57

Scottish Intercollegiate Guidelines Network

Cardiac Rehabilitation
A national clinical guideline
1 Introduction 1
2 Psychological and educational interventions 3
3 Exercise training 8
4 Interventions in specific patient groups 14
5 Long term follow up 17
6 Information for patients and professionals 20
7 Implementation and audit 22
8 Development of the guideline 25
References 28
Abbreviations 32
January 2002
SIGN Executive
Royal College of Physicians
9 Queen Street
Edinburgh EH2 1JQ
www.sign.ac.uk

Scottish Intercollegiate Guidelines Network, 2002

ISBN 1 899893 92 X
First published 2002
SIGN consents to the photocopying of this
guideline for the purpose of implementation in
NHS Scotland
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1
++
High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very
low risk of bias
1
+
Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1
-
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2
++
High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias
and a high probability that the relationship is causal
2
+
Well-conducted case control or cohort studies with a low risk of confounding or bias
and a moderate probability that the relationship is causal
2
-
Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
GRADES OF RECOMMENDATION
A
At least one meta-analysis, systematic review, or RCT rated as 1
++
and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1
+
, directly applicable to
the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2
++
, directly applicable to the target
population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1
++
or 1
+
C A body of evidence including studies rated as 2
+
, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2
++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2
+
GOOD PRACTICE POINTS
! !! !! Recommended best practice based on the clinical experience of the guideline
development group
This guideline is supported and endorsed
by the British Association for Cardiac
Rehabilitation (BACR)
1
1 INTRODUCTION
1 Introduction
1.1 REMIT AND DEFINITIONS
This guideline provides evidence-based recommendations for best practice in cardiac rehabilitation.
It is primarily concerned with rehabilitation following myocardial infarction (MI) or coronary
revascularisation, but also addresses the rehabilitation needs of patients with angina or heart
failure. Cardiac rehabilitation has much in common with secondary prevention. To appreciate the
difference, it may be considered that cardiac rehabilitation facilitates recovery whereas secondary
prevention prevents further illness. This guideline complements the existing SIGN guidelines on
secondary prevention following MI,
1
stable angina,
2
and heart failure.
3
There are many definitions of cardiac rehabilitation.
4,5
The guideline development group felt that
the following definition contained the key elements of cardiac rehabilitation: Cardiac rehabilitation
is the process by which patients with cardiac disease, in partnership with a multidisciplinary team
of health professionals, are encouraged and supported to achieve and maintain optimal physical
and psychosocial health. The involvement of partners, other family members, and carers is also
important.
This guideline will be of interest to patients, general practitioners, cardiologists and physicians,
primary and secondary care nurses, physiotherapists, physiologists, clinical psychologists, dietitians,
occupational therapists, health service managers, and other health care professionals working
with patients with cardiac disease.
1.2 THE FOUR PHASES OF CARDIAC REHABILITATION
It is useful to consider four phases of cardiac rehabilitation, as each represents a different component
of the journey of care: inpatient care, the early post discharge period, exercise training, and finally
long term follow up. Some countries recognise three phases only, by calling the early post discharge
period Phase 2A and exercise training Phase 2B. Common to each phase, and irrespective of
which model of cardiac rehabilitation is chosen, are the need to tailor interventions to the individual
and the importance of good communication with specialist cardiac services, primary and community
care. There is evidence that treatment plans are not carried out in the community because doctors
and nurses wait for patients to consult. A proactive approach to patient participation and monitoring
is therefore recommended.
Phase 1 occurs during the inpatient stage or after a step change in the patients cardiac condition
(defined as any myocardial infarction, onset of angina, any emergency hospital admission for
coronary heart disease (CHD), cardiac surgery or angioplasty, or first diagnosis of heart failure).
During this phase medical evaluation, reassurance and education, correction of cardiac
misconceptions, risk factor assessment, mobilisation and discharge planning are the key elements.
6
It is customary to involve family and partners from this early stage. A nurse counsellor can improve
both the patients and the partners knowledge of heart disease and reduce anxiety and depression
compared with those receiving routine care.
7
Phase 2 is the early post discharge period, a time when many patients feel isolated and insecure.
Support can be provided by home visiting, telephone contact,
8-13
and by supervised use of the
Heart Manual.
14
This manual is a self-help programme for patients recovering from a heart attack
that has been shown to reduce anxiety, depression and hospital readmission rate.
Phase 3 has historically taken the form of a structured exercise programme in a hospital setting
with educational and psychological support and advice on risk factors. Increasingly it is recognised
that both components can be undertaken safely and successfully in the community.
15,16
A menu-
based approach recognises the need to tailor the delivery of services to the individual,
6,7
and is
likely to include specific education to reduce cardiac misconceptions and encourage smoking
cessation and weight management; vocational rehabilitation to assist return to work or retirement;
and referral to a psychologist, cardiologist, or exercise physiologist.
2
Phase 4 involves the long term maintenance of physical activity and lifestyle change. Available
evidence suggests that both must be sustained for cardiac benefits to continue.
17,18
Membership of
a local cardiac support group, which involves exercise in a community centre such as a gym or
leisure centre, may help maintain physical activity and behavioural change.
1.3 THE NEED FOR A GUIDELINE
Compared with the rest of the UK, Scotland has a disproportionately high incidence and prevalence
of CHD.
19
Every year, the estimated 8,000 Scots surviving an MI, 13,000 angina patients requiring
admission to hospital, and 6,000 patients who undergo coronary bypass surgery or angioplasty are
potential candidates for cardiac rehabilitation. Around 6,000 patients with heart failure may also
be eligible.
20
Some patients, for example those who experience a myocardial infarction and then
go on to be revascularised, may require cardiac rehabilitation on more than one occasion.
1.4 CURRENT PROVISION
The provision of exercise-based cardiac rehabilitation in the UK has increased since a British
Cardiac Society Working Party Report showed just 99 programmes in 1989.
21
151 programmes
were identified in 1992,
22
273 in 1996,
23
and most recently 300 in 1997.
24
Unfortunately, the
growth in quantity has not been matched by improvements in quality. Programmes tend to be
inadequately resourced and do not adhere to national guidelines.
25
A survey of Scottish outpatient
cardiac rehabilitation programmes in 1994 found that although most offered exercise, relaxation
and education, only a small proportion did so in a manner likely to reproduce the benefits found
in randomised trials.
26
Later surveys suggest that the measurement of exercise, psychological and
quality of life parameters remains patchy,
24
and that psychosocial factors are still poorly assessed.
23
The CHD Task Force identified 44 secondary care cardiac rehabilitation programmes in Scotland
during the year 2000.
27
Two thirds of Phase 3 programmes were hospital-based at that time. One
half used the Heart Manual either alone or in combination with Phase 3 exercise. 71% of patients
attending a Phase 3 programme had survived a myocardial infarction, while 20% were post
coronary bypass. Only small numbers of angioplasty, angina or heart failure patients attended
such programmes. Median values for duration and frequency of exercise programmes were 11
weeks and twice per week respectively. Education programmes were often provided at separate
times from exercise classes, depending on facilities available and lasted a median of six weeks.
Most programmes offered psychological interventions, but only 16% had access to a clinical
psychologist. 83% of programmes were co-ordinated by nurses and physiotherapists.
1.5 UPTAKE
Although beneficial outcomes from cardiac rehabilitation can be expected in most of these patients,
only a minority participate.
28
A recent UK survey found that 14-23% of infarct patients, 33-56%
of coronary bypass patients, and 6-10% of angioplasty patients were enrolled into cardiac
rehabilitation programmes.
29
Reported rates of uptake of cardiac rehabilitation nevertheless
underestimate the true level of activity because inpatient cardiac rehabilitation and the contribution
to cardiac rehabilitation made by home-based programmes such as the Heart Manual are not
usually included in the figures.
36
The shortfall in Phase 3 uptake relates to ease of access to
services.
31
Women and elderly patients are less likely to be invited to attend cardiac rehabilitation
programmes.
32-34
Uptake and completion of Phase 3 cardiac rehabilitation is also predicted by
social deprivation,
28
level of education
33
and negative attitudes towards rehabilitation from partner
and family.
35
The provision of outreach classes in health and community centres is likely to
increase uptake in rural areas.
36
1.6 REVIEW AND UPDATING
This guideline was issued in January 2002 and will be considered for review in 2005, or sooner if
new evidence becomes available. Any updates to the guideline will be noted on the SIGN website:
www.sign.ac.uk.
CARDIAC REHABILITATION
3
2 Psychological and educational interventions
Comprehensive cardiac rehabilitation consists of exercise training together with education and
psychological support. The purpose of these interventions is to facilitate a return to normal living
and to encourage patients to make lifestyle changes in order to prevent further events. Educational
and psychological support is also necessary to deal with psychological distress, which is common
following MI.
2.1 PSYCHOLOGICAL PREDICTORS OF RISK
Research has shown that psychological distress and poor social support are powerful predictors of
outcome following MI, independent of the degree of physical impairment.
37-43
Psychological distress
is also an important predictor of hospitalisation costs frollowing a cardiac event, with distressed
patients accruing four times the costs of non-distressed patients.
44
One study found that total
health care costs over one year following MI were 41% higher for patients with elevated depression
scores.
45
Depression and anxiety may also play a role in the aetiology of CHD.
43
2.1.1 DEPRESSION
Estimates of the prevalence of depression in MI patients range from 15% to 45%.
39,46,47
Depression
is associated with a three to four fold increase in cardiac mortality
38-40,48
and is strongly predictive
of poor symptomatic, psychological, social and functional outcome at three and 12 months.
49
Depression is common in patients with angiographically proven CHD who have not had an
infarction
50
and is associated with an increased risk of cardiac events in unstable angina.
2.1.2 ANXIETY
High levels of anxiety may also have an adverse effect on outcome. Anxiety while in the coronary
care unit is associated with an increased risk of acute coronary syndrome and arrhythmic events
over the following 12 months.
40
The Cardiac Arrhythmia Suppression Trial showed increased
mortality associated with higher state anxiety (i.e. anxiety at that point in time, rather than an
enduring personality characteristic of anxiety).
51
B Patients with coronary disease should be screened for anxiety and depression using a
validated assessment tool (see sections 2.2 and 2.5.2).
2.1.3 PERSONALITY
Early reports suggested that Type A behaviour, characterised by competitive and aggressive behaviour
and hostility, was an independent risk factor for CHD.
52,53
A recent systematic review has not
shown Type A behaviour as a risk factor, but concluded that hostility might still have an aetiological
role. The same review found no studies supporting Type A or hostility as prognostic factors in
CHD.
43
Successful coping with a hectic and stressful life is not harmful and it is important to
avoid giving over-cautious messages to people who enjoy being busy and vigorous.
