Cardiac Rehabilitation: Current Review of the Literature and Its Role in Patients with Heart Failure
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Purpose of review
Cardiovascular (CV) disease remains the leading cause of death in the USA despite major advances in its treatment. With time, cardiac rehabilitation (CR) programs have gathered interest to help increase CV health and improve functional status after a CV event. Patients with heart failure have also been shown to benefit. In this review, we will evaluate the current literature showcasing the benefits of CR, particularly in patients with heart failure, discuss current limitations, and avenues for future investigation.
Studies have shown that CR is beneficial in reducing morbidity, mortality, hospitalizations, activity-related symptoms, and increasing quality of life. Similar findings have also been observed in patients with heart failure who underwent CR in addition to optimal medical management.
The positive effects of CR are well established in patients with coronary disease. Recent literature is also showing a trend to benefit in patients with heart failure, though much of the evidence is limited to patients with systolic dysfunction. Despite recommendations by professional societies, the use of CR remains underutilized. Further investigation is needed to better understand the impact of CR in heart failure. Moreover, strategies to increase CR utilization must be explored.
KeywordsHeart failure Cardiovascular disease Cardiac rehabilitation
Compliance with Ethical Standards
Conflict of Interest
Nishant P. Shah, Ahmed AbuHaniyeh, and Haitham Ahmed each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 2.Fang J, Ayala C, Luncheon C, Ritchey M, Loustalot F. Use of outpatient cardiac rehabilitation among heart attack survivors—20 States and the District of Columbia, 2013 and Four States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(33):869–73. https://doi.org/10.15585/mmwr.mm6633a1.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011;123(21):2344–52. https://doi.org/10.1161/CIRCULATIONAHA.110.983536. CrossRefPubMedGoogle Scholar
- 9.Shaw LW. Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after myocardial infarction. The National Exercise and Heart Disease Project. Am J Cardiol. 1981;48(1):39–46. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=cctr&AN=CN-00025397%5Cnhttp://sfx.scholarsportal.info/uhn?sid=OVID:cctrdb&id=pmid:6972693&id=doi:&issn=0002-9149&isbn=&volume=48&issue=1&spage=39&pages=39-46&date=1981&title=American+jouGoogle Scholar
- 11.• Yancy CW, Jessup M, Bozkurt B, et al. ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American college of cardiology foundation/american heart association task force on practice guidelines. J Am Coll Cardiol 2013. 2013;62(16):1495–539. https://doi.org/10.1016/j.jacc.2013.05.020. Societal guidelines on recommendations for cardiac rehabilitation in patients with heart failure.
- 12.Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47(10):2130–9. https://doi.org/10.1016/j.jacc.2006.04.026. CrossRefPubMedGoogle Scholar
- 14.Morris J, Heady J. Mortality in relation to the physical activity of work: a preliminary note on experience in middle age. Br J Intern Med. 1953;10(4):245–54.Google Scholar
- 15.Hellerstein H. Exercise therapy in coronary disease. Bull New York Acad Med J Ubran Heal. 1968;44(8):1028–47.Google Scholar
- 16.DHHS. Cardiac Rehabilitation and Intensive Cardiac Rehabilitation.; 2010.Google Scholar
- 17.AACPR. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs.; 2013. http://www.ncbi.nlm.nih.gov/nlmcatalog/101609574.
- 19.Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. In: Cochrane Database of Systematic Reviews.; 2011. doi: https://doi.org/10.1002/14651858.CD001800.pub2.
- 20.• Dunlay S, Pack Q, Thomas R, Killian J, Roger V. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med. 2014;127(6):538–46. Recent population based study that showed participants who enrolled in cardiac rehabilitation after a myocardial infarction had lower hospital readmission rates and death.Google Scholar
- 21.• Rauch B, Davos CH, Doherty P, et al. The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: a systematic review and meta-analysis of randomized and non-randomized studies—the cardiac rehabilitation outcome study (CROS). Eur J Prev Cardiol. 2016;23(18):1914–39. https://doi.org/10.1177/2047487316671181. Recent systematic review and meta-analysis that evaluated the role of cardiac rehabilitation in patients post acute coronary syndrome or coronary artery bypass grafting. Participants did have an associated reduction in mortality in a modern era of optimal therapy, however there was heterogeneity amongst study designs and rehabilitation programs which suggest a call for standardizations of programs.
- 23.• Ernstsen L, Rangul V, Nauman J, et al. Protective effect of regular physical activity on depression after myocardial infarction: the HUNT study. Am J Med. 2016;129(1):82–8. https://doi.org/10.1016/j.amjmed.2015.08.012. A small study showing the effect of physical activity in preventing depression post myocardial infarction.
- 24.Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease...reprinted with permission from the Cochrane Database of Systematic Reviews. Cardiopulm Phys Ther J (American Phys Ther Assoc Cardiopulm Sect. 2001;12(4):131–140 10p. http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=106909977&site=ehost-live.
