Cardiac Rehabilitation

Aka: Cardiac Rehabilitation, Activity after Myocardial Infarction

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II. Definitions

  1. Cardiac Rehabilitation
    1. Supervised program to improve CV health following MI, Angioplasty or heart surgery
    2. Program includes Exercise, education and emotional counseling

III. Background

  1. Cardiac Rehabilitation has great efficacy and cost effectiveness as a secondary prevention tool
  2. Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 20-30% participation)
    1. Cardiac Rehabilitation post-hospitalization referral rates are 40% of those eligible
    2. Lower referral rates in women, as well as non-white patients

IV. Indications

  1. Medicare reimbursed indications (3 sesssions per week for 3 months)
    1. Following acute Myocardial Infarction (STEMI or non-STEMI) in the last 12 months
    2. Status-post Coronary Artery Bypass Graft (CABG)
    3. Status-post Percutaneous Coronary Intervention (PCI)
    4. Stable Angina Pectoris
    5. Status-post Vascular Surgery
    6. Status-post Heart Transplantation
    7. Status-post Heart Valve Repair or Replacement
    8. Recent CVA (women only)
  2. Other indications
    1. Stable Congestive Heart Failure with reduced left-ventricular ejection fraction
    2. Symptomatic Peripheral Arterial Disease
    3. Status-post Ventricular Assist Device placement
    4. Pacemaker or Implantable Cardioverter-Defibrillator

V. Protocol: Cardiac Rehabilitation Phases

  1. General
    1. Standard programs
      1. Medicare covers up to two, 1 hour sessions per day
      2. Exercise training program for a total of a 36 session program over 12 to 24 weeks (up to 36 weeks)
        1. Medicare may cover an additional 36 sessions if medically needed
    2. Intensive programs (limited availability)
      1. Intensive programs may include up to 72 sessions over up to 18 weeks
      2. Medicare approved programs
        1. Dean Ornish Program for Reversing Heart Disease
        2. Pritikin Intensive Cardiac Rehab Program
        3. Benson-Henry Institute Cardiac Wellness Program
  2. Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
    1. Supervised, structured early Physical Activity
    2. Patient Education
    3. Risk stratification (low level, graded, Exercise tolerance testing)
  3. Phase II Cardiac Rehabilitation (Early Outpatient)
    1. Start within 1-2 weeks of sentinel cardiac event (unless delayed for medical/surgical reasons)
    2. Supervised Physical Activity program
      1. Reassess symptom-limited Exercise tolerance
      2. Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
      3. Overall plan is updated at a minimum every 30 days
    3. Monitoring of Blood Pressure, pulse, cardiac rhythm
      1. Maintain Blood Pressure <140/90 mmHg
    4. Nutrition counseling
      1. May involve education on cooking and grocery shopping
      2. Diabetes Mellitus Type II control with Hemoglobin A1C <8%
      3. LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
      4. Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
    5. Cardiac Risk Factor modification
      1. Tobacco Cessation (and other Substance Use Disorder Management)
    6. Reassess cardiac symptoms at rest and with activity
    7. Psychosocial support to screen for and manage Major Depression, cognitive disorders
    8. Gait assessment and Fall Prevention
  4. Phase III Cardiac Rehabilitation Maintenance (Late Outpatient)
    1. Supervised, extended outpatient program
    2. Maintain and reinforce phase I and II management
    3. Reinforce medication use, Patient Education
  5. Phase IV Community Based Maintenance Programs
    1. Reinforce independent maintenance of long-term, heart healthy lifestyle changes
    2. Self-directed Exercise (aerobic fitness, Strength Training, flexibility, balance and group Exercise)
    3. Continuing education, peer support, and as needed, qualified Exercise instructors
    4. Continued health monitoring (self monitoring as well as regular clinic visits)

VI. Protocol: Activity restrictions following acute Myocardial Infarction

  1. Gradually increase activity over 6-8 weeks following MI
  2. Return to work by 8 weeks after MI
  3. Activity program may start by 3-4 weeks after MI
  4. Sexual activity restarted at 4-6 weeks after MI
    1. See Sexual Intercourse after Myocardial Infarction

VII. Protocol: Other Measures

  1. Influenza Vaccine each year

VIII. Efficacy

  1. Reduced Angina, Dyspnea, and Fatigue
  2. Reduced Major Depression after acute coronary event
  3. Exercise performance improved
  4. Activities of Daily Living (ADL) performance improved
  5. Quality of life improved
  6. Decreased re-hospitalization rate
  7. Decreased work absence
  8. Reduced age-adjusted cardiovascular mortality by 50%
  9. References
    1. Bondestam (1995) Am J Cardiol 75:767-71 +PMID: 7717276 [PubMed]
    2. Lakhani (2023) Am J Cardiol 192: 60-66 +PMID: 36736014 [PubMed]
    3. Milani (2007) Am J Med 120(9): 799-806 +PMID: 17765050 [PubMed]
    4. Dibben (2021) Cochrane Database Syst Rev (11): CD01800 +PMID: 34741536 [PubMed]
    5. Dibben (2018) Heart 104(17): 1394-402 +PMID: 29654095 [PubMed]

IX. References

  1. Boggiano (2025) Am Fam Physician 112(3): 272-7 [PubMed]
  2. Leon (2005) Circulation 111(3): 369-76 [PubMed]
  3. Stephens (2009) Am Fam Physician 80(9): 955-60 [PubMed]
  4. Servey (2016) Am Fam Physician 94(1): 37-43 [PubMed]
  5. Wenger (2008) J Am Coll Cardiol 51(17): 1619-31 [PubMed]

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