2.1.4 CARDIAC MISCONCEPTIONS
Cardiac misconceptions are incorrect or muddled beliefs about heart problems, which frequently
lead people to be over-cautious and to respond inappropriately. One study found that functional
capacity at 12 months post-MI was strongly related to age and initial causal attribution.
51
Another
study found that male angina patients are more likely to attribute causes of angina to controllable
factors than female patients.
52
Where causes are thought to be less controllable, (e.g. my stressful
job caused my MI), patients are likely to have more problems in return to work, domestic and
social functioning, also sexual difficulties and poor attendance at cardiac rehabilitation,
56-58
irrespective of their level of anxiety and severity of their MI.
B Rehabilitation staff should identify and address health beliefs and cardiac misconceptions
in patients with coronary heart disease.
2
++
2
++
1
+
2
++
2
+
4
2 PSYCHOLOGICAL AND EDUCATIONAL INTERVENTIONS
1
++
1
+
4
2.2 MEASUREMENT OF PSYCHOLOGICAL WELLBEING
No consensus has been reached regarding the most appropriate instrument to use for measurement
of psychological wellbeing, but the simplest and most widely used is the Hospital Anxiety and
Depression Scale (HADS).
59
This is a generic 14 item questionnaire with separate subscales for
anxiety and depression. A copy of the HAD Scale together with the scores for each answer is
available on the SIGN website. Scores of 0-7 in respective subscales are considered normal, with
8-10 borderline, and 11 or over indicating clinical caseness.
Timing of administration is important. It is quite natural for patients to be anxious and/or depressed
in the immediate aftermath of a myocardial infarction or other acute cardiac event. However,
persistent symptoms are associated with a poor prognosis (see sections 2.1.1 and 2.1.2) and
should be treated appropriately. For this reason the HAD Scale should be repeated at 6-12 weeks
after the event, if indicated. The HAD Scale is not a substitute for clinical assessment and common
sense. Some anxious and depressed patients may wish to conceal their symptoms, possibly because
they are embarrassed to admit they are experiencing difficulties, and the cardiac rehabilitation
team should be prepared to ignore low scores under these circumstances.
! !! !! Screening for anxiety and depression should take place at discharge, 6-12 weeks post MI
or following a decision on surgical intervention, and repeated at three month intervals if
appropriate. This will allow measurement of baseline risk in order to assess prognosis and
tailor treatment, and subsequent monitoring of improvement following intervention.
Other domains of health status may also need to be evaluated, and a variety of instruments are
available.
91,93
These include generic instruments such SF-36, EQ-5D (formerly EuroQuol), and the
Dartmouth COOP;
60,61
and instruments specifically developed for use in cardiac patients, such as the
Quality of Life after Myocardial Infarction (QLMI) questionnaire
62
and the Cardiovascular Limitations
and Symptoms Profile (CLASP).
63
Further details of these instruments and the permissions required
for their use are provided with the electronic version of this guideline on the SIGN website.
2.3 EFFECTIVENESS OF PSYCHOLOGICAL AND EDUCATIONAL INTERVENTIONS
Psychological and educational interventions are diverse in nature and not always well described
in the literature, creating problems when attempting to evaluate their efficacy. Psychological
interventions include individual and group counselling, stress management, relaxation, group
psychotherapy, cognitive-behavioural approaches, goal setting, and hypnotherapy.
64,65
Educational
interventions include individual and group education on aspects of CHD, healthy eating and diet,
smoking cessation, hypertension, exercise and MI; self-monitoring diaries; booklets; medication
advice; and vocational counselling.
66,67
2.3.1 CARDIOVASCULAR OUTCOMES
A meta-analysis of 8,988 patients in 37 trials
65
found that cardiac rehabilitation programmes
including psychological and/or educational interventions resulted in a 34% reduction in cardiac
mortality and a 29% reduction in recurrent MI at 1-10 years follow up. Studies with the greatest
response to intervention showed the largest reduction in cardiac mortality and recurrent MI,
implying that success with risk factors, related behaviours, or emotional distress contributes to the
reduction in cardiac events. Similar cardiovascular outcomes were reported by two earlier meta-
analyses.
64,66
2.3.2 PSYCHOLOGICAL AND OTHER OUTCOMES
The evidence that educational and psychological treatments within cardiac rehabilitation will
reduce risk factors and psychological distress is suggestive but not conclusive. Two meta-analyses
support the use of such therapy
64,66
whereas a third did not.
65
The inclusion of two recent large
trials which gave negative results for psychological outcomes may have been responsible.
68,69
Possible explanations for the lack of benefit in these trials are: the inclusion of subjects with low
levels of psychological symptoms, outcome measures insufficiently sensitive to detect change,
provision of a uniform treatment for a heterogeneous range of complaints, and a lack of appropriate
training in cardiac psychological interventions.
47
CARDIAC REHABILITATION
1
++
5
Greater adherence to adult learning principles (see section 2.4.3) led to greater benefit in one of the
earlier meta-analyses.
66
Two reviews suggest that targeted psychological and educational interventions,
tailored to the needs of individuals do lead to measurable psychological benefits
47,70
A Cardiac rehabilitation programmes should include both psychological and educational
interventions as part of comprehensive rehabilitation.
2.4 PRINCIPLES OF BEHAVIOURAL CHANGE
2.4.1 TARGETING THERAPY
Evidence suggests that it is more effective to target therapy to those identified as either more
distressed or in greater need of behavioural change, rather than deliver all aspects of a programme
to every patient.
64,65
This is reflected in the menu-driven approach or targeted therapy recommended
by the British Association for Cardiac Rehabilitation (BACR)
71
and the Scottish Needs Assessment
Programme (SNAP).
20
B Psychological and behavioural interventions should be targeted at the needs of individual
patients.
2.4.2 PSYCHOLOGICAL PRINCIPLES AND MODELS OF BEHAVIOURAL CHANGE
Several psychological models have been shown to be effective in developing strategies for
behavioural change:
" Cognitive Behavioural Therapy (CBT) is a structured therapy addressing individuals core
beliefs, assumptions, thinking patterns and behaviour. CBT approaches help an individual
identify dysfunctional thoughts and the beliefs that underlie them, and provide a structured
approach to managing change in behaviour, thinking and mood. CBT has been shown to be
effective in a wide range of conditions, including anxiety, depression, post traumatic stress
disorder, and medical conditions.
72
It has been used successfully with angina patients.
73
" Health Belief and Illness Representation models, together with methods of enhancing self-
efficacy, provide additional strengths in the behavioural change process (see sections 2.1.4
and 2.5.1). These models also draw on cognitive-behavioural principles.
" Motivational Interviewing
74
is an approach to help individuals build commitment and reach
a decision to change. It enhances intrinsic motivation so that change comes from within rather
than being imposed, thereby strengthening the behavioural change. It has particular use where
people are ambivalent or reluctant to change. It uses strategies drawn from several therapeutic
models. Motivational Interviewing has clear application with cardiac patients and was used
effectively in a randomised trial of behavioural change before coronary revascularisation.
75
Systematic reviews are currently being undertaken.
The above systematic and individualised approaches are qualitatively different from education,
which alone may not be sufficient to produce behavioural change. The use of these principles is
equally important in exercise programmes.
2.4.3 EDUCATIONAL PRINCIPLES
Analysis of studies of health education in cardiac patients has found that the most important
determinant of effectiveness is the quality of the intervention,
76
defined as adherence to the five
principles of adult learning:
" relevance (tailored to patients knowledge, beliefs, circumstances)
" individualisation (tailored to personal needs)
" feedback (informed regarding progress with learning or change)
" reinforcement (rewarded for progress)
" facilitation (provided with means to take action and/or reduce barriers).
1
++
1
1
++
1
+
4
2 PSYCHOLOGICAL AND EDUCATIONAL INTERVENTIONS
CARDIAC REHABILITATION
6
Outcome was found to be poorer in studies that did not adhere to these principles. Behaviourally-
orientated interventions tended to have larger effects, while studies showing change in knowledge
only were less likely to produce behavioural change. A systematically developed intervention
based on a theoretical model was more likely to be effective.
7,14
Behavioural techniques such as
self-monitoring and personal communication, including written or audio-visual techniques,
improved outcome. Information provision alone was less effective.
76
The type or duration of the
intervention was found to be unrelated to effectiveness.
A Comprehensive cardiac rehabilitation should be delivered by healthcare staff using
established principles of adult education and behavioural change.
2.5 EDUCATIONAL AND PSYCHOLOGICAL INTERVENTIONS
2.5.1 THE HEART MANUAL
The Heart Manual is a six-week cognitive behavioural rehabilitation tool for use in the immediate
post MI period. Developed from the Health Belief model, the programme is designed to correct
misconceptions about the cause of heart attack and at the same time to help patients develop
strategies for dealing with stress, in order to neutralise enduring misconceptions. It emphasises
self-management, but must be recommended by a doctor and facilitated by specially trained
nurses. The Heart Manual is one way of providing educational and psychological support for post
MI patients, although it will not meet the needs of a minority who require additional help.
The initial randomised controlled trial evaluating the Heart Manual found that those receiving the
manual had improved emotional states and fewer GP contacts and hospital readmissions at six
months post MI.
14
Subsequent studies have found significantly fewer readmissions in treated
patients
77
and improvement in emotional state and sense of control at six months.
78

A Use of the Heart Manual is recommended to facilitate comprehensive cardiac rehabilitation.
2.5.2 TREATMENT OF DEPRESSION AND ANXIETY
A Cochrane Review found that antidepressants reduced depression in patients with a wide range
of physical diseases including CHD.
79
Several randomised trials have indicated that early
psychological intervention can improve mood and other outcomes in cardiac patients.
7,14,80,81
Although a degree of anxiety and depression and associated symptoms such as poor sleep, poor
concentration, lack of energy, or mildly low mood are common in patients with CHD, persistent
significant unhappiness or anxiety is not usual and should not be accepted as an appropriate
reaction. Major disturbances of mood are too commonly considered a normal response to severe
illness when they are in fact abnormal and might respond to treatment. Antidepressant medication
is effective for those who have clear symptoms of major depression and should be prescribed
whenever there is a persistent lowering of mood characterised by pessimism and lack of pleasure
in life. Major depression is much less common than mild depression, which is best treated in
other ways, but is under-recognised and under-treated in patients with cardiac disease.
A recent evidence-based guideline describes effective psychological therapies for anxiety and
depression,
72
which should be considered along with medication. Guidelines for the use of
antidepressant medication and psychological therapy in depressed patients with cardiac disease
are given in a recent review.
70
A All cardiac patients in whom anxiety or depression is diagnosed should be treated
appropriately.
! !! !! Caution must be exercised in selecting an antidepressant which does not have significant
cardiac side effects. Relevant guidelines should be consulted.
