Cardiac rehabilitation explained

Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life".[1] CR is a comprehensive model of care delivering established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life and reducing the risk of future heart problems.[2] [3]

CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist.[4] Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.

Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology[5] and the European Society of Cardiology,[6] among other associations.[7] [8] Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator).[9]

Cardiac rehabilitation setting

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. Hybrid programs are also increasingly being offered.[10] [11]

Cardiac rehabilitation phases

Inpatient program (phase I)

Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises.[12]

Outpatient program (phase II)

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4 - 6 weeks after cardiac surgery.[13] [14] [15] This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues.[16] Shorter time to start is associated with better outcomes.[17]

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program.

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.[18]

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered,[19] and it is well-established that the more the better.[20]

After CR is finished, there are long-term maintenance programs (phase III) available to interested patients,[21] as benefits are optimized with long-term adherence. Unfortunately however, patients generally have to pay out-of-pocket for these services.

Under-use of cardiac rehabilitation

CR is significantly under-used globally.[22] Rates vary widely.[23]

Under-use is caused by multi-level factors; a recent review is available.[24] At the health system level, this includes lack of available programs.[25] At the provider level, low referral rates are a major barrier.[26] [27] At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible,[28] but most can be mitigated.[29] Women,[30] ethnocultural minorities,[31] [32] older patients,[33] those of lower socio-economic status, with comorbidities, and living in rural areas[34] are less likely to access CR, despite the fact that these patients often need it most.[35] Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.

Strategies are now established on how we can mitigate these barriers to CR use.[36] [37] It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html).[38] It is also key for healthcare providers to promote CR to patients at the bedside.[39] The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.

Training more healthcare professionals to deliver CR can also help.[40] CR programs can also join a registry to assess and improve their utilization—among other quality indicators.[41] [42] Offering programs tailored to under-served groups such as women may also facilitate program participation.[43] [44] [45]

Benefits

Participation in CR may be associated with many benefits.[46] For acute coronary syndrome patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%.[47] [48] The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence.[49]

CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity,[50] and is cost-effective.[51] In low and middle-income countries, there is some evidence that CR is effective in improving functional capacity, risk factors and quality of life as well.[52]

There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same.[53] Home-based CR is generally safe.[54] Home-based programs with technology are similarly shown to be effective.[55] [56] [57]

There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues,[58] atrial fibrillation,[59] heart transplant recipients,[60] and heart failure.[61]

Cardiac rehabilitation societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR.[62] The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR),https://globalcardiacrehab.com/ a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations,[63] ICCPR seeks to promote CR in low-resource settings,[64] among other aims outlined in their Charter.[65]