- 25.Hunt SA, Hunt SA, Abraham WT, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation. 2005;112(12):e154–235. https://doi.org/10.1161/CIRCULATIONAHA.105.167586. CrossRefPubMedGoogle Scholar
- 27.Hobbs FDR, Roalfe AK, Davis RC, Davies MK, Hare R. Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). Eur Heart J. 2007;28(9):1128–34. https://doi.org/10.1093/eurheartj/ehm102.CrossRefPubMedGoogle Scholar
- 31.Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L TLCR-HF (CARE-HSI. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005;352:1539–1549. doi: https://doi.org/10.1056/NEJMoa050496.
- 33.McKelvie RS. Exercise training in patients with heart failure: clinical outcomes, safety, and indications. Heart Fail Rev 2008;13(1):3–11. doi: https://doi.org/10.1007/s10741-007-9052-z.
- 34.Hambrecht R, Niebauer J, Fiehn E, et al. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol. 1995;25(6):1239–49. https://doi.org/10.1016/0735-1097(94)00568-B. CrossRefPubMedGoogle Scholar
- 36.Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999;99:1173–82. https://doi.org/10.1161/01.CIR.99.9.1173.CrossRefPubMedGoogle Scholar
- 37.Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004;116(10):693–706. doi: https://doi.org/10.1016/j.amjmed.2003.11.033.
- 39.C.M. O, D.J. W, K.L. L, et al. Efficacy and safety of exercise training in patients with chronic heart failure HF-ACTION randomized controlled trial. JAMA - J Am Med Assoc. 2009;301(14):1439–50. http://jama.ama-assn.org/cgi/reprint/301/14/1439%5Cnhttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed9&NEWS=N&AN=2009196870.Google Scholar
- 42.Swank AM, Horton J, Fleg JL, et al. Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Hear Fail. 2012;5(5):579–85. https://doi.org/10.1161/CIRCHEARTFAILURE.111.965186.CrossRefGoogle Scholar
- 43.• Bakker E, Snoek J, Meindersma E, et al. Absence of fitness improvement is associated with outcomes in heart failure patients. Med Sci Sport Exerc. 2017; Epub ahead. A small study that evaluated the clinical impact of baseline cardiorespiratory fitness and improvements of fitness after cardiac rehabilitation in heart failure patients. The authors found that the inability to improve peak VO2, or combination of poor baseline cardiorespiratory fitness and inability to improve peak VO2 resulted in worse clinical outcomes.Google Scholar
- 45.Gottlieb S, Fisher M, Freudenberger R, et al. Effects of exercise training on peak performance and quality of life in congestive heart failure patients. J Card Fail 1999;5(3):188–194.Google Scholar
- 46.Weilenga R, Huisveld I, Bol E, et al. Exercise training in elderly patients with chronic heart failure. Coron Artery Dis 1998;9:765–770.Google Scholar
- 49.• Chen Y, Li Y. Safety and efficacy of exercise training in elderly heart failure patients: a systematic review and meta-analysis. Int J Clin Pract. 2013;67(11):1192–8. A systematic review and meta-analysis that evaluated the impact of cardiac rehabilitation in elderly patients with heart failure. The authors found that exercise training improved six minute walk distance and quality of life. An impact on mortality or hospital readmission was not seen.Google Scholar
- 51.• Reeves GR, Whellan DJ, Duncan P, et al. Rehabilitation therapy in older acute heart failure patients (REHAB-HF) trial: design and rationale. Am Heart J. 2017;185:130–9. https://doi.org/10.1016/j.ahj.2016.12.012. Design and rational of the first randomized clinical trial of cardiac rehabilitation on older patients hospitalized for acute decompensated heart failure to see if physical interventions can prevent hospital readmissions.
- 52.• Acanfora D, Scicchitano P, Casucci G, et al. Exercise training effects on elderly and middle-age patients with chronic heart failure after acute decompensation: a randomized, controlled trial. Int J Cardiol. 2016;225:313–23. https://doi.org/10.1016/j.ijcard.2016.10.026. A clinical trial looking at the impact of cardiac rehabilitation in both middle and older patients with heart failure who had a recent hospitalization for decompensated heart failure. The authors found that exercise training improved cardiac performance indexes and pulmonary function in both middle and older age groups.