70
1
++
1
+
2
+
1
++
1
+
7
2.5.3 PSYCHOLOGICAL THERAPY
Psychological therapy encompasses a continuum from generic counselling, where practitioners
use psychological methods but have no specialist training in any one model, to psycho-
therapeutically-trained practitioners using specific theoretical models. Cardiac rehabilitation
programmes currently have very limited access to trained therapists, which has implications for
outcome for those with more marked psychological distress.
Simple psychological therapy, especially solution-focused therapy, may be appropriate for patients
with mild distress and can be delivered effectively by rehabilitation staff sensitive to patients
needs. It is often helpful to involve partners. Patients with more complex problems need treatment
from therapists with specialist training and experience in techniques such as cognitive behavioural
therapy.
72,82-84
As therapeutic expertise is an important predictor of successful outcome, appropriate
supervision of staff providing therapy is essential.
B Patients with moderate to severe psychological difficulties should be treated by staff with
specialist training in techniques such as cognitive behavioural therapy.
2.6 ASPECTS OF BEHAVIOURAL CHANGE
2.6.1 SMOKING CESSATION
Smoking status should be ascertained in all patients and cessation methods employed in smokers.
Brief advice from a health professional, tailored self help materials, individual and group
counselling, bupropion with behavioural support, and nicotine replacement therapy can all increase
rates of smoking cessation. (This important topic has been reviewed in previous SIGN guidelines,
1,2
see in particular in the section on lifestyle modification in the SIGN guideline on management of
diabetes.
85
)
2.6.2 HEALTHY EATING AND DIET
The British Dietetic Association
86
have recently produced their own evidence-based accredited
guidelines on secondary prevention of cardiovascular disease, which emphasise the increased
consumption of omega-3 fatty acids (from oily fish or rapeseed oil) and increased intake of fruit
and vegetables to a minimum of five portions per day. Reduction in saturated fats and total or
partial replacement by unsaturated fats (rapeseed or olive oil) is also recommended. These guidelines
highlight that concentrating dietary advice only on those patients in need of weight loss or lipid
lowering is inappropriate.
2.6.3 SEXUAL ACTIVITY
The British Heart Foundation have published a Factfile on sexual activity following myocardial
infarction.
87
(See section 6 for sources of further information for patients and health professionals.)
2 PSYCHOLOGICAL AND EDUCATIONAL INTERVENTIONS
1
++
1
+
CARDIAC REHABILITATION
8
3 Exercise training
The exercise component of cardiac rehabilitation has evolved from the recognition that physical
deconditioning occurs following MI and the knowledge that regular exercise protects against
cardiovascular disease.
88
Physical inactivity increases the risk of developing coronary heart disease
two fold.
89
National surveys of physical activity in Scotland confirm that inactivity is high in the
general population.
90
Structured exercise as a therapeutic intervention is central to cardiac
rehabilitation.
20,71,91,146
Daily exercise should also be encouraged as part of an active living
philosophy.
92
3.1 BENEFIT OF EXERCISE TRAINING
3.1.1 MORTALITY AND CARDIOVASCULAR OUTCOMES
Randomised trials distinguish between two types of exercise-based cardiac rehabilitation: exercise-
only and exercise in addition to psychological and educational interventions, usually termed
comprehensive cardiac rehabilitation.
A Cochrane review of men and women of all ages with previous MI, revascularisation or angina
found that exercise-only cardiac rehabilitation reduced all cause mortality by 27%, cardiac death
by 31% and a combined end point of mortality, non fatal myocardial infarction and revascularisation
by 19%.
92
The benefits accrued over an average of 2.4 years. There was no effect on non fatal
myocardial infarction alone and there was no apparent additional benefit from comprehensive
cardiac rehabilitation. Most subjects were low risk middle aged men post MI. Patients with heart
transplants, artificial valves and heart failure were excluded.
There are two possible explanations for the failure of comprehensive cardiac rehabilitation to
show additional benefit. One is that exercise-only cardiac rehabilitation is likely to include
psychological and educational support, even if this is not offered in a structured fashion. The
other is that most of the exercise-only trials were conducted in the pre-thrombolytic era, whereas
most of the comprehensive trials were published more recently. This means that the benefits in
the comprehensive rehabilitation trial are likely to be additional to those of thrombolysis,
prophylactic medication, and/or revascularisation.
3.1.2 PSYCHOLOGICAL AND OTHER OUTCOMES
There has been a wider acceptance in recent years that mortality and reinfarction are not the only
methods of measuring the effectiveness of cardiac rehabilitation. Exercise alone has been shown
to improve physical performance, muscle strength, and symptoms of breathlessness and angina.
Comprehensive cardiac rehabilitation will in addition aid psychological function, social recovery,
return to work, and biological risk factors.
91
A Exercise training should form a core element of cardiac rehabilitation programmes.
3.2 SAFETY ISSUES
Most patients will benefit from and should be encouraged to undertake at least low to moderate
intensity exercise. However, patients with clinically unstable cardiac disease or limiting co-morbid
illness should be excluded from exercise training.
The incidence of serious adverse events during supervised exercise is low.
94,95
The most recent
study of one rehabilitation centre documented four major complications (three cardiac arrests and
one non fatal MI) over a nine year period.
96
There were no fatalities, giving a frequency of one
major complication per 67,126 patient hours of exercise. All three cardiac arrests occurred in
patients who had completed at least 12 weeks of exercise training and were enrolled in a maintenance
programme.
1
+
9
3.3 ASSESSMENT BEFORE EXERCISE TRAINING
For most patients, clinical risk stratification based on history, examination and resting ECG combined
with a functional capacity test such as a shuttle walking test
97
(see section 3.3.1) or a six minute
walking test
98
will be sufficient.
High risk patients may be defined as those who have:
" experienced a myocardial infarction complicated by heart failure, cardiogenic shock and/or
complex ventricular arrhythmias
" angina or breathlessness occurring at a low level of exercise, e.g. inability to complete the first
four minutes of the shuttle walking test
" ST segment depression 1 mm on resting ECG
" undergone exercise testing with marked ST depression 2 mm or angina at <5 METS
(e.g. three minutes of a Bruce protocol).
Exercise testing and echocardiography are recommended to assess residual ischaemia and
ventricular function respectively
1
but are not a necessary part of cardiac rehabilitation except
for high intensity exercise or in high risk patients.
D Clinical risk stratification is sufficient for low to moderate risk patients undergoing low to
moderate intensity exercise.
D Exercise testing and echocardiography are recommended for high risk patients and/or high
intensity exercise training (and to assess residual ischaemia and ventricular function where
appropriate).
D Functional capacity should be evaluated before and on completion of exercise training
using a valid and reliable measure.
3.3.1 THE SHUTTLE WALKING TEST
The shuttle walking test was developed for patients with respiratory disease
99
but has recently
been used to assess functional capacity before and after cardiac rehabilitation in patients who
have undergone cardiac surgery
97,100
or pacemaker insertion,
101
and in patients with chronic heart
failure.
102,103
The shuttle walking test is a low cost low tech alternative to exercise testing that
informs the rehabilitation team on a suitable exercise programme and appropriate training heart
rate, and allows assessment of progress during cardiac rehabilitation without the need for cardiac
technicians, physicians or expensive equipment. The shuttle walking test protocol is given in Box
1 overleaf. Details of how to obtain copies of the tape are available on the SIGN website.
3.4 STAFFING
There is no consensus on staffing levels for Phase 3 exercise programmes. Current UK guidelines
recommend that two trained staff should be present at all times during exercise training with a
patient to staff ratio of not more than 5:1.
104
Australian guidelines recommend a ratio of no more
than 10 patients to one staff member.
91
There is a similar lack of consensus on life support
training: UK guidelines recommend basic life support training for all, provided at least one member
of staff has advanced life support training,
104
whereas Australian guidelines make no such stipulation
for patients undergoing low to moderate intensity exercise training.
91
D The ratio of patients to trained staff should be no more than 10:1 during exercise classes.
D Staff with basic life support training and the ability to use a defibrillator are required for
group exercise of low to moderate risk patients.
D Immediate access to on-site staff (hospital emergency team) with advanced life support
training is required for high risk patients and classes offering high intensity exercise training.
3 EXERCISE TRAINING
4
4
4
CARDIAC REHABILITATION
10
Box 1
SHUTTLE WALKING TEST
Equipment required
" Calibrated cassette player and shuttle walk test tape.
99
" Two marker cones and non slippery, flat walking surface at least 10 metres in length.
" Heart rate monitor with record facility and adjustable upper alarm limits.
Protocol
" Each subject should be screened by a member of the cardiac rehabilitation team for any
exclusion criteria before proceeding (see section 3.2).
" Place two cones exactly 9 metres apart, thus allowing the subjects to walk 10 metres when
they go round the cone at the end of each shuttle.
" Subjects then listen to the instructions on the audio cassette. These should be repeated
verbally to ensure that they understand what is expected during the test.
" Subjects walk around the 10 metre course aiming to be turning at the first marker cone
when the first audio signal is given, and turning at the second cone at the next audio signal.
" Subjects should be accompanied around the first level of the test to help them keep
pace with the audio signals. Thereafter the operator stands mid way between the two
marker cones offering advice on completion of a level: Walk a bit faster now if you can.
" Progression to the next level of difficulty is indicated by a triple bleep which lets the
subject know that an increase in walking speed is required.
" The full test comprises 12 levels each of one minute duration with walking speeds that
rise incrementally from 1.2 miles per hour (1.9 km per hour) to 5.3 miles per hour (8.5 km
per hour).
" The test is completed at 12 minutes or if one of the termination criteria are met.
Termination criteria
" Any anginal symptoms or feeling too breathless to continue.
" Feeling dizzy or faint.
" Leg pain limiting further exercise.
" Achieved level of perceived exertion 15 (Borg Scale)
128
(see section 3.7).
" Achieved heart rate 85% predicted (detected by audible upper alarm limit).
" Failure to meet the speed requirements of the test subject more than half a metre from the
cone when the bleep sounds.
97,100

Following the test
" Subjects should continue to walk slowly around the course a further four times to avoid any
syncopal attacks associated with abrupt cessation of exercise.
" Subjects are then seated and asked to confirm their limiting symptom.
" Record total distance walked, heart rate and perceived exertion for each level completed,
peak heart rate and reason for test termination.
" If subjects have fully recovered after 10 minutes then no further action is required.
If they report continuing breathlessness or angina then a further rest period should
follow during which they may receive sublingual nitrates, have an ECG or be seen by
a doctor as appropriate.
11
3.5 LOCATION
A number of randomised trials
77,105-110
and large observational studies
15,111-117
have found that low
to moderate intensity exercise for low to moderate risk patients can be provided as safely and as
effectively in the home or community as in a hospital setting. Patients at high risk and those
undergoing high intensity training should only exercise at venues with full resuscitation facilities
and staff trained in advanced life support.
B Low to moderate intensity exercise training can be undertaken as safely and effectively in
the home and community as in a hospital setting for low to moderate risk patients.