Notes and References

  1. Book: WHO Expert Committee on Rehabilitation after Cardiovascular Diseases, with Special Emphasis on Developing Countries.. Rehabilitation after cardiovascular diseases, with special emphsis on developing countries : report of a WHO expert committee.. 9241208317. Geneva. 28401958.
  2. Cowie A, Buckley J, Doherty P, Furze G, Hayward J, Hinton S, Jones J, Speck L, Dalal H, Mills J . 6 . Standards and core components for cardiovascular disease prevention and rehabilitation . Heart . 105 . 7 . 510–515 . April 2019 . 30700518 . 6580752 . 10.1136/heartjnl-2018-314206 .
  3. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell N, Derman W, Melo Ghisi GL, Oldridge N, Sarkar BK, Yeo TJ, Lopez-Jimenez F, Mendis S, Oh P, Hu D, Sarrafzadegan N . 6 . Cardiac rehabilitation delivery model for low-resource settings . Heart . 102 . 18 . 1449–1455 . September 2016 . 27181874 . 5013107 . 10.1136/heartjnl-2015-309209 .
  4. Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, Bjarnason-Wehrens B, Derman W, Abreu A, Babu AS, Santos CA, Jong SK, Cuenza L, Yeo TJ, Scantlebury D, Andersen K, Gonzalez G, Giga V, Vulic D, Vataman E, Cliff J, Kouidi E, Yagci I, Kim C, Benaim B, Estany ER, Fernandez R, Radi B, Gaita D, Simon A, Chen SY, Roxburgh B, Martin JC, Maskhulia L, Burdiat G, Salmon R, Lomelí H, Sadeghi M, Sovova E, Hautala A, Tamuleviciute-Prasciene E, Ambrosetti M, Neubeck L, Asher E, Kemps H, Eysymontt Z, Farsky S, Hayward J, Prescott E, Dawkes S, Santibanez C, Zeballos C, Pavy B, Kiessling A, Sarrafzadegan N, Baer C, Thomas R, Hu D, Grace SL . 6 . Nature of Cardiac Rehabilitation Around the Globe . English . eClinicalMedicine . 13 . 46–56 . August 2019 . 31517262 . 6733999 . 10.1016/j.eclinm.2019.06.006 .
  5. Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA . 6 . AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation . Circulation . 124 . 22 . 2458–2473 . November 2011 . 22052934 . 10.1161/CIR.0b013e318235eb4d . free .
  6. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FD, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WM, Binno S . 6 . 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR) . European Heart Journal . 37 . 29 . 2315–2381 . August 2016 . 27222591 . 4986030 . 10.1093/eurheartj/ehw106 .
  7. Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, Ramakrishnan S, Yadav R, Chaudhary G, Kapoor A, Mahajan A, Sinha AK, Mullasari A, Pradhan A, Banerjee AK, Singh BP, Balachander J, Pinto B, Manjunath CN, Makhale C, Roy D, Kahali D, Zachariah G, Wander GS, Kalita HC, Chopra HK, Jabir A, Tharakan J, Paul J, Venogopal K, Baksi KB, Ganguly K, Goswami KC, Somasundaram M, Chhetri MK, Hiremath MS, Ravi MS, Das MK, Khanna NN, Jayagopal PB, Asokan PK, Deb PK, Mohanan PP, Chandra P, Girish CR, Rabindra Nath O, Gupta R, Raghu C, Dani S, Bansal S, Tyagi S, Routray S, Tewari S, Chandra S, Mishra SS, Datta S, Chaterjee SS, Kumar S, Mookerjee S, Victor SM, Mishra S, Alexander T, Samal UC, Trehan V . 6 . Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India . Indian Heart Journal . 69 . Suppl 1 . S63–S97 . April 2017 . 28400042 . 5388060 . 10.1016/j.ihj.2017.03.006 . free .
  8. Web site: Quality statement 7 (developmental): Options for cardiac rehabilitation Chronic heart failure in adults Quality standards . 2022-09-06 . www.nice.org.uk.
  9. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell NR, Derman W, Ghisi GL, Sarkar BK, Yeo TJ, Lopez-Jimenez F, Buckley J, Hu D, Sarrafzadegan N . 6 . Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement . Progress in Cardiovascular Diseases . 59 . 3 . 303–322 . 2016-11-01 . 27542575 . 10.1016/j.pcad.2016.08.004 . Controversies in Hypertension .
  10. Keteyian SJ, Ades PA, Beatty AL, Gavic-Ott A, Hines S, Lui K, Schopfer DW, Thomas RJ, Sperling LS . 6 . A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE . Journal of Cardiopulmonary Rehabilitation and Prevention . 42 . 1 . 1–9 . January 2022 . 34433760 . 10.1097/HCR.0000000000000634 . 237306143 .
