The American College of Sports Medicine met to consider the importance of cardiac rehabilitation (CR) in 1971, which led to the publication of the first edition of the Guidelines for Graded Exercise Testing and Exercise Prescription and the initial certification conference for program directors in 1975.3 In 1975, the American Heart Association's (AHA) Committee on CR Exercise presented its first guidelines on exercise testing and training for patients with or at high risk for heart disease.4 This was a period when a formal curriculum was being developed for training professionals in the field of CR at several universities including Ball State University, East Stroudsburg University, San Diego State University, Wake Forest University, and the University of Wisconsin (Madison and Lacrosse).
An important event in the genesis of the journal was a conference organized by Michael Pollock at Mount Sinai Medical Center, Milwaukee, in 1978 entitled “Heart Disease and Rehabilitation: State of the Art.” He sensed an enthusiasm from the 750 attendees that sparked the idea for a new professional journal. Dr Pollock felt the need for a physician co-editor and at the time, Dr Victor Froelicher was at the University of California, San Diego, and the Principal Investigator of an NIH-sponsored trial on the effect of exercise training on heart disease patients using new nuclear imaging techniques. Ultimately, Dr Froelicher agreed to be co-editor and Drs Pollock and Froelicher became the first editors-in-chief for the journal.
A stellar editorial board was recruited, an editorial office was established, and the first editorial assistant was hired in 1980. Drs Pollock and Froelicher had convinced more than 15 CR groups to submit enough articles for the first 2 issues of a yet-to-be-released publication. Unfortunately, Houghton Mifflin sold their medical division in the middle of 1980, and the Journal of Cardiac Rehabilitation (JCR) was in jeopardy of never going to press. Sam Fox, MD, recommended a new publishing company, LeJacq Publishing, Inc, which agreed to publish the JCR. The first issue of the JCR was published in January of 1981.5 In the inaugural issue the editors gave a rationale for the new journal and a view of its purpose and proposed content was included. Drs Pollock and Froelicher stated:
Reports of research and clinical management appear scattered through journals of more fields than any one professional person can review. We, who are cardiac rehabilitation workers and our patients lose much because of this scattering of new information. We need a forum in which to share our knowledge and our concerns. The Journal of Cardiac Rehabilitation will be such an international gathering place in which all cardiac rehabilitation workers, both scientists and practitioners, can share their investigations and observations. By providing a wide range of scientific papers of uniformly high academic standard, the journal will give focus to this new and exciting area of medicine. The journal's many features will enable cardiac rehabilitation staff to stay up to date with this fast-changing field. In addition to scientific papers and review articles, the journal will offer a forum for discussion in its feature “Letters to the Editors.” It will also present case reports of unusual interest, reviews of new books and audio-visual materials, and an international calendar of cardiac rehabilitation programs and events.5
The birth of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) in 1985 closely followed that of the JCR. During the 1980s, numerous state associations were formed and the need for a common national voice was recognized. This was first accomplished through local, regional, and national meetings. In 1985, a national organization was formed and the AACVPR was founded. The JCR was essential to the mission of this new organization and became the official journal of the AACVPR, which led to our first name change (Journal of Cardiopulmonary Rehabilitation) that year (Table 1). In February 1988, the Lippincott Company became the publishers and a 30+ yr relationship now leads us into our 40th yr.
GETTING INTO THE MAINSTREAM: THE QUEST FOR JCR'S INCLUSION IN INDEX MEDICUS (1990-1995)
In 1989, Barry Franklin, PhD, was nominated by the AACVPR Board to serve as the next Editor-in-Chief of the JCR; an appointment that he accepted, knowing that very high standards had already been established in following the pioneering work of Drs Pollock and Froelicher. Because the JCR had been previously declined for inclusion in Index Medicus, Franklin established that goal as the #1 priority. Working with the AACVPR Board, a 5-yr strategic plan was established. Objectives included securing comprehensive and timely manuscript reviews, soliciting more original research reports and relevant contributions from major experts in the field, and broadening the journal armamentarium to include editorial and abstract summaries of the contemporary literature, roundtables, commentaries, and regular columns (eg, nutrition, pharmacology, and patient counseling/management) reflecting the unique multidisciplinary nature of our profession. These important additions were designed to provide state-of-the-art practical information for JCR's readership.