D Exercise training for high-risk patients and for those who require high intensity exercise
(see section 3.6.1) should be hospital-based or in a venue with full resuscitation facilities.
! !! !! Patients exercising at home should have access to regular review and support by cardiac
rehabilitation staff.
3.6 EXERCISE CONTENT
Cardio-respiratory fitness requires aerobic training of low to moderate intensity, long duration and
with repetitive movement of large muscle groups. The frequency, intensity and duration of exercise
can be varied to achieve the desired training effect. The individuals preference best determines
the appropriate mode of activity. All trials included in a recent Cochrane review
93
were of aerobic
exercise such as cycling, walking, jogging, rowing or calisthenics. In the UK, aerobic circuit
training is traditionally used for group exercise training
104
and is an effective method for achieving
a training heart rate.
Exercise sessions should have:
" a 15-minute warm up period
" an aerobic conditioning phase of 20-30 minutes
(resistance training, if appropriate, can be included after the conditioning phase)
" a 10-minute cool down period
" 5-10 minutes relaxation.
3.6.1 INTENSITY OF EXERCISE
Early studies of exercise-based cardiac rehabilitation randomised patients to high intensity exercise
training plus usual care, or usual care alone.
146
Four randomised trials have since compared high
intensity training versus low to moderate intensity training. Three found no differences in deaths
or reinfarction, physical, psychological or social outcomes,
118,119
physical working capacity or
quality of life at 12 months.
120
In one study, patients enrolled in a high intensity training group
did have significantly greater improvements in maximal oxygen uptake and rest to maximal exercise
ejection fraction at 12 months.
153
High intensity exercise training may be desirable for those whose work is physically demanding,
and for younger men and women who wish to resume demanding sports. High intensity exercise
involves training at a heart rate that is more than 75% of the maximum heart rate during a
symptom limited exercise test, as indicated in Table 1.
90,91,130
Although high intensity exercise
rarely provokes ventricular tachycardia or myocardial infarction,
94,95
it is suggested that patients
should undergo a symptom limited exercise test first.
121
High risk patients should either be excluded
from or carefully monitored during high intensity exercise.
122-126
B Aerobic, low to moderate intensity exercise, designed to suit a range of fitness levels, is
recommended for most patients undergoing exercise training.
3 EXERCISE TRAINING
1
+
4
1
+
3
4
1
+
2
++
2
+
CARDIAC REHABILITATION
12
3.6.2 FREQUENCY AND LENGTH OF PROGRAMME
Most early trials of exercise-based cardiac rehabilitation consisted of three exercise sessions per
week for eight weeks or longer.
93,146
Twice weekly exercise has since been found to increase maximum
physical working capacity to the same extent as thrice weekly exercise.
127
A further study has
suggested that once weekly, hospital-based exercise plus two equivalent home-based exercise
sessions is as effective at improving physical work capacity as thrice weekly hospital-based
exercise.
110
This suggests that incorporation of regular, sustained exercise into an individuals
lifestyle is likely to be more important than the frequency or length of formal exercise training.
A The formal exercise component of cardiac rehabilitation should be offered at least twice a
week for a minimum of eight weeks.
C Once weekly group exercise with two equivalent home-based sessions improves exercise
capacity as effectively as thrice weekly hospital-based exercise.
3.7 MONITORING OF EXERCISE TRAINING
Exercise intensity may be monitored either by perceived exertion using Borgs scale
128
(see Table 1)
or by pulse monitor.
104
A perceived exertion scale allows quantification of the subjective intensity
of exercise. Ratings on Borgs scale have been found to relate closely to other objective measures
of exercise intensity, namely oxygen uptake and heart rate.
129
The aim is to enable patients to
achieve a level of comfortable breathlessness
130
while exercising, and so distinguish between
high intensity and low to moderate intensity exercise. Patients can take several sessions to become
familiar with and competent in the use of this scale. Levels of perceived exertion should only be
used as a guide to exercise intensity, as cardiac patients may report significantly lower scores of
perceived exertion at a given intensity of exercise when compared to age-matched controls.
131
Pulse monitoring is best done by using pulse monitors, which may help patients until they are
familiar with and competent in the use of the Borg scale. It is difficult to take ones own pulse
while exercising, and this practice is not recommended.
D Exercise intensity should be monitored and adjusted by perceived exertion using the Borg
scale or by pulse monitor.
! !! !! Patients should be taught how perceived exertion can be used to regulate exercise intensity.
Table 1: Correlation of training level with perceived exertion and heart rate
91
e s i c r e x E
l e v e l g n i n i a r t
d e v i e c r e p f o e t a R
) g r o B ( n o i t r e x e
d e v i e c r e P
e t a r g n i h t a e r b
m o r f e t a r t r a e h l a m i x a M %
t s e t e s i c r e x e d e t i m i l m o t p m y s
W O L
E T A R E D O M
H G I H
l l a t a n o i t r e x e o N 6
t h g i l y r e v , y r e V 7
8
t h g i l y r e V 9
0 1
t h g i l y l r i a F 1 1
2 1
d r a h t a h w e m o S 3 1
4 1
) y v a e h ( d r a H 5 1
6 1
d r a h y r e V 7 1
8 1
d r a h y r e v , y r e V 9 1
n o i t r e x e l a m i x a M 0 2
G N I S
K L A T
P S A G
0 6 - 0 5
5 7 - 0 6
5 8 - 5 7
4
1
+
4
13
3.8 RESISTANCE TRAINING
A key outcome of cardiac rehabilitation is to return patients to a fully active lifestyle. This requires
muscle strength as well as aerobic endurance. Resistance (or strength) training improves muscular
strength, cardiovascular function, coronary risk factors and psychological well being.
146
In most
studies, low to moderate intensity resistance training (<70% maximum voluntary contraction)
was incorporated after four weeks of supervised aerobic training,
146
but more recent studies have
enrolled patients as early as four weeks post event.
132,133
Single set resistance training two or three
times per week (where an exercise is performed as one set of 10-15 repetitions) is as effective and
less time consuming than once weekly multiple set programmes (where the same muscle group is
exercised two or more times at one session).
134
C Low to moderate risk cardiac patients can undertake resistance training.
! !! !! Patients may benefit from supervised aerobic training prior to resistance training to allow
them to master the skills of self monitoring and regulating exercise intensity.
! !! !! Blood pressure may increase more during resistance training than during aerobic training.
Hypertensive patients should not be enrolled in such a programme until their blood pressure
is well controlled.
3.9 LONG TERM EXERCISE TRAINING
See section 5.5.
1
+
2
+
4
3 EXERCISE TRAINING
CARDIAC REHABILITATION
14
4 Interventions in specific patient groups
Although cardiac rehabilitation has been defined as relevant to all patients with heart disease,
most of the research to date concerns middle-aged white males with recent myocardial infarction
or coronary artery surgery. Other groups, notably older patients, women and higher risk patients
with heart failure or angina were excluded from most early trials
135,136,146
yet these groups make up
the majority of patients with coronary heart disease.
137
A small, but increasing, amount of research
has been conducted into the effects of cardiac rehabilitation in these subgroups.
4.1 POST MYOCARDIAL INFARCTION
As discussed in section 3.1, both exercise-only and comprehensive cardiac rehabilitation reduce
all cause mortality and cardiac death, non fatal myocardial infarction and revascularisation.
93,135,136
Exercise has also been shown to improve physical performance, muscle strength, and symptoms
of breathlessness and angina, whilst comprehensive cardiac rehabilitation aids psychological
function, social recovery, return to work and biological risk factors.
91
Rehabilitation programmes
should be tailored to the needs of each individual patient (see section 1.2).
A Comprehensive cardiac rehabilitation is recommended following myocardial infarction.
4.2 POST CORONARY BYPASS AND ANGIOPLASTY
The benefits of exercise-based cardiac rehabilitation for patients undergoing revascularisation
were not considered separately in any of the reviews identified. Three randomised trials
included in the Cochrane review reported the effects of exercise-based cardiac rehabilitation
after bypass surgery,
138-140
while one comprised only patients who had undergone angioplasty.
141
None of the studies reviewed were designed or powered to show the effect of cardiac
rehabilitation on cardiovascular morbidity or mortality post revascularisation. Comprehensive
cardiac rehabilitation led to lower serum lipids
140
and a perception of improved health
138
after bypass surgery, while exercise-only cardiac rehabilitation was associated with improved
exercise capacity but had no effect on lipids or body weight.
139
In the trial of cardiac rehabilitation following angioplasty included in the Cochrane review, the
exercise group was less likely to require revascularisation during follow up.
141
Possibly because
they have not undergone bypass surgery or survived an MI, angioplasty patients make fewer lifestyle
changes than other cardiac patients
142
and are less likely to attend a cardiac rehabilitation
programme.
143
Two additional randomised trials of cardiac rehabilitation post angioplasty were
identified.
144,145
One found that comprehensive cardiac rehabilitation improved exercise capacity,
diet and smoking but not quality of life or psychological factors,
144
while the other provided
further evidence that comprehensive cardiac rehabilitation following angioplasty reduces the need
for further revascularisation.
145
A Comprehensive cardiac rehabilitation is recommended for patients who have undergone
coronary revascularisation.
4.3 STABLE ANGINA
Systematic reviews of exercise-only cardiac rehabilitation for patients with angina have shown
that exercise training improves exercise capacity, symptoms and ischaemia.
137,146-149
Comprehensive
cardiac rehabilitation has shown similar benefits and either less progression or more regression of
atherosclerosis in the intervention groups.
88,150
The programmes included in these studies were all
more intensive than contemporary programmes in Scotland.
26
Three more recent trials of exercise-only cardiac rehabilitation confirm that exercise training
improves exercise capacity. One found improvements in myocardial ischaemia on exercise
testing.
151
One trial evaluated effects on quality of life and found improvements.
152
Evidence from
two trials suggests a dose response: there were more benefits with higher exercise intensity.
152,153
1
+
1
+
1
++
1
+
1
+
15
4 INTERVENTIONS IN SPECIFIC PATIENT GROUPS
Two recent randomised controlled trials of comprehensive cardiac rehabilitation have also reported
benefits. In one trial there were fewer cardiac events in the intervention group,
154
and in the other
patients waiting for non urgent coronary artery bypass graft (CABG) had improved quality of life,
although length of stay in hospital was reduced by an average of only one day.
155
Comprehensive cardiac rehabilitation based predominantly on a cognitive behavioural approach
was evaluated in one randomised trial involving 80 patients with angina.
73
There were improvements
in exercise capacity, emotional distress, symptoms and disability. A randomised trial of health
education for patients with angina in primary care found that it improved exercise, diet, and
quality of life, but did not affect smoking rates, lipids, or blood pressure levels.
156,157
A Patients with stable angina should be considered for comprehensive cardiac rehabilitation
if they have limiting symptoms.
