exercise training, and empowering patient self-management to address the symptom of breathlessness evident in cardiac and pulmonary conditions, the evidence of concordance is not surprising. Furthermore, historically cardiac rehabilitation and pulmonary rehabilitation were designed and evaluated separately despite the similarities between the central concepts and fundamental principles.49 , 50 The evidence for the effectiveness of cardiac and pulmonary rehabilitation programs with core elements of exercise training and education resulting in behavioral change continues to grow. This may inform the potential of collaboratively designing rehabilitation programs. The opportunity for joint delivery of some aspects of the cardiac and pulmonary rehabilitation programs could possibly be exploited to ensure future benefit to patients specifically those with comorbid conditions of heart and lung disease of which the most common symptom for both conditions is breathlessness.

Despite concordance, variations in program design and emphasis exist in the educational activities and additional complementary components of the rehabilitation programs. Psychological interventions are recommended components for cardiac rehabilitation, while NIV and oxygen therapy in specific patient populations are prominent in guidelines for pulmonary rehabilitation programs. Nutritional interventions are not yet established as a recommended component of pulmonary rehabilitation but are clearly recommended for CVD to reduce risk factors. These variations are not surprising as they form contextual factors related to ensuring that rehabilitation programs are able to be individually tailored to the concerns of participants. A departure from concordance is apparent when focusing on the psychological health of cardiac and pulmonary patients. Stress management and psychological interventions have been determined to be effective at improving health outcomes for people with cardiac conditions although no evidence currently exists for patients with pulmonary diseases.51

A concordant approach can be found in educational topics of both cardiac and pulmonary rehabilitation programs with overarching focus on medical management, anatomy and pathophysiology, physical activity, diet and weight management, smoking cessation, anxiety control and relaxation strategies, and symptom management. Again, there is an emphasis on a patient-centered approach as contextual variations address the underlying perceived issues of patients attending the program and the pathophysiological differences in cardiac and pulmonary disease processes. The tailoring of a program seeks to address the patient's needs and personal goals by incorporating appropriate evidence-based interventions. Yet, the delivery of the education, while the topics were concordant across cardiac and pulmonary programs, appears to be didactic with limited underpinning of any educational framework. To truly design an individually tailored education program, future research should consider evaluating the impact of identifying learning needs and the application of current educational frameworks52 to promote and maintain the focus on the person, rather than prescribed sequence of the delivery of topics within rehabilitation programs.

These findings from this review suggest that there are opportunities to find synergies in designing lifestyle modification programs that assist with the rehabilitation of people with breathlessness, rather than categorizing a person to complete either pulmonary or cardiac rehabilitation. People with COPD are up to 5 times more likely to have a cardiovascular condition as well as COPD (OR = 4.98; 95% CI = 4.85 to 5.81; P < .001, n = 1 204 100).53 More specifically, they are 1.76 times (95% CI, 1.64-1.89) more likely to experience arrhythmias, 1.61 times more likely to experience angina pectoris (95% CI, 1.47-1.76), 1.61 times more likely to experience acute myocardial infarction (95% CI, 1.43-1.81), and 3.84 times (95% CI, 3.56-4.14) more likely to have congestive heart failure than the general population.54 , 55 Risk of hospitalization due to a cardiovascular event is elevated in people with COPD, and they are 2.07 times (95% CI, 1.82-2.36) more likely to die from cardiovascular conditions.54 There appears to be a relationship between lung function impairment and cardiovascular events, which is mediated through established CVD risk factors.55 , 56 Consideration may need to be given to whether running 2 separate rehabilitation programs tagged as pulmonary or cardiac is the best approach and cost-effective method for supporting individuals with chronic cardiopulmonary dysfunction.

Considering the poor completion rates currently being documented in both models of pulmonary and cardiac rehabilitations, there is a need to design sustainable programs that truly are individually tailored and meet overall needs of patients. Pulmonary rehabilitation commencement rates are approximately 50% of referrals, and of those who enter pulmonary rehabilitation 30% of patients do not complete the program.57 , 58 Reasons for poor uptake and completion rates are reported to be travel and transport challenges and a lack of perceived benefit of pulmonary rehabilitation.57 The issues for attendance are comparable in cardiac rehabilitation, with nonattenders being more likely to be older, have lower income and/or greater social deprivation, deny the severity of their illness, experience difficulty in accessing a program, have lower self-efficacy, and be less likely to believe that they can influence their health outcomes and/or perceive that their physician does not recommend cardiac rehabilitation.59–61

Designing a breathlessness modification program that specifically targets breathlessness symptom management within a rehabilitation framework may improve the patient's perception of benefit. When a program is tailored to address the symptom of greatest concern to the patient, as well as addressing the disease process of his or her comorbid conditions, there may be a perception of greater benefit by the patient. Such innovative changes to how health professionals view and deliver rehabilitation for people who experience breathlessness may lead to improved uptake and sustained benefits in the longer term. Future research into a centralized model of rehabilitation that focuses on symptom management and holistic care incorporating cardiac and pulmonary rehabilitation interventions rather than disease management could be justified.

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LIMITATIONS

This systematic review of clinical or practice guidelines may have missed publications due to the a priori protocol-defined search strategy. Furthermore, guidelines that were published after the a priori defined search period may not have been identified and therefore not included in this review. An extensive search of international society websites related to cardiac and pulmonary conditions was conducted in addition to the search of databases to source all relevant guidelines, and it is possible that guidelines may not have been identified. Overall, the evidence level for some recommendations within included guidelines was found to be low, and many guidelines have not used a GRADE approach when evaluating the literature and, therefore, may limit the application of the guideline recommendations to clinical practice.

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CONCLUSION

The results for this systematic review demonstrate concordance in many design principles between cardiac and pulmonary rehabilitation clinical practice guidelines, focusing on addressing the symptom of breathlessness. These findings suggest opportunities to identify synergies across rehabilitation programs to refocus these programs on symptom management rather than prescribed features based upon disease processes. Future research could focus on deconstructing current pulmonary and cardiac rehabilitation programs and redesigning a more holistic program that is individually tailored with an additional focus on the patient's symptoms and concerns.

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Keywords:

cardiac rehabilitation; cardiovascular disease; chronic obstructive pulmonary disease; pulmonary rehabilitation

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