From 1990 to 1995, nearly 400 submitted manuscripts were peer-reviewed, and 167 (42%) were ultimately accepted for publication. In 1994, the JCR was designated as the official journal of the Canadian Association of Cardiac Rehabilitation (CACR), reflecting the widening influence that it held in the international community (Table 1).
Finally, the odyssey to secure JCR's inclusion in Index Medicus, after previous unsuccessful attempts, is one worth recounting. After the most recent application was denied in January 1994, an appeals process began, spearheaded by Dr Franklin, who believed that an unconventional, face-to-face meeting with the Executive Editor of Index Medicus at the National Library of Medicine (NLM), in Bethesda, Maryland, offered a more proactive opportunity to secure the elusive designation: now in Index Medicus. After multiple communications and negotiations with this office, he was offered a brief period (5 min) to plead the case for the uniqueness and quality of the JCR, and clarification of the requirements necessary to secure JCR's inclusion in Index Medicus. Franklin returned from the meeting with additional ideas that included a letter writing campaign to the NLM on the merits of this journal, which had then been published for nearly 15 yr. The AACVPR Board, JCR Editorial Board, and members of the AACVPR and the CACR then waited patiently, once again, until the following letter was received in early November 1995, with key excerpts shown below:
As you know, the National Library of Medicine uses an advisory committee, the Literature Selection Technical Review Committee, composed of authorities knowledgeable in the field of biomedicine, such as physicians, researchers, educators, editors, health science librarians, and historians, to review and recommend the journal titles NLM should index. The Committee recently completed a review of journals for possible inclusion in the National Library of Medicine's MEDLARS system. I am pleased to inform you that the Journal of Cardiopulmonary Rehabilitation has been selected to be indexed and included in Index Medicus and MEDLINE on the MEDLARS system. MEDLARS is available online in U.S. and throughout the world. Citations from the articles indexed, the indexing terms, and the English abstract printed in the journal will be included in MEDLARS. Since indexing for the Journal of Cardiopulmonary Rehabilitation will begin with vol. 15, no. 1, January/February 1995, it would be helpful to receive one complimentary copy of that issue and future ones.
Sincerely yours, Lois Ann Colaianni Executive Editor Index Medicus
This accomplishment along with the continued expansion of high-quality AACVPR/CACR educational programming and supporting scientific statements on the value of cardiovascular and pulmonary rehabilitation and prevention from other major associations catapulted our formidable mission, that is, the treatment and prevention of cardiovascular and pulmonary disease, into the mainstream of contemporary medical care. The publication of the first and second editions of the AACVPR CR guidelines as well as the Cardiac Rehabilitation Clinic Practice Guidelines, No. 7, October 1995,6 spearheaded by the exemplary leadership of Nanette Wenger, MD (Co-Chair), Erika Sivarajan Froelicher, RN, PhD (Co-Chair), and L. Kent Smith, MD, MPH (Project Director), in aggregate, gave yet further support.
ADDING AN IMPACT FACTOR
A subsequent challenge was the inclusion of the JCR into the International Scientific Indexing (ISI) evaluation process that grades scientific journals by the frequency that its journal articles are cited by other scientific journals. This was important as, at many institutions and in many countries, the quality of a scientist's publications is graded by the impact factor that ISI provides for publications. Without an impact factor many investigators would direct their publications elsewhere. Dr Philip Ades took on this process and an initial application in 2004 was rejected partly because JCR was evaluated as a nursing journal whereas our focus was broader and multidisciplinary. Our second application was submitted in January 2007 as a cardiovascular medical journal concurrent with our name change to the Journal of Cardiopulmonary Rehabilitation and Prevention (JCRP) after the JCRP had celebrated its 25th anniversary. In April 2007, we received the simple message by e-mail that “We have been monitoring your journal and have accepted it for coverage in Current Contents/Clinical Medicine and Science Citation Index Expanded” from M. Luisa Rojo, Editor Current Contents/Clinical Medicine ISI, Philadelphia, PA.