4.4 CHRONIC HEART FAILURE
Systematic reviews of exercise-based cardiac rehabilitation in stable, chronic heart failure have
found benefits to exercise capacity and possibly to symptoms.
35,146-149
Benefit is probably derived
from peripheral adaptations (vasodilation and improved muscle oxidative capacity) rather than
improvements in ventricular function.
35,137,146
An RCT of exercise training in heart failure reported
improvements in exercise capacity, myocardial perfusion, quality of life, total mortality and hospital
admissions.
158
An overview of randomised trials in Europe
159
that included 134 patients concluded
that exercise training improved exercise capacity and autonomic indices (e.g. heart rate variability),
that training could be conducted either in hospital or at home, that 16 weeks was better than six
and that a combination of cycle ergometry and calisthenics was better than cycle ergometry alone.
Women did as well as men, and elderly patients were able to train free from complications and
with benefit to symptoms, although less effectively than younger patients.
In a systematic review of comprehensive disease management for heart failure, there were fewer
hospital attendances, and improved quality of life, functional capacity, patient satisfaction and
compliance with diet and medications.
160
The studies in the review were small with selected
participants (who tended to be elderly) and the interventions included education, social support,
nurse follow up at home, graduated exercise, and sometimes psychological and pharmacist input.
In a more recent randomised trial in Scotland, specialist nurses provided follow up to patients
with heart failure by home visits and telephone contact.
161
The intervention, which included
education, disease monitoring and psychological support, reduced the risk of readmission to
hospital for heart failure by more than half.
There is limited evidence on the effects of psychological and education only intervention in heart
failure. One pre-post test study of 50 patients reported fewer hospital re-admissions.
162
In one
recent randomised trial,
163
education in hospital with one home visit was found to increase self-
care, but had no impact on hospital attendance rates.
A Patients with chronic heart failure should be considered for comprehensive cardiac
rehabilitation if they have limiting symptoms.
4.5 OLDER PATIENTS
Although many patients with coronary disease are older than 75 years, this group has been excluded
from many trials of cardiac rehabilitation. Systematic reviews indicate that older patients benefit
at least as much as younger patients from exercise-based cardiac rehabilitation.
146,147,149
A recent
randomised trial of exercise-only cardiac rehabilitation in 101 elderly patients with coronary
disease
164-166
reported not only greater exercise tolerance, but also improved physical activity,
quality of life and well-being.
One non-randomised controlled trial compared primary care-based comprehensive cardiac
rehabilitation (counselling and exercise) with usual care.
167
Uptake of the exercise component was
low (20%). Despite this, there were fewer hospital re-admissions and visits to emergency departments
in the intervention group.
1
+
1
+
2
+
1
+
1
+
2
++
2
+
CARDIAC REHABILITATION
16
These findings are in line with a systematic review of comprehensive disease management in
patients with heart failure, most of whom were elderly.
160
B Older people should be included in comprehensive cardiac rehabilitation programmes.
4.6 WOMEN
Women were excluded from most of the early studies of cardiac rehabilitation, accounting for
between only 4% and 11% of patients enrolled in exercise-only and comprehensive cardiac
rehabilitation trials.
Systematic reviews indicate that women benefit from exercise-based cardiac rehabilitation in
terms of functional capacity at least as much as men.
147,168
A review of 134 patients with heart
failure undergoing exercise training found that women benefited as much as men in terms of
increased exercise capacity and improved autonomic indices.
159
More women have been included in studies of psychological and educational interventions. In a
recent review
65
up to 34% of patients in some studies were women, suggesting that the benefits
reported are relevant to women as well as men. Another systematic review reported on 12
comprehensive programmes aimed at lifestyle change (most of which were based on education,
although some included psychological interventions or exercise programmes) which included
women. In most trials benefits were similar in women and men.
169
B Women should be included in programmes of comprehensive cardiac rehabilitation.
4.7 OTHER GROUPS
4.7.1 CARDIAC TRANSPLANT PATIENTS
Few studies have examined the effect of cardiac rehabilitation in patients following cardiac
transplantation. One small RCT
170
compared a six-month exercise-based cardiac rehabilitation
programme with usual care. There were improvements in exercise capacity of the exercise group.
A series of five small observational studies also suggest that exercise-based cardiac rehabilitation
improved exercise tolerance in these patients.
146
4.7.2 VALVE SURGERY PATIENTS
There is little evidence on the benefits of cardiac rehabilitation following valve surgery. One
small non-randomised trial reported no differences in exercise tolerance between groups (nor in
reported physical activity levels).
171
4.7.3 PATIENTS WITH CONGENITAL HEART DISEASE
In a non-randomised, controlled trial in Norway, children with congenital heart disease who
undertook supervised exercise appeared to achieve some improvements in exercise capacity and
psychological function compared to a control group.
172
Trials involving Chinese children (reviewed
in abstract only) with congenital heart disease have found that behavioural and exercise training
improved self care, compliance and reduced length of hospital stay.
173 ,174
4.7.4 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS
Patients with implantable cardioverter defibrillators (ICDs) have high levels of psychological
distress and continue to be at risk of sudden cardiac death.
175
They may benefit from comprehensive
cardiac rehabilitation but research in this area is needed.
1
+
2
++
2
+
1
+
2
+
1
+
2
+
1
_
17
5 Long term follow up
In the long term, most people with cardiac disease receive most or all of their care in primary
care and the community. Once the process of short term recovery is complete, the emphasis of
cardiac rehabilitation shifts to long term maintenance of physical activity and lifestyle change,
with appropriate secondary prophylactic drug therapy. The boundaries between cardiac
rehabilitation, secondary prevention and normal medical care are blurred. The overall aim is
comprehensive cardiac care.
Although many patients make good recoveries, others continue to have substantially impaired
health.
176,177
People with coronary disease require frequent admissions to hospital
177,181
and have
a high rate of infarction or reinfarction.
178-181
A healthy lifestyle can reduce substantially the risk of
further coronary events
1,2
but is difficult to achieve and maintain.
147,156,182,183
Drug treatment is
effective but uptake and compliance are often suboptimal.
184
Recommendations on lifestyle
modification and secondary drug treatment from the SIGN guidelines on secondary prevention
following MI
1
and stable angina
2
are summarised in Table 2. The recently completed Heart Protection
Study seems likely to extend the indications for statin therapy to all patients with coronary disease
irrespective of their serum cholesterol.
185
Table 2: Lifestyle modification and drug therapy for secondary prevention of CHD
5.1 TRANSITION TO PRIMARY CARE
The main responsibility for long term follow up in coronary disease lies with the individual and
is facilitated by primary care. For patients who have been treated in hospital, care is transferred
from secondary to primary care when it is evolving and complex. It also needs to be flexible and
tailored to individual needs. There is plenty of opportunity for aspects of care to get lost during
transfer, and plenty of evidence that this happens in practice.
183
Although there is little direct
evidence about how best this transition can be improved,
190,191
good communication appears to
be an essential first step.
186
In particular, tailored information should be provided with details of
treatment and cardiac rehabilitation to date, ongoing monitoring required, and future treatment
planned.
5 LONG TERM FOLLOW UP
Drug therapy
# Aspirin (75 mg/day) or clopidogrel (75 mg/day)
# Statin (if total cholesterol 5 mmol/l)
# -blocker
# ACE-inhibitor
Hypertension # BP lowering (if BP 140/90 mm Hg)
Smoking
# Brief supportive advice, reinforced regularly
# Nicotine replacement therapy
Diet
# Increase fruit and vegetables (at least 5 portions per day)
# Increase omega-3 fatty acid (oily fish or rapeseed oil)
# Replace saturated fat with unsaturated fat (e.g. olive or rapeseed oil)
# Weight loss if obese (BMI >30 kg/m
2
)
Exercise # Regular low to moderate intensity exercise (3-5 times per week)
Diabetes # Optimise glycaemic and blood pressure control
CARDIAC REHABILITATION
18
5.2 FOLLOW UP IN PRIMARY CARE
A systematic review of 12 randomised trials of secondary prevention programmes in coronary
heart disease found that structured disease management programmes improved risk factor profiles
and increased secondary preventive treatment.
187
They also reduced hospital admissions and
enhanced quality of life. The programmes included in this review differed considerably all
were multi-faceted, with about half including medical and lifestyle treatments, and the rest
being predominantly lifestyle and psychosocial. Most were based from hospitals, but two
conducted in UK primary care suggest that a structured approach benefits health related quality
of life and uptake of secondary prevention.
In the first study in Belfast, health visitors were trained to give health education on diet,
exercise and smoking and how to monitor blood pressure levels.
17,156,157
After two years, they
reported significantly more physical activity and better diet in the intervention group, but no
changes in smoking, blood pressure or lipids. Participants reported less angina and scored better
for physical mobility on the Nottingham Health Profile. Total mortality was reduced in the
intervention group. However, three years after the intervention finished most of the benefits
that had been present at two years had disappeared.
17
In the second study, in Grampian, nurse-led secondary prevention clinics were used to promote
medical and lifestyle components of secondary prevention.
177,188
At one year, significantly more
patients took aspirin, had better blood pressure treatment and lipid treatment, were moderately
physically active and had low fat diets; but there were no differences in smoking. The clinics
improved patients health related quality of life, especially physical and functioning aspects (where
they scored particularly poorly at baseline) and fewer patients required hospital admission.
In a third study, nurse-led clinics were compared to GP recall and audit with feedback.
189
Secondary prevention improved in all three groups and was best in the nurse-led group for aspirin
prescribing. Two other interventions have been tested: cardiac liaison nurses
190
and postal prompts
to patients and their GPs.
191
Although the former increased follow up in primary care, neither
showed benefit to secondary preventive drug prescribing or risk factors. These trials emphasise
that structured follow up in primary care must be coupled to appropriate drug prescribing.
A Structured care and follow up in primary care should be provided for patients with coronary
heart disease.
5.3 SHARED CARE
There is some evidence that patients with more complicated heart disease benefit from hospital-
based clinics or a shared care approach. Comprehensive heart failure disease management clinics
have been found to improve quality of life, functional capacity, patient satisfaction and compliance
with medications, and to reduce hospital admissions in patients with heart failure.
160
These clinics
were run in secondary care by staff with high levels of expertise. There is evidence from one RCT
that similar benefits were not achieved by increasing less specialist follow up in primary care.
193
However, all of these studies were conducted overseas, and more research is needed in the UK.
There are also benefits to patients with angina from courses of intensive and specialist hospital-
based interventions. In particular, symptoms in patients with angina can be improved.
73
Hospital-
based or shared care programmes for patients awaiting coronary revascularisation have been shown
to reduce risk factors, improve quality of life, and shorten length of stay in hospital.
73,155,192
A Coronary heart disease patients with limiting symptoms or awaiting coronary
revascularisation should be referred for further comprehensive cardiac rehabilitation.