  11. Heindl B, Ramirez L, Joseph L, Clarkson S, Thomas R, Bittner V . Hybrid cardiac rehabilitation - The state of the science and the way forward . Progress in Cardiovascular Diseases . 70 . 175–182 . 2022-01-01 . 34958846 . 10.1016/j.pcad.2021.12.004 . 245480348 .
  12. Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S . Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19 . American Journal of Physical Medicine & Rehabilitation . 99 . 9 . 769–774 . September 2020 . 32541352 . 7315835 . 10.1097/PHM.0000000000001505 .
  13. Zhang Y, Cao H, Jiang P, Tang H . Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study . Medicine . 97 . 8 . e9785 . February 2018 . 29465559 . 5841979 . 10.1097/MD.0000000000009785 .
  14. Shajrawi A, Granat M, Jones I, Astin F . Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study . The Journal of Nursing Research . 29 . 1 . e131 . November 2020 . 33136697 . 7808357 . 10.1097/JNR.0000000000000408 .
  15. Dafoe W, Arthur H, Stokes H, Morrin L, Beaton L . Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation . The Canadian Journal of Cardiology . 22 . 11 . 905–911 . September 2006 . 16971975 . 2570237 . 10.1016/s0828-282x(06)70309-9 .
  16. Astin F, Closs SJ, McLenachan J, Hunter S, Priestley C . Primary angioplasty for heart attack: mismatch between expectations and reality? . Journal of Advanced Nursing . 65 . 1 . 72–83 . January 2009 . 19032516 . 10.1111/j.1365-2648.2008.04836.x .
  17. Web site: Cardiac rehabilitation wait times and relation to patient outcomes - European Journal of Physical and Rehabilitation Medicine 2015 June;51(3):301-9 . 2023-04-05 . www.minervamedica.it . en.
  18. Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, Bjarnason-Wehrens B, Derman W, Abreu A, Babu AS, Santos CA, Jong SK, Cuenza L, Yeo TJ, Scantlebury D, Andersen K, Gonzalez G, Giga V, Vulic D, Vataman E, Cliff J, Kouidi E, Yagci I, Kim C, Benaim B, Estany ER, Fernandez R, Radi B, Gaita D, Simon A, Chen SY, Roxburgh B, Martin JC, Maskhulia L, Burdiat G, Salmon R, Lomelí H, Sadeghi M, Sovova E, Hautala A, Tamuleviciute-Prasciene E, Ambrosetti M, Neubeck L, Asher E, Kemps H, Eysymontt Z, Farsky S, Hayward J, Prescott E, Dawkes S, Santibanez C, Zeballos C, Pavy B, Kiessling A, Sarrafzadegan N, Baer C, Thomas R, Hu D, Grace SL . 6 . Nature of Cardiac Rehabilitation Around the Globe . English . eClinicalMedicine . 13 . 46–56 . August 2019 . 31517262 . 6733999 . 10.1016/j.eclinm.2019.06.006 . free .
  19. Chaves G, Turk-Adawi K, Supervia M, Santiago de Araújo Pio C, Abu-Jeish AH, Mamataz T, Tarima S, Lopez Jimenez F, Grace SL . 6 . Cardiac Rehabilitation Dose Around the World: Variation and Correlates . Circulation: Cardiovascular Quality and Outcomes . 13 . 1 . e005453 . January 2020 . 31918580 . 10.1161/CIRCOUTCOMES.119.005453 . 210133397 . free .
  20. Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL . Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis . Mayo Clinic Proceedings . 92 . 11 . 1644–1659 . November 2017 . 29101934 . 10.1016/j.mayocp.2017.07.019 . free . 40193168 . 10315/38072 .
  21. Chowdhury M, Heald FA, Sanchez-Delgado JC, Pakosh M, Jacome-Hortua AM, Grace SL . The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex . Heart & Lung . 50 . 4 . 504–524 . July 2021 . 33836441 . 10.1016/j.hrtlng.2021.02.016 . free . 233201693 . 10315/38987 .
  22. Santiago de Araújo Pio C, Beckie TM, Varnfield M, Sarrafzadegan N, Babu AS, Baidya S, Buckley J, Chen SY, Gagliardi A, Heine M, Khiong JS, Mola A, Radi B, Supervia M, Trani MR, Abreu A, Sawdon JA, Moffatt PD, Grace SL . 6 . Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement . International Journal of Cardiology . 298 . 1–7 . January 2020 . 31405584 . 10.1016/j.ijcard.2019.06.064 . free . free . 10034/622555 .