- 53.• Pahor M, Guralnik JM, Ambrosius AT, et al. Effect of structured physical activity on prevention of major mobility disability in older adults. The LIFE Study Randomized Clinical Trial. JAMA. 2014;311(23):2387–96. A clinical trial that compared a structured, moderate-intensity physical activity program to a health education program in older adults with the primary outcome being major mobility disability. The authors found that a structured physical activity program resulted in reduced major mobility disability among older adults at risk for disability.CrossRefPubMedPubMedCentralGoogle Scholar
- 54.• Newman AB, Dodson JA, Church TS, et al. Cardiovascular events in a physical activity intervention compared with a successful aging intervention: the LIFE study randomized trial. JAMA Cardiol. 2016;1(5):568–74. An evaluation of the LIFE trial that studied the rates of major adverse cardiovascular events in older individuals who were randomized to either a structured physical activity program or a health education program. The authors found that a structured physical activity program was not associated with reduced cardiovascular events.Google Scholar
- 57.• Suchy C, Massen L, Rognmo O, et al. Optimising exercise training in prevention and treatment of diastolic heart failure (OptimEx-CLIN): rationale and design of a prospective, randomised, controlled trial. Eur J Prev Cardiol. 2014;21(2):18–25. Design and rational for a multicentered clinical trial studying the impact of cardiac rehabilitation in patients with heart failure with preserved ejection fraction.CrossRefPubMedGoogle Scholar
- 58.• Koifman E, Grossman E, Elias A, et al. Multidisciplinary rehabilitation program in recently hospitalized patients with heart failure and preserved ejection fraction: rationale and design of a randomized controlled trial. Am Heart J. 2014;168(6):830–7. Another trial evaluating the impact of cardiac rehabilitation in patients with heart failure with preserved ejection fraction.CrossRefPubMedGoogle Scholar
- 62.• Pandey A, Kitzman DW, Brubaker P, et al. Response to endurance exercise training in older adults with heart failure with preserved or reduced ejection fraction. J Am Geriatr Soc. 2017;65(8):1698–704. https://doi.org/10.1111/jgs.14867. A study that evaluated the role of cardiac rehabilitation in both patients with reduced and preserved systolic function. The authors found that in older patients there was a greater improvement in peak VO2 in those with preserved systolic function.CrossRefPubMedGoogle Scholar
- 63.Forman DE, Sanderson BK, Josephson RA, Raikhelkar J, Bittner V. American College of Cardiology’s Prevention of Cardiovascular Disease Section. Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities. J Am Coll Cardiol. 2015;65(24):2652–9. https://doi.org/10.1016/j.jacc.2015.04.052. CrossRefPubMedGoogle Scholar
- 65.Slaughter MS, Pagani FD, Rogers JG, et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Hear Lung Transplant. 2010;29(4 SUPPL.). doi: https://doi.org/10.1016/j.healun.2010.01.011.
- 67.• Kerrigan DJ, Williams CT, Ehrman JK, et al. Cardiac rehabilitation improves functional capacity and patient-reported health status in patients with continuous-flow left ventricular assist devices: the rehab-vad randomized controlled trial. JACC Hear Fail. 2014;2(6):653–9. https://doi.org/10.1016/j.jchf.2014.06.011. A clinical trial which showed that patients with continuous flow left ventricular assist devices had improved functional capacity and health status when attending cardiac rehabilitation programs.
- 68.• Haddad M, Saurav A, Smer A, et al. Cardiac rehabilitation in patients with left ventricular assist device: a systematic review and meta-analysis. J Cardiopulm Rehabil Prev. 2017;37(6):390–6. Recent systematic review and meta-analysis showing improved outcomes in patients with left ventricular assist devices who enroll in exercise based cardiac rehabilitation programs.Google Scholar
- 71.Brown TM, Hernandez AF, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients. Findings From the American Heart Association’s Get With The Guidelines Program. J Am Coll Cardiol. 2009;54(6):515–21. https://doi.org/10.1016/j.jacc.2009.02.080.CrossRefPubMedPubMedCentralGoogle Scholar
- 73.• Park LG, Schopfer DW, Zhang N, Shen H, Whooley MA. Participation in cardiac rehabilitation among patients with heart failure. J Card Fail. 2017;23(5):427–31. https://doi.org/10.1016/j.cardfail.2017.02.003. A retrospective study that found low participation rates of heart failure patients in cardiac rehabilitation programs.
- 74.• Kim M, Kim M-S, Lim S-J, Ahn J-M, Kim J-J, Park S-J. Comparison of supervised hospital-based versus educated home-based exercise training in Korean heart failure patients. Korean Circ J. 2017;47(5):742. https://doi.org/10.4070/kcj.2017.0061. A small single centered prospective study that compared hospital based exercise therapy to home based exercise therapy in patients with heart failure. The authors found improvements in functional capacity and quality of life in the hospital based exercise group, but no difference in long term cardiac events.
- 75.Miller S, Mandrusiak A, Adsett J. Getting to the heart of the matter: what is the landscape of exercise rehabilitation for people with heart failure in Australia? Hear Lung Circ. 2017;17:E pup ahead of print.Google Scholar
- 77.• Ades PA, Keteyian SJ, Wright JS, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the million hearts cardiac rehabilitation collaborative. Mayo Clin Proc. 2017;92(2):234–42. https://doi.org/10.1016/j.mayocp.2016.10.014. An initiative aimed at addressing the under utilization of cardiac rehabilitation with a goal to increase participation rates from 20% to at least 70% by year 2022. An increase of this magnitude is calculated to save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.