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The role of cardiac rehabilitation in improving cardiovascular outcomes

Nature Reviews Cardiology volume 19, pages 180–194 (2022)Cite this article

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Abstract

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.

Key points

  • Cardiac rehabilitation is a complex, multicomponent intervention that includes exercise training and physical activity promotion, health education, cardiovascular risk management and psychological support, personalized to the individual needs of patients with heart disease.

  • Data from randomized, controlled trials support cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization.

  • Despite this robust evidence base and strong guideline recommendations, global access to cardiac rehabilitation is persistently poor, with scarce cardiac rehabilitation provision in low-income and middle-income settings.

  • Home-based and technology-based models of cardiac rehabilitation with appropriate quality assurance as an alternative or adjunct to traditional, centre-based programmes are needed to improve access to cardiac rehabilitation.

  • Cardiac rehabilitation programmes need to cater for and manage the needs of the increasing number of patients with heart disease who present with two or more chronic diseases.

  • Further research needs to strengthen the evidence base for cardiac rehabilitation in patients with heart failure with preserved ejection fraction, atrial fibrillation or congenital heart disease and after cardiac valve surgery or heart transplantation.

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Fig. 1: Components of comprehensive cardiac rehabilitation.
Fig. 2: Cardiac rehabilitation and all-cause mortality in patients with coronary heart disease: 1970–2020.
Fig. 3: Global incidence of ischaemic heart disease and availability of cardiac rehabilitation.

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Acknowledgements

The authors thank J. Uddin (Physiotherapy Unit, Department of Cardiac Surgery Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh) for drafting the content of Box 6, G. Dibben (MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK) for preparing Fig. 2 for initial submission and U. Ahmed (MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK) for editorial review of the text.

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  1. MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health & Well Being, University of Glasgow, Glasgow, UK

    Rod S. Taylor

  2. College of Medicine and Health, University of Exeter, Exeter, UK

    Rod S. Taylor

  3. University of Exeter Medical School (Primary Care), Smeall Building, St Luke’s Campus, Exeter, UK

    Hasnain M. Dalal & Sinéad T. J. McDonagh

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All the authors researched data for the article, contributed substantially to discussions of its content, wrote the article, and reviewed and/or edited the manuscript before submission.

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R.S.T. is a member of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP) Science Committee 2020–2022 and lead investigator for the following ongoing funded projects: ‘Implementation of an evidence-based cardiac rehabilitation home programme for heart failure patients and their caregivers in Scotland: SCOT:REACH-HF project’, funded by Heart Research UK; ‘A randomized controlled trial of a facilitated home-based rehabilitation intervention in patients with heart failure with preserved ejection fraction and their caregivers: the REACH-HFpEF Study’, funded by NIHR HTA Programme (NIHR130487). H.M.D. is a co-opted member of the British Association of Cardiovascular Prevention and Rehabilitation (BACPR) and a co-lead for the ongoing funded research projects: ‘D REACH-HF: Digital Rehabilitation Enablement in Chronic Heart Failure’, funded by the British Heart Foundation, Hope for Hearts fund’; ‘Extending the reach and implementation of the successful REACH-HF programme with a digitally delivered training programme’, funded by NIHR Programme Development Grant (NIHR202040). S.J.D.M. is a researcher on the following ongoing funded research projects: ‘D REACH-HF: Digital Rehabilitation Enablement in Chronic Heart Failure’, funded by the British Heart Foundation, Hope for Hearts fund’; ‘Extending the reach and implementation of the successful REACH-HF programme with a digitally delivered training programme’, funded by NIHR Programme Development Grant (NIHR202040).

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Taylor, R.S., Dalal, H.M. & McDonagh, S.T.J. The role of cardiac rehabilitation in improving cardiovascular outcomes. Nat Rev Cardiol 19, 180–194 (2022). https://doi.org/10.1038/s41569-021-00611-7

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