  23. Grace SL, Kotseva K, Whooley MA . Cardiac Rehabilitation: Under-Utilized Globally . Current Cardiology Reports . 23 . 9 . 118 . July 2021 . 34269894 . 10.1007/s11886-021-01543-x . free . 235916856 . 10315/38989 .
  24. Book: Stewart C, Ghisi GL, Davis EM, Grace SL . Cardiac Rehabilitation Barriers Scale (CRBS) . 2023 . Krägeloh CU, Alyami M, Medvedev ON . International Handbook of Behavioral Health Assessment . 1–57 . Cham . Springer International Publishing . en . 10.1007/978-3-030-89738-3_39-1 . 978-3-030-89738-3 .
  25. Turk-Adawi K, Supervia M, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, Bjarnason-Wehrens B, Derman W, Abreu A, Babu AS, Santos CA, Jong SK, Cuenza L, Yeo TJ, Scantlebury D, Andersen K, Gonzalez G, Giga V, Vulic D, Vataman E, Cliff J, Kouidi E, Yagci I, Kim C, Benaim B, Estany ER, Fernandez R, Radi B, Gaita D, Simon A, Chen SY, Roxburgh B, Martin JC, Maskhulia L, Burdiat G, Salmon R, Lomelí H, Sadeghi M, Sovova E, Hautala A, Tamuleviciute-Prasciene E, Ambrosetti M, Neubeck L, Asher E, Kemps H, Eysymontt Z, Farsky S, Hayward J, Prescott E, Dawkes S, Santibanez C, Zeballos C, Pavy B, Kiessling A, Sarrafzadegan N, Baer C, Thomas R, Hu D, Grace SL . 6 . Cardiac Rehabilitation Availability and Density around the Globe . eClinicalMedicine . 13 . 31–45 . August 2019 . 31517261 . 6737209 . 10.1016/j.eclinm.2019.06.007 .
  26. Ghisi GL, Polyzotis P, Oh P, Pakosh M, Grace SL . Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review . Clinical Cardiology . 36 . 6 . 323–335 . June 2013 . 23640785 . 3736151 . 10.1002/clc.22126 .
  27. Ghanbari-Firoozabadi M, Mirzaei M, Nasiriani K, Hemati M, Entezari J, Vafaeinasab M, Grace SL, Jafary H, Sadrbafghi SM . 6 . Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting . Rehabilitation Process and Outcome . 9 . 1179572720936648 . 2020-01-01 . 34497466 . 8282146 . 10.1177/1179572720936648 . free .
  28. Shanmugasegaram S, Gagliese L, Oh P, Stewart DE, Brister SJ, Chan V, Grace SL . Psychometric validation of the cardiac rehabilitation barriers scale . Clinical Rehabilitation . 26 . 2 . 152–164 . February 2012 . 21937522 . 3351783 . 10.1177/0269215511410579 .
  29. Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL . Interventions to promote patient utilisation of cardiac rehabilitation . The Cochrane Database of Systematic Reviews . 2019 . 2 . CD007131 . February 2019 . 30706942 . 6360920 . 10.1002/14651858.CD007131.pub4 .
  30. Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ . Sex differences in cardiac rehabilitation enrollment: a meta-analysis . The Canadian Journal of Cardiology . 30 . 7 . 793–800 . July 2014 . 24726052 . 10.1016/j.cjca.2013.11.007 . free . free . 10315/27523 .
  31. Midence L, Mola A, Terzic CM, Thomas RJ, Grace SL . Ethnocultural diversity in cardiac rehabilitation . en-US . Journal of Cardiopulmonary Rehabilitation and Prevention . 34 . 6 . 437–444 . November–December 2014 . 25357126 . 10.1097/HCR.0000000000000089 . free .
  32. Koehler Hildebrandt AN, Hodgson JL, Dodor BA, Knight SM, Rappleyea DL . Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A Systematic Review . Journal of Cardiopulmonary Rehabilitation and Prevention . 36 . 5 . 320–330 . September 2016 . 27496250 . 10.1097/HCR.0000000000000183 . 10829735 . free .
  33. Grace SL, Shanmugasegaram S, Gravely-Witte S, Brual J, Suskin N, Stewart DE . Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE? . Journal of Cardiopulmonary Rehabilitation and Prevention . 29 . 3 . 183–187 . 2009 . 19471138 . 2928243 . 10.1097/HCR.0b013e3181a3333c .
  34. Leung YW, Brual J, Macpherson A, Grace SL . Geographic issues in cardiac rehabilitation utilization: a narrative review . Health & Place . 16 . 6 . 1196–1205 . November 2010 . 20724208 . 4474644 . 10.1016/j.healthplace.2010.08.004 .
  35. Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, Bossano Prescott EI, González-Juanatey JR . 6 . Participation and adherence to cardiac rehabilitation programs. A systematic review . International Journal of Cardiology . 223 . 436–443 . November 2016 . 27557484 . 10.1016/j.ijcard.2016.08.120 . 205234011 .