5.4 SELF-HELP GROUPS
In Scotland, there is a long history of self-help groups for patients with cardiac disease. Nineteen
self-help groups were identified in 1994, located in sports and community centres, schools and
universities, hospitals and church halls, and providing care following hospital-based
programmes.
30,194
1
+
1
+
3
19
In 2001, there were over 30 cardiac support groups in Scotland.
195
The structure and content of
programmes varied widely and included exercise sessions, relaxation sessions, invited speakers,
and group discussions. Many of the exercise programmes were professionally supervised by
physiotherapists, nurses, or fitness instructors; but none were equipped with defibrillators.
There is no direct evidence about the effectiveness of self-help groups in cardiac rehabilitation.
An important aspect of self help groups is the interaction between people and the opportunity
to share experiences. Many patients value this, although others strongly dislike the idea.
30
Indirect evidence about group interaction from professionally-led programmes is mixed: some
studies reported improvements in psychosocial functioning and others deterioration.
75,196-200
Self
help groups depend entirely on the small numbers of dedicated people who organise them and
the enthusiasm of their members. Their main limitation is that only a minority of patients with
coronary disease attend them.
! !! !! Self help groups should be encouraged and enabled to use the same evidence-based approach
to cardiac rehabilitation advocated for professionally led programmes.
5.5 LONG TERM EXERCISE PROGRAMMES
Meta analysis of exercise-based cardiac rehabilitation trials has shown that the greatest benefit
is associated with exercising for 12 weeks or longer.
135
If the benefits of exercise are to be
sustained, moderate physical activity should continue long term, but this proves difficult for
most people with coronary disease once supervision is withdrawn.
147
Some people may devise
their own exercise programmes, or return to previous sports, join a self help group or a sports
centre, or use walking-based home exercise programmes.
201
Others prefer formal, class-based
cardiac exercise programmes.
31
There is no good evidence that any one of these options is
better than any other, so the choice should be determined by patient preference. Clearly it is
helpful if as many options as possible are available locally.
B People with stable coronary disease should be encouraged to continue regular moderate
intensity aerobic exercise.
The British Association for Cardiac Rehabilitation has made the following recommendations for
those who have completed a Phase 3 exercise programme and wish to undertake supervised long
term exercise. Patients should:
" be clinically stable
" understand their symptoms (and if they have angina know how to use sublingual nitrates)
" be able to self monitor and regulate their exercise
" be able to achieve an exercise capacity of more than 5 METS (equivalent to three minutes of a
Bruce Protocol).
202
Referral for supervised long term exercise should include the following information (with consent):
" details of the cardiac event and other relevant medical history
" subsequent progress including complications and/or interventions
" the Phase 3 exercise prescription and summary of functional capacity
" results of exercise tolerance test if available
" details of the patients medication.
! !! !! Fitness instructors delivering maintenance exercise programmes should be on the Exercise
and Fitness Register and hold an S/NVQ Level 3 Instructor qualification.
! !! !! If more than five years has elapsed since the individuals last assessment, if cardiac symptoms
have recurred, or if the patient is beginning long term supervised exercise without having
first completed a Phase 3 programme, (re)assessment by clinical risk stratification and a
test of functional capacity with or without a formal exercise test is recommended.
(See section 3.)
3
2
+
3
4
1
+
2
+
3
4
4
5 LONG TERM FOLLOW UP
CARDIAC REHABILITATION
20 20
6 Information for patients and professionals
6.1 NOTES FOR DISCUSSION WITH PATIENTS
These notes are provided for use by clinicians in discussing cardiac rehabilitation with patients.
They are not intended for direct distribution to patients, but they might be incorporated into
locally produced patient information materials.
Rehabilitation should start as soon as the patient is medically stable. Partners and other
family members should be included in the process where possible.
" Patients should be advised on the basic workings of the heart, the nature of
angina and MI, and the risk factors for CHD. Written information should be
provided for patients to take home.
" Discuss modification of risk factors, e.g. that a smoker who quits after an MI can
expect a 50% reduction in their risk of mortality in the next five years, along
with other components of the education programme e.g. diet, stress management,
living with CHD, drug therapy, understanding CHD.
" Reassure the patient that cardiac rehabilitation encourages people with heart
disease to recover faster and return to a full and productive life and that cardiac
rehabilitation is safe.
" Almost everyone with heart disease can benefit from some type of cardiac
rehabilitation. No one is too old or too young. Women benefit as much as men.
" The long term success of any cardiac rehabilitation programme is directly related
to patient compliance.The most important person in the rehabilitation team is
the patient. Patients should be encouraged to take charge of their own recovery.
PSYCHOLOGICAL ASPECTS OF CARDIAC REHABILITATION
" Patients should be warned that they may become weepy, or experience symptoms
of acute anxiety in the days and weeks after suffering an MI and that this is
normal.
" If they are not as able as they had hoped on their return home they should try not
to view this as a setback.
" A lower mood after discharge is possible and has been called homecoming
depression. Patients may be grumpy and uncommunicative with their partner.
" In the weeks and months following the patients MI, partners and other family
members may all have concerns, and should be involved in the cardiac
rehabilitation programme and encouraged to support each other.
" Sources of local community support available should be discussed, e.g. nurse
counsellor, supervised use of the Heart Manual, GP, primary care secondary
prevention clinic, self-help groups.
" The importance of ongoing contact with health care professionals should be
reinforced.
EXERCISE
" Discuss exercise opportunities, risks and benefits, e.g. that exercise does not
need to be intensive to bring benefits brisk walking for 15 to 20 minutes,
preferably daily or at least five times per week, is adequate exercise for most post
MI patients.
" Patients should choose home or hospital-based exercise (or both) secure in the
knowledge that low to moderate intensity exercise can be undertaken safely and
effectively in either setting.
" Emphasise that if the benefits of exercise are to be sustained then exercise must
continue long term.
CARDIAC REHABILITATION
20 20
6 Information for patients and professionals
6.1 NOTES FOR DISCUSSION WITH PATIENTS
These notes are provided for use by clinicians in discussing cardiac rehabilitation with patients.
They are not intended for direct distribution to patients, but they might be incorporated into
locally produced patient information materials.
Rehabilitation should start as soon as the patient is medically stable. Partners and other
family members should be included in the process where possible.
n Patients should be advised on the basic workings of the heart, the nature of
angina and MI, and the risk factors for CHD. Written information should be
provided for patients to take home.
n Discuss modification of risk factors, e.g. that a smoker who quits after an MI can
expect a 50% reduction in their risk of mortality in the next five years, along
with other components of the education programme e.g. diet, stress management,
living with CHD, drug therapy, understanding CHD.
n Reassure the patient that cardiac rehabilitation encourages people with heart
disease to recover faster and return to a full and productive life and that cardiac
rehabilitation is safe.
n Almost everyone with heart disease can benefit from some type of cardiac
rehabilitation. No one is too old or too young. Women benefit as much as men.
n The long term success of any cardiac rehabilitation programme is directly related
to patient compliance.The most important person in the rehabilitation team is
the patient. Patients should be encouraged to take charge of their own recovery.
PSYCHOLOGICAL ASPECTS OF CARDIAC REHABILITATION
n Patients should be warned that they may become weepy, or experience symptoms
of acute anxiety in the days and weeks after suffering an MI and that this is
normal.
n If they are not as able as they had hoped on their return home they should try not
to view this as a setback.
n A lower mood after discharge is possible and has been called homecoming
depression. Patients may be grumpy and uncommunicative with their partner.
n In the weeks and months following the patients MI, partners and other family
members may all have concerns, and should be involved in the cardiac
rehabilitation programme and encouraged to support each other.
n Sources of local community support available should be discussed, e.g. nurse
counsellor, supervised use of the Heart Manual, GP, primary care secondary
prevention clinic, self-help groups.
n The importance of ongoing contact with health care professionals should be
reinforced.
EXERCISE
n Discuss exercise opportunities, risks and benefits, e.g. that exercise does not
need to be intensive to bring benefits brisk walking for 15 to 20 minutes,
preferably daily or at least five times per week, is adequate exercise for most post
MI patients.
n Patients should choose home or hospital-based exercise (or both) secure in the
knowledge that low to moderate intensity exercise can be undertaken safely and
effectively in either setting.
n Emphasise that if the benefits of exercise are to be sustained then exercise must
continue long term.
21
6.2 SOURCES OF FURTHER INFORMATION
Action on Smoking and Health
www.ash.org.uk
Agency for Healthcare Research and Quality (US)
Recovering from heart problems through cardiac rehabilitation
AHCPR Publication No.96-0674 October 1995, NIH
http://hstat.nlm.nih.gov/hq/Hquest/db/local.ahcpr.consumer.crpp/screen/TocDisplay/s/54146/
action/Toc
American Heart Association
www.americanheart.org
BBC Health
www.bbc.co.uk/health/
British Association for Cardiac Rehabilitation
www.bcs.com/bacr/
British Cardiac Society
www.bcs.com
9 Fitzroy Square, London
Tel: 020 7383 3887
British Heart Foundation
www.bhf.org.uk
The Gatehouse, 112 Park Hill Road, Harborne, Birmingham, B17 9HD
Chest Heart and Stroke Scotland
www.chss.org.uk
Tel: 0131 225 6963 24 hour advice line: 0845 0776000
(Details of local groups available from the head office)
Coronary Prevention Group
www.healthnet.org.uk
Diabetes UK
www.diabetes.org.uk
Family Heart Association
Tel: 01628 628 638
HealthTouch.com
www.healthtouch.com
Health Education Board for Scotland
www.hebs.scot.nhs.uk
Examples of cardiac rehabilitation practice in the United Kingdom:
www.hebs.scot.nhs.uk/topics/heart/heartproject.cfm
Heart Manual Office
Administration Building, Astley Ainslie Hospital, Grange Loan, Edinburgh EH9 2HL
Tel: 0131 537 9127
Email: heart.manual@lpct.scot.nhs.uk
The Heart Manual Project is a non-profit-making NHS organisation that supports the use of the Heart Manual
within the health service. To maintain quality, as well as for safety reasons, the Heart Manual is not supplied
directly to the public, or to untrained staff. The project maintains a register of qualified facilitators and organises
facilitator training.
Johns Hopkins Heart Health (US)
www.jhbmc.jhu.edu/cardiology/REHAB/
NHS Direct
www.nhs.direct.nhs.uk/healthy_living/
Scottish Health on the Web
www.show.scot.nhs.uk
6 INFORMATION FOR PATIENTS AND PROFESSIONALS
CARDIAC REHABILITATION
22
7 Implementation and audit
7.1 STATEMENT OF INTENT
This guideline is not intended to be construed or to serve as a standard of medical care. Standards
of care are determined on the basis of all clinical data available for an individual case and are
subject to change as scientific knowledge and technology advance and patterns of care evolve. The
ultimate judgement regarding a particular clinical procedure or treatment plan must be made in
light of the clinical data presented by the patient and the diagnostic and treatment options available.
