Anatomia y mas

Journal of the American College of Cardiology © 2008 by the American College of Cardiology Foundation Published by Elsevier Inc.

Vol. 51, No. 17, 2008 ISSN 0735-1097/08/$34.00 doi:10.1016/j.jacc.2008.01.030

STATE-OF-THE-ART PAPER

Current Status of Cardiac Rehabilitation
Nanette K. Wenger, MD, MACP, FACC, FAHA Atlanta, Georgia
Cardiac rehabilitation is increasingly recognized as anintegral component of the continuum of care for patients with cardiovascular disease. Its application is a class I recommendation in most contemporary cardiovascular clinical practice guidelines. Despite the documentation of substantial morbidity and mortality benefits, cardiac rehabilitation services are vastly underutilized. The core components of cardiac rehabilitation have been detailedlydelineated. Implementation of newly available performance measures offers the potential to enhance referral to, enrollment in, and completion of cardiac rehabilitation. (J Am Coll Cardiol 2008;51:1619–31) © 2008 by the American College of Cardiology Foundation

Over a decade ago, the 1995 clinical practice guideline Cardiac Rehabilitation from the U.S. Department of Health and Human Services, Agency forHealthcare Policy and Research (AHCPR), and the National Heart, Lung, and Blood Institute (1) characterized cardiac rehabilitation as the provision of comprehensive long-term services involving medical evaluation; prescriptive exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. This delineation remains highly relevant and applicable today. The AHCPRguideline highlights the effectiveness of multifaceted and multidisciplinary cardiac rehabilitation services integrated in a comprehensive approach. The goal of this multifactorial process is to limit the adverse physiological and psychological effects of cardiac illness, to reduce the risk of sudden death or reinfarction, to control cardiac symptoms, to stabilize or reverse progression of theatherosclerotic process, and to enhance the patient’s psychosocial and vocational status. Provision of cardiac rehabilitation services, per the guideline (1), was to be directed by a physician, but implementation could be accomplished by a variety of health care professionals. Although traditionally most candidates for cardiac rehabilitation services were patients following myocardial infarction (MI)(2) or coronary artery bypass graft (CABG) surgery, contemporary use also includes patients following percutaneous coronary interventions (PCIs); heart or heart/ lung transplantation recipients; patients with stable angina or stable chronic heart failure; those with peripheral arterial disease with claudication; and patients following cardiac surgical procedures for heart valve repair orreplacement (3). Indeed, referral for cardiac rehabilitation is a class I indication (useful and effective) in most contemporary clinical practice guidelines, including those for ST-segment elevaFrom the Emory University School of Medicine, Atlanta, Georgia. Manuscript received December 6, 2007; revised manuscript received January 11, 2008, accepted January 21, 2008.

tion MI (4), unstableangina/non–ST-segment elevation MI (5), chronic stable angina (6), PCI (7), CABG surgery (8), heart failure (9), valvular heart disease (10), peripheral arterial disease (11), and cardiovascular prevention in women (12). In recent years, participants in cardiac rehabilitation programs have increasingly included patients who are older, those who have multiple comorbidities, and those with heart failure and/orperipheral arterial disease, as well as patients following PCI or cardiac transplantation. The 1995 cardiac rehabilitation clinical practice guideline (1) documented that a minority of patients appropriate for cardiac rehabilitation services were referred or enrolled. Over a decade later, the use of cardiac rehabilitation services by Medicare beneficiaries after MI or CABG surgery remains...