  36. Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL . Interventions to promote patient utilisation of cardiac rehabilitation . The Cochrane Database of Systematic Reviews . 2019 . 2 . CD007131 . February 2019 . 30706942 . 6360920 . 10.1002/14651858.cd007131.pub4 .
  37. Aljehani R, Grace SL, Aburub A, Turk-Adawi K, Ghisi GL . Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers . Healthcare . 11 . 8 . 1196 . April 2023 . 37108029 . 10.3390/healthcare11081196 . 10138187 . free .
  38. Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, Williamson K, Gupta M, Alter DA, Stewart DE . 6 . Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study . Archives of Internal Medicine . 171 . 3 . 235–241 . February 2011 . 21325114 . 10.1001/archinternmed.2010.501 .
  39. Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL . Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course . BMC Health Services Research . 20 . 1 . 768 . August 2020 . 32819388 . 7439558 . 10.1186/s12913-020-05619-2 . free .
  40. Babu AS, Heald FA, Contractor A, Ghisi GL, Buckley J, Mola A, Atrey A, Lopez-Jimenez F, Grace SL . 6 . Building Capacity Through ICCPR Cardiovascular Rehabilitation Foundations Certification (CRFC): Evaluation of Reach, Barriers, and Impact . Journal of Cardiopulmonary Rehabilitation and Prevention . 42 . 3 . 178–182 . May 2022 . 34840246 . 10.1097/hcr.0000000000000655 . 244714261 . 10315/40874 . free .
  41. Grace SL, Elashie S, Sadeghi M, Papasavvas T, Hashmi F, de Melo Ghisi G, Vargas JL, Al-Hashemi M, Turk-Adawi K . 6 . Pilot testing of the International Council of Cardiovascular Prevention and Rehabilitation Registry . International Journal for Quality in Health Care . 35 . 3 . July 2023 . 37421311 . 10329404 . 10.1093/intqhc/mzad050 .
  42. Turk-Adawi K, Ghisi GL, Tran C, Heine M, Raidah F, Contractor A, Grace SL . First report of the International Council of Cardiovascular Prevention and Rehabilitation's Registry (ICRR) . Expert Review of Cardiovascular Therapy . 21 . 5 . 357–364 . May 2023 . 37024997 . 10.1080/14779072.2023.2199154 . 258008458 . 10315/41813 . free .
  43. Mamataz T, Ghisi GL, Pakosh M, Grace SL . Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis . Maturitas . 160 . 32–60 . June 2022 . 35550706 . 10.1016/j.maturitas.2022.01.008 . 246424701 . 10315/40875 . free .
  44. Mamataz T, Ghisi GL, Pakosh M, Grace SL . Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review . BMC Cardiovascular Disorders . 21 . 1 . 459 . September 2021 . 34556036 . 8458788 . 10.1186/s12872-021-02267-0 . free .
  45. Ghisi GL, Kin SM, Price J, Beckie TM, Mamataz T, Naheed A, Grace SL . Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline . English . The Canadian Journal of Cardiology . 38 . 12 . 1786–1798 . December 2022 . 36085185 . 10.1016/j.cjca.2022.06.021 . free . 251967685 . free . 10315/40876 .
  46. Taylor RS, Dalal HM, McDonagh ST . The role of cardiac rehabilitation in improving cardiovascular outcomes . Nature Reviews. Cardiology . 19 . 3 . 180–194 . March 2022 . 34531576 . 8445013 . 10.1038/s41569-021-00611-7 .
  47. Web site: Exercise-based rehabilitation for coronary heart disease . 2022-09-06 . www.cochrane.org . en.
  48. Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, Cowie A, Zawada A, Taylor RS . 6 . Home-based versus centre-based cardiac rehabilitation . The Cochrane Database of Systematic Reviews . 6 . 6 . CD007130 . June 2017 . 28665511 . 4160096 . 10.1002/14651858.CD007130.pub4 .
  49. Kabboul NN, Tomlinson G, Francis TA, Grace SL, Chaves G, Rac V, Daou-Kabboul T, Bielecki JM, Alter DA, Krahn M . 6 . Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis . Journal of Clinical Medicine . 7 . 12 . 514 . December 2018 . 30518047 . 6306907 . 10.3390/jcm7120514 . free .