7.2 IMPLEMENTATION
Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an
essential part of clinical governance. It is acknowledged that every Trust cannot implement every
guideline immediately on publication, but mechanisms should be in place to ensure that the care
provided is reviewed against the guideline recommendations and the reasons for any differences
assessed and, where appropriate, addressed.
Standards for cardiac rehabilitation for NHS Scotland are given in the Clinical Standards Board for
Scotland (CSBS) recommendations for coronary heart disease, which have focused initially on
secondary prevention in a hospital setting.
203
The CSBS peer review visits have included an
examination of the provision of cardiac rehabilitation, which has highlighted the key role played
by the cardiac rehabilitation team in the collection of data required to show that a Trust is
meeting the standards. Essentially similar standards for cardiac rehabilitation are given in the
National Service Framework for Coronary Heart Disease for England and Wales.
204
Given the variation in provision of cardiac rehabilitation services in Scotland it would be prudent
to have an initial focus on ensuring comprehensive and high quality services for MI survivors and
those undergoing revascularisation. In particular, the inclusion of women and older patients should
be addressed. As evidence of the cost benefit of extending services to other groups emerges,
services can be extended in an incremental fashion. Managed Clinical Networks may prove to be
the best way of ensuring the effective delivery and coordination of cardiac rehabilitation across
primary and secondary care.
205
7.3 RESOURCE IMPLICATIONS OF IMPLEMENTING THE GUIDELINE
The review of cost effectiveness literature considered economic evaluations of comprehensive
cardiac rehabilitation based on three observational studies,
44,167,206
four randomised controlled
trials
152,207-209
and three reworkings of previously published data.
210-212
The most methodologically
rigorous economics study examined the costs incurred and quality of life gained in a randomised
trial of cardiac rehabilitation in moderately anxious or depressed patients.
207
Estimated survival
benefit was determined from an earlier meta-analysis.
135
The best estimates for cost-effectiveness
and cost-utility were $21,800 per life year gained and $6,800 per Quality Adjusted Life Year
(QALY) respectively (1991 prices). The most up-to-date conversions of this analysis for the UK
estimated that the cost per life year gained was approximately 6,400 and the cost per QALY
2,700 (1999 prices).
211
The process of ensuring that rehabilitation programmes are best placed to deliver maximum health
gain may not be resource neutral. However, cardiac rehabilitation does compare favourably in
cost-effectiveness terms with other cardiovascular interventions such as treatment of hypertension,
hyperlipidaemia, thrombolytics for inferior myocardial infarction and angioplasty for patients
with severe angina and single vessel disease.
213
Viewed in this way, expenditure on cardiac
rehabilitation services may be considered a worthwhile use of scarce health care resources.
The guideline development group have developed an estimate of the staff resources required to
deliver multidisciplinary cardiac rehabilitation to patients with a wide range of needs. These
represent the staff likely to be required to rehabilitate 500 patients. The following assumptions
have been made:
23
n The 500 patients will be a mixture of post MI, revascularisation, angina, and heart failure
patients, with post MI and revascularisation patients predominating.
n All patients with be suitable for some form of rehabilitation, with 250 (50%) opting for group
exercise training, 150 (30%) preferring a home-based programme, and 100 (20%) not interested
in any rehabilitation.
n Patients attending Phase 3 group classes and those who undertake home-based programmes
will each have a formal assessment of functional capacity at the beginning and end of their
programmes.
n Group exercise classes will run twice a week for eight weeks and will accommodate 12-15
patients at any one time. It follows that six separate classes will be required each week.
n The population served will be predominantly urban, arbitrarily defined as 80% of patients
living within 10 miles of a district general or teaching hospital. For Health Boards with a
significant rural population, costs are likely to be higher because of smaller class sizes and
longer travelling times.
n The first point of contact for patients with psychological distress will be a nurse therapist with
training in cognitive behavioural therapy, rather than a clinical psychologist. A smaller number
of clinical psychologist hours will then be required to help those patients whose anxiety or
depression does not resolve with the advice and treatment provided by their nurse therapists.
These assumptions allow the following estimates of whole time equivalent (WTE) staff
requirements to be made for Health Boards with and without a significant rural population:
These estimates reflect the likely requirement for cardiac rehabilitation if the targets set by the
Clinical Standards Board for Scotland are to be met. Health Boards may wish to vary the amount
spent on cardiac rehabilitation according to local needs and priorities. The cost of providing
cardiac rehabiltiation services in Scotland has also been considered by the Scottish Needs
Assessment Programme.
20
A review of the cost-effectiveness literature and details of the derivation of these staffing requirements,
together with an estimation of the associated costs is provided on the SIGN website: www.sign.ac.uk.
7.4 AUDIT
If audit of cardiac rehabilitation is to be efficient and ongoing then audit data will need to fall out
of routinely collected clinical data. The use of stand alone IT systems for audit requires double
entry of data, which is time consuming and should be discouraged. Recommended minimum
data fields in addition to the CHD Task Force minimum data set for the implementation of this
guideline are detailed overleaf. These have been designed primarily to meet the requirements of
both the Clinical Standards Board for Scotland and the CHD Task Force, and are not intended to
limit or restrict in any way those who wish to collect and audit additional data fields.
7 IMPLEMENTATION AND AUDIT
f f a t S E T W
e s r u n e d a r G G
t s i p a r e h t o i s y h P 1 r o i n e S
n a i t i t e i D 1 r o i n e S
t s i c a m r a h P e d a r g D
) A e d a r G ( t s i g o l o h c y s P l a c i n i l C
) 3 e d a r G ( l a c i r e l C d n a t i d u A
0 . 3
0 . 2
3 . 0
2 . 0
2 . 0
5 . 0
t n e m e l p p u s l a r u R
e s r u n e d a r G G 5 . 0
CARDIAC REHABILITATION
24
B A H E R C A I D R A C R O F T N E V E G N I T A I T I N I
a n i g n A R N / N / Y y r e g r u s e v l a V R N / N / Y
n o i t c r a f n i l a i d r a c o y M R N / N / Y e r u l i a f t r a e H R N / N / Y
y r e g r u s s s a p y B R N / N / Y r o t a l l i r b i f e d c a i d r a c l a n r e t n I R N / N / Y
y t s a l p o i g n A R N / N / Y r e h t O R N / N / Y
L A T I P S O H
e s r u N b a h e R y b n e e S R N / N / Y
e m m a r g o r p b a h e R y l n o e s i c r e x E y l n o n o i t a c u d E R C e v i s n e h e r p m o C
d e t i v n I R N / N / Y R N / N / Y R N / N / Y
d e t r a t S R N / N / Y R N / N / Y R N / N / Y
) % 5 7 ( d e t e l p m o C R N / N / Y R N / N / Y R N / N / Y
E M O H
d e u s s i l a u n a M t r a e H R N / N / Y
d e t e l p m o c l a u n a M t r a e H R N / N / Y
E M M A R G O R P O T Y R T N E
r a e Y / h t n o M / y a D
E M M A R G O R P M O R F T I X E
r a e Y / h t n o M / y a D
B A H E R F O M R O F E N O T S A E L T A G N I T E L P M O C T O N R O F S N O S A E R
d e t s e r e t n i t o n t n e i t a P s n o i t a g i t s e v n i g n i o g r e d n U
t r o p s n a r t o N k r o w o t n r u t e R
l e v a r t o t r a f o o T y t i c a p a c n i l a c i s y h P
r e k a m y a d i l o H y t i c a p a c n i l a t n e M
d e i D r e h t O
S T N E M S S E S S A
e g r a h c s i d e r o f e b e r o c s D A H R N / d e s u f e R / = D / = A
) e r o m r o 8 s e u l a v r o f ( e r o c s D A H p u w o l l o F R N / d e s u f e R / I N / = D / = A
e m m a r g o r p g n i n i a r t e r o f e b y t i c a p a c l a n o i t c n u F R N / N / Y
e m m a r g o r p g n i n i a r t r e t f a y t i c a p a c l a n o i t c n u F R N / N / Y
E C I V D A
s n o i t p e c n o c s i m c a i d r a C R N / N / Y
n e v i g n o i t a m r o f n i n e t t i r W R N / N / Y
d e w e i v o e d i V R N / N / Y
n e e s s r e r a C R N / r e r a c o N / N / Y
r e r a c h t i w d e s s u c s i d t r o p p u s e f i l c i s a B R N / N / Y
L A R R E F E R
c i n i l c n o i t n e v e r p y r a d n o c e S R N / I N / N / Y
e s i c r e x e 4 e s a h P R C A B R N / I N / N / Y
p u o r g p l e h f l e S R N / I N / N / Y
c i n i l C y g o l o i d r a C R N / I N / N / Y
n a i t i t e i D R N / I N / N / Y
t s i p a r e h T l a n o i t a p u c c O R N / I N / N / Y
y p a r e h t o i s y h P R N / I N / N / Y
y g o l o h c y s P R N / I N / N / Y
n o i t a s s e c g n i k o m S R N / I N / N / Y
t s i g o l o i s y h p e s i c r e x E R N / I N / N / Y
NI= not indicated NR = not recorded

25
8 DEVELOPMENT OF THE GUIDELINE
8 Development of the guideline
SIGN is a collaborative network of clinicians, other health care professionals, and patient
organisations, funded by the Clinical Resource and Audit Group (CRAG) of the Scottish Executive
Health Department. SIGN guidelines are developed by multidisciplinary groups using a standard
methodology based on a systematic review of the evidence. Further details about SIGN and the
guideline development methodology are contained in SIGN 50: A guideline developers handbook,
available at www.sign.ac.uk.
8.1 THE GUIDELINE DEVELOPMENT GROUP
Dr Chris Isles Consultant Physician, Dumfries & Galloway Royal Infirmary
(Chairman)
Ms Gillian Armstrong Physiotherapist, Glasgow Royal Infirmary
Dr Alan Begg General Practitioner, Montrose
Dr John Bowbeer General Practitioner, Ayr (resigned from group in 2000)
Dr Anthony Breslin Consultant in Public Health, Forth Valley Health Board, Stirling
Ms Ailsa Brown Health Economist, Greater Glasgow Health Board
Dr Neil Campbell CRC Fellow, Department of General Practice,
University of Aberdeen
Ms Francesca Chappell Information Officer, SIGN
Dr John Gillies General Practitioner, Selkirk
Dr Belinda Green Consultant Cardiologist, Ninewells Hospital, Dundee
Mr Angus Gunn Patient representative, Edinburgh
Ms Patricia Isoud Cardiac Rehabilitation Sister, Western Infirmary, Glasgow
Dr Grace Lindsay Lecturer, Nursing and Midwifery Studies, University of Glasgow
Dr Paul MacIntyre Consultant Physician and Cardiologist,
Royal Alexandra Hospital, Paisley
Dr Karen Smith Clinical Research Fellow (cardiac nursing),
Ninewells Hospital, Dundee
Ms Nicola Stuckey Clinical Psychologist, Astley Ainslie Hospital, Edinburgh
Ms Morag Thow Lecturer, Department of Physiotherapy,
Glasgow Caledonian University
Dr Iain Todd Consultant in Cardiovascular Rehabilitation,
Astley Ainslie Hospital, Edinburgh
Ms Joanne Topalian Programme Manager, SIGN
Dr Chris Baker, Medical Director, Dumfries & Galloway NHS Trust, provided advice on
implementation and audit.