The name change to the Journal of Cardiopulmonary Rehabilitation and Prevention (JCRP) reinforced the additional emphasis on preventive cardiology and secondary prevention of coronary heart disease beyond simply an exercise-based intervention that had been embedded in the journal and the profession since its inception.7–9 Over the years, strong citation data affirmed the importance of receiving an impact factor (Table 2).10–19
DEVELOPING STRONG PARTNERSHIPS
In 1994, the AHA took a giant step forward for the field of CR with its publication of the seminal Position Statement on Cardiac Rehabilitation.20 The statement defined CR as a combination of prescriptive exercise training with coronary risk factor modification in patients with established heart disease, and declared that “as such, cardiac rehabilitation is standard care that should be integrated into the overall treatment plan of patients with coronary artery disease.”20 One year later in 1995, the United States Agency for Health Care Policy and Research published an expansive, evidence-based and detailed Clinical Practice Guideline on Cardiac Rehabilitation6 in which expert leaders from the AACVPR and the AHA played a major role. Hence, the groundwork was established for the development of strong future partnerships between the AACVPR and the AHA, and later the American College of Cardiology (ACC), the Centers for Disease Control and Prevention (CDC), and other agencies and organizations. Collaborative efforts among these organizations led to the generation of practice standards for CR, policy statements, performance measures, clinical competency requirements, disease management strategies, and advocacy initiatives. The JCRP played an integral role in disseminating information to its multidisciplinary readership on these many important topic areas in publishing or co-publishing-related articles and policy statements.
The practice of CR and disease management was evident in many key publications from the 1990s to the present. The large Clinical Practice Guideline6 was subsequently distilled into the succinct “AHA/AACVPR Core Components of Cardiac Rehabilitation/Secondary Prevention Programs” initially published in 20007 and updated in 200721; and the original AHA statement on CR was updated in collaboration with the AACVPR in 2005.22 In order to support advocacy efforts aimed at procuring support from the Centers for Medicare & Medicaid Services (CMS) to cover CR services for patients with systolic heart failure, a key white paper was published to document the safety and effectiveness of cardiac rehabilitative exercise-based CR in chronic heart failure.23 As a result, coverage for such patients was approved by the CMS in February 2014. Similarly, the recently published statement on home-based CR summarizes evidence to document the efficacy of CR conducted beyond the walls of the standard on-site, conventional, medically supervised on-site group programs.24 This important paper can be used in future practice guidelines and to support advocacy efforts. More recently, AACVPR's heightened involvement with other organizations beyond traditional CR is reflected in its participation on the 2018 Guideline on the Management of Blood Cholesterol and the Million Hearts Initiative of the CDC and the Cardiac Rehabilitation Collaborative.25,26
CLINICAL COMPETENCY STANDARDS AND PERFORMANCE MEASURES
To optimize favorable outcomes from CR and secondary prevention programs, demonstration of staff competencies is essential. Collaborative standards have been published for CR staff and for physicians as medical directors of CR programs.27–29 As the field of preventive cardiology matures, specific competence and training statements to develop expertise in cardiovascular disease prevention have been published in collaboration with the AACVPR.30
It is remarkable to witness the growing importance of CR as heralded by the AHA's 1994 statement,20 such that inpatient and outpatient cardiovascular performance measures now include referral and enrollment of patients into CR programs. These collaboratively developed performance measures were initially published in 200731 and subsequently updated in 2010 and 2018.32,33 The AACVPR is now a key partner in the development of performance measures beyond traditional CR, and extending into the field of primary prevention of cardiovascular diseases34 and the conceptual framework of performance measures as a whole.35
GROWTH OF A PROFESSION—THE CARDIAC REHABILITATION GUIDELINES
The role of the JCRP and the AACVPR in pursuing accepted treatment patterns, based upon the evidence-based literature, was at the forefront of their respective missions. To a large extent, based upon the interest and success of the journal, in 1987-88 AACVPR leadership explored the development of translational and program guidelines for CR. Although several years would pass before a formal guideline document would emerge, it was the value and relationship of the journal to the leadership and its members that would drive guideline development. Thus, stemming from the value and success of the journal, this new and important endeavor became a mainstay for CR practitioners. Those who played significant roles in the development and continued efforts in the success of the “Guidelines” documents are listed in Supplemental Digital Content 1 (available at: http://links.lww.com/JCRP/A152).