The membership of the guideline development group was confirmed following consultation with
the member organisations of SIGN. Declarations of interests were made by all members of the
guideline development group. Further details are available from the SIGN Executive.
8.2 SYSTEMATIC LITERATURE REVIEW
The evidence base for this guideline was synthesised in accordance with SIGN methodology. A
number of systematic literature searches were carried out (full details of the search strategies used
and the coverage of the Internet search are available from the SIGN Executive). Papers were only
included if they adhered to recognisable methodological principles, including adequate sample
size, a clearly identified hypothesis and measure of outcome, and accurate reporting of results.
An Internet search was carried out to identify existing guidelines and reviews on cardiac
rehabilitation. This search used a range of general and specialised search engines, specific medical
sites such as the National Guideline Clearinghouse (www.guideline.gov), and the following
CARDIAC REHABILITATION
26
databases: Medline, Healthstar, Embase, PsychINFO, Cinahl, and the Cochrane Library. A search
for economic literature was also performed in Medline, Healthstar, Embase, the Cochrane Library,
and NEED. The search for systematic reviews and meta-analyses covered the period January 1991
to May 2000. The Cochrane review Exercise-based Rehabilitation for Coronary Heart Disease,
93
an
AHCPR publication Cardiac Rehabilitation: Clinical Guideline No.17,
146
Effective Health Care:
Cardiac Rehabilitation,
147
and systematic reviews by Oldridge et al (1988)
135
and Goble and
Worcester (1999)
91
provided much of the evidence for this guideline.
Additional searches were performed covering the period January 1995 to September 2000 to bring
the literature up to date for randomised controlled trials and the evidence base was further updated
during the course of development of the guideline.
8.3 CONSULTATION AND PEER REVIEW
8.3.1 NATIONAL MEETING
A national open meeting is the main consultative phase of SIGN guideline development, at which
the guideline development group presents their draft recommendations for comment. The national
open meeting for this guideline was held in March 2001 and was attended by representatives of
all the key specialties relevant to the guideline. The draft guideline was also available on the SIGN
web site for a limited period at this stage to allow those unable to attend the meeting to contribute
to the development of the guideline.
8.3.2 SPECIALIST REVIEW
The guideline was reviewed in draft form by a panel of independent expert referees, who were
asked to comment primarily on the comprehensiveness and accuracy of interpretation of the
evidence base supporting the recommendations in the guideline. SIGN is grateful to all of these
experts for their contribution to this guideline.
Professor Annie Anderson Faculty of Epidemiology & Public Health,
University of Dundee
Mrs Mandy Andrew Cardiovascular Facilitator, Perth & Kinross
LHCC and Tayside Primary Care Trust
Dr Jenny Bell Director, BACR Phase 4 Education Project
Dr Hugh Bethell General Practitioner, Alton
Mrs Lesley Brooks Cardiac Specialist Nurse, Perth Royal Infirmary
Professor Sir Charles George Medical Director, British Heart Foundation, London
Dr John Irving Consultant Cardiologist, St Johns Hospital, Livingston
Professor Marie Johnston Professor of Health Psychology, St Andrews University
Dr Kate Jolly Department of Public Health & Epidemiology,
University of Birmingham
Professor Bob Lewin British Heart Foundation Rehabilitation Research Unit,
University of York
Professor Richard Mayou Department of Psychiatry, University of Oxford
Dr Andrew McLeod Consultant Cardiologist, Poole Hospital NHS Trust
Dr Allan Merry General Practitioner, Ardrossan
Dr Jill Pell Consultant in Public Health Medicine,
Greater Glasgow Health Board
Dr Ann Taylor Physiotherapy Division, Kings College London
Dr Rod Taylor Senior Lecturer in Public Health,
University of Birmingham
Mrs Joan Thain Health Visitor, Westburn Centre, Aberdeen
Professor David Thompson Department of Health Studies, University of York
Professor Erkki Vartiainen National Public Health Institute, Finland
Dr Alex Watson General Practitioner, Dundee
27
8.3.3 SIGN EDITORIAL GROUP
The guideline was then reviewed by an Editorial Group comprising relevant specialty representatives
on SIGN Council, to ensure that the peer reviewers comments had been addressed adequately
and that any risk of bias in the guideline development process as a whole had been minimised.
The Editorial Group for this guideline was as follows:
Dr David Alexander British Medical Association, Scottish General Practice Committee
Dr Jim Beattie Royal College of General Practitioners
Dr Doreen Campbell CRAG Secretariat, Scottish Executive Department of Health
Mrs Patricia Dawson Royal College of Nursing
Professor Gordon Lowe Chairman of SIGN, Co-Editor
Ms Juliet Miller Director of SIGN, Co-Editor
Miss Tracy Nairn National Paramedical Advisory Committee
Dr Sara Twaddle Health Economics Adviser to SIGN
Dr Bernice West National Nursing, Midwifery & Health Visiting Advisory Committee
8 DEVELOPMENT OF THE GUIDELINE
CARDIAC REHABILITATION
28
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REFERENCES
CARDIAC REHABILITATION
Abbreviations
ACE Angiotensin converting enzyme
AHCPR Agency for Health Care Policy and Research
BACR British Association for Cardiac Rehabilitation
BMI Body mass index
BP Blood pressure
CABG Coronary artery bypass graft
CHD Coronary heart disease
CRAG Clinical Research and Audit Group
CSBS Clinical Standards Board for Scotland
ECG Electrocardiogram
GP General practitioner
HADS Hospital Anxiety and Depression Scale
ICD Implantable cardioverter defibrillator
METS Metabolic equivalents
MI Myocardial infarction
NHS National Health Service
NIH National Institutes for Health
NSF National Service Framework
QALY Quality adjusted life year
QLMI Quality of life after myocardial infarction
RCT Randomised controlled trial
S/NVQ Scottish/National Vocational Qualification
SIGN Scottish Intercollegiate Guidelines Network
SNAP Scottish Needs Assessment Programme
UK United Kingdom
US United States
32
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19 Oct 2004

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Functional capacity should be evaluated before and
on completion of exercise training using a valid and
reliable measure (e.g. the shuttle walking test)
D
Aerobic, low to moderate intensity exercise is
recommended for most patients undergoing exercise
training and can be undertaken safely and effectively
in the home or community
B
EXERCISE TRAINING
Monitor exercise intensity by perceived exertion
using the Borg scale or by using a pulse monitor
D
The ratio of patients to trained staff during exercise
classes should be no more than 10:1
Staff with basic life support training and the ability to
use a defibrillator are required for group exercise of
low to moderate risk patients
Immediate access to on-site staff with advanced life
support training is required for high risk patients or
classes offering high intensity training
D
Clinical risk stratification is sufficient for low to
moderate risk patients undergoing low to moderate
intensity exercise
Exercise testing and echocardiography are
recommended for high risk patients and/or high
intensity exercise (and to assess residual ischaemia
and ventricular function where appropriate)
D
PHASE 1
The inpatient stage or after a step change in the patients
cardiac condition (MI, onset of angina, any emergency
hospital admission for CHD, cardiac surgery or
angioplasty, or first diagnosis of heart failure).
Includes medical evaluation, reassurance and education,
correction of cardiac misconceptions, risk factor
assessment, mobilisation and discharge planning.
PHASE 2
The early post discharge period, a time when many
patients feel isolated and insecure. Psychological distress
and poor social support are powerful predictors of
outcome following MI, independent of the degree of
physical impairment.
Support can be provided by home visiting, telephone
contact,

and by supervised use of the Heart Manual or an
equivalent cognitive behavioural programme.
PHASE 3
Structured exercise training together with continuing
educational and psychological support and advice on
risk factors. All components can be undertaken safely
and effectively in the community.
A menu-based approach recognises the need to tailor
services to the individual and is likely to include specific
education to reduce cardiac misconceptions, encourage
smoking cessation and weight management; vocational
rehabilitation to assist return to work or retirement; and
referral to a psychologist, cardiologist, or exercise
physiologist if appropriate.
Most patients will benefit from and should be encouraged
to undertake at least low to moderate intensity exercise.
However, patients with clinically unstable cardiac
disease, complicating illness, or serious psychotic illness
should be excluded from exercise training.
PHASE 4
Long term maintenance of physical activity
and lifestyle change.
Quick reference guide CARDIAC REHABILITATION SIGN 57
A Comprehensive cardiac rehabilitation is
recommended:
! Following myocardial infarction
! Following coronary revascularisation
! For patients with stable angina or chronic heart
failure with limiting symptoms or after a new event
B Women and older patients should be included in
comprehensive cardiac rehabilitation programmes
B Patients with moderate to severe psychological
difficulties should be treated by staff with specialist
training in techniques such as cognitive behavioural
therapy
Caution should be exercised in selecting an
antidepressant without significant cardiac side effects
"
A Patients in whom anxiety or depression is diagnosed
should be treated appropriately
Screening should take place at discharge, 6-12 weeks
post MI or following a decision on surgical intervention,
and repeated at three month intervals if appropriate
"
B Screen patients for anxiety and depression
using a validated assessment tool, such as the
Hospital Anxiety and Depression (HAD) scale
A Use the Heart Manual to facilitate comprehensive
cardiac rehabilitation
B Identify and address health beliefs and cardiac
misconceptions with CHD patients
B Target psychological and behavioural interventions
at the needs of individual patients with coronary
heart disease
A Comprehensive cardiac rehabilitation should include
both psychological and educational interventions and
should be delivered using established principles of
adult education and behavioural change
PSYCHOLOGICAL AND
EDUCATIONAL INTERVENTIONS
Exercise training is a core element of cardiac
rehabilitation and should be offered at least twice a
week for a minimum of eight weeks
A
Low to moderate risk cardiac patients can undertake
resistance training
C
Encourage people with stable coronary disease to
continue regular moderate intensity aerobic exercise
C
Structured care and follow up in primary care should
be provided for patients with coronary heart disease
A
Fitness instructors running maintenance exercise
programmes should hold an S/NVQ Level 3 Instructor
qualification
"
LONG TERM FOLLOW UP