First edition (1991).36 Under the direction of Barry Franklin, PhD, and Linda Hall, PhD, the first AACVPR CR Guidelines writing group was developed.36 Much was addressed: program structure, risk stratification, monitoring, exercise prescription, patient assessment/education, personnel, and patient safety. The manuscript was approved by the AACVPR Board of Directors and the Guidelines for CR Programs was published by Human Kinetics which continues as the publisher in 2019.
Second edition (1995).37 Drs Franklin and Hall agreed to undertake the second installment of the “CR guidelines.” The edition expanded to 150 pages and added sections on program administration, resistance training, psychosocial intervention, outcomes, and documentation. Of significance to the future of our work, the AACVPR position statement “Core Competencies for CR Professionals” (1994) was also included.28
Third edition (1999).38 In 1997, Mark Williams, PhD, was asked to take on the role of Editor-in-Chief, a position he would occupy for 3 editions. To broaden the approach to CR, the Guidelines title now included “Secondary Prevention,” and took on 2 new sections addressing “Modifiable CVD Risk Factors” and “Special Populations.” The third edition comprised 300 pages and 500+ citations and 21 appendices and was endorsed by the ACC and the AHA as well as the Sports, Cardiovascular and Wellness Nutritionists (SCAN) of the American Dietetic Association.
Fourth edition (2004).39 This edition brought significant content upgrades beginning with the addition of “Emergence of Nutrition and Plant-based Diets” and ∼650 updated citations and 24 appendices. Major updates to recommendations for management of emergency procedures, code carts, charting, and equipment maintenance/calibration procedures were particularly impactful to program standards.
Fifth edition (2013).40 The most recent volume exceeded 300 pages incorporating >900 citations including annotated reference citations by each chapter. Accessible web-based resources, including a variety of functional forms, were also available. An added chapter to the guidelines, “Outcome Assessment and Utilization,” addressed relevant issues on a variety of levels.
Sixth edition (2020).41 CR continues to be a complex intervention with a multidisciplinary treatment approach directed at cardiovascular risk reduction via patient-specific interventions (eg, regular moderate-to-vigorous physical activity, dietary modification, and smoking cessation) and physical activity. With expanded qualifying diagnoses, participants are increasingly diverse, oftentimes with multiple comorbidities. Interventions employed in CR must accommodate an evolving patient demographic, be increasingly accessible, and remain evidence-based. The sixth edition, scheduled for release in 2020, is being edited by Patrick Savage, MS, and will continue this tradition, providing updated recommendations and guidelines for the treatment and care of our patients.
With the foresight and pioneering vision of Drs Pollock and Froelicher in 1981, the JCRP is now well-established and widely recognized as the primary resource for the publication of current clinically relevant research and clinical related reviews and scientific statements in North America and around the world. As summarized in this commentary, the JCRP has adapted and evolved over the past 40 yr (Figure). Advancements in technology have created an information explosion where data availability is ever expanding. Adaptations implemented by the JCRP to increase both timeliness of communications and access to articles include establishing social media accounts (eg, Facebook, Linkedin, and Twitter), allowing authors to present ancillary materials via the use of Supplemental Digital Content, and expanding the number of articles in each issue by including some that are provided only digitally (ie, not in the print version of the journal). The JCRP will continue to evolve to stay current with timely, up-to-date information and dissemination approaches. It will remain committed to providing high-quality research and clinical findings that will advance the evidence base for CR, pulmonary rehabilitation, and cardiopulmonary prevention.
Cardiac rehabilitation is now standard of care for individuals with coronary heart disease, chronic heart failure, heart valve replacement, heart transplant and symptomatic peripheral artery disease, supported by multiple position papers, and organization guidelines. Guided by its Editor, its Associate Editors, its Editorial Board, and the Publication Committees of both AACVPR and the CACR, its role in CR and prevention will continue to expand as new knowledge emerges. It will continue to publish up-to-date position papers and guidelines,24,42,43 along with review papers44,45 and research studies to remain the leading journal in its field. Accordingly, it is important to pause for a moment to reflect on, and recognize the exemplary efforts of the many scientists, researchers, and clinicians who led us to this point in the development of our rewarding field and formidable mission.
The authors thank Kate Maude, JCRP Managing Editor, for her assistance with accessing historical information for the JCRP.
Dr Ades was supported by the National Institute of General Medical Sciences Center of Biomedical Research Excellence award P20GM103644-01A.
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