  50. Francis T, Kabboul N, Rac V, Mitsakakis N, Pechlivanoglou P, Bielecki J, Alter D, Krahn M . 6 . The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis . The Canadian Journal of Cardiology . 35 . 3 . 352–364 . March 2019 . 30825955 . 10.1016/j.cjca.2018.11.013 . 73474249 .
  51. Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM . Cost-effectiveness of cardiac rehabilitation: a systematic review . Heart . 104 . 17 . 1403–1410 . September 2018 . 29654096 . 6109236 . 10.1136/heartjnl-2017-312809 .
  52. Mamataz T, Uddin J, Ibn Alam S, Taylor RS, Pakosh M, Grace SL . Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials . Progress in Cardiovascular Diseases . 70 . 119–174 . 2021-07-13 . 34271035 . 9187522 . 10.1016/j.pcad.2021.07.004 . 236000955 . ACROSS collaboration .
  53. McDonagh . Sinead Tj . Dalal . Hasnain . Moore . Sarah . Clark . Christopher E. . Dean . Sarah G. . Jolly . Kate . Cowie . Aynsley . Afzal . Jannat . Taylor . Rod S. . 2023-10-27 . Home-based versus centre-based cardiac rehabilitation . The Cochrane Database of Systematic Reviews . 2023 . 10 . CD007130 . 10.1002/14651858.CD007130.pub5 . 1469-493X . 10604509 . 37888805 . October 27, 2024 .
  54. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK, Whooley MA . 6 . Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology . Circulation . 140 . 1 . e69–e89 . July 2019 . 31082266 . 10.1161/CIR.0000000000000663 . 153312127 . free .
  55. Chong MS, Sit JW, Karthikesu K, Chair SY . Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis . International Journal of Nursing Studies . 124 . 104087 . December 2021 . 34562846 . 10.1016/j.ijnurstu.2021.104087 . 237636685 .
  56. Ramachandran HJ, Jiang Y, Tam WW, Yeo TJ, Wang W . Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis . European Journal of Preventive Cardiology . 29 . 7 . 1017–1043 . May 2022 . 34254118 . 8344786 . 10.1093/eurjpc/zwab106 .
  57. Jin K, Khonsari S, Gallagher R, Gallagher P, Clark AM, Freedman B, Briffa T, Bauman A, Redfern J, Neubeck L . 6 . Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis . European Journal of Cardiovascular Nursing . 18 . 4 . 260–271 . April 2019 . 30667278 . 10.1177/1474515119826510 . 58601002 .
  58. Abraham LN, Sibilitz KL, Berg SK, Tang LH, Risom SS, Lindschou J, Taylor RS, Borregaard B, Zwisler AD . 6 . Exercise-based cardiac rehabilitation for adults after heart valve surgery . The Cochrane Database of Systematic Reviews . 2021 . 5 . CD010876 . May 2021 . 33962483 . 8105032 . 10.1002/14651858.CD010876.pub3 .
  59. Risom SS, Zwisler AD, Johansen PP, Sibilitz KL, Lindschou J, Gluud C, Taylor RS, Svendsen JH, Berg SK . 6 . Exercise-based cardiac rehabilitation for adults with atrial fibrillation . The Cochrane Database of Systematic Reviews . 2 . 2 . CD011197 . February 2017 . 28181684 . 10.1002/14651858.cd011197 . John Wiley & Sons, Ltd . 6464537 . Risom SS . Chichester, UK .
  60. Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS . Exercise-based cardiac rehabilitation in heart transplant recipients . The Cochrane Database of Systematic Reviews . 2017 . 4 . CD012264 . April 2017 . 28375548 . 6478176 . 10.1002/14651858.CD012264.pub2 .
  61. Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M . Cardiac rehabilitation and physical activity: systematic review and meta-analysis . Heart . 104 . 17 . 1394–1402 . September 2018 . 29654095 . 6109237 . 10.1136/heartjnl-2017-312832 .
  62. Grace . Sherry L . 2023-01-02 . Evidence is indisputable that cardiac rehabilitation provides health benefits and event reduction: time for policy action . European Heart Journal . 44 . 6 . 470–472 . 10.1093/eurheartj/ehac690 . 36746185 . 0195-668X. subscription .
  63. Turk-Adawi K, Supervia M, Ghisi G, Cuenza L, Yeo TJ, Chen SY, Anchique-Santos C, Grace SL . 6 . The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go? . eClinicalMedicine . 61 . 102092 . July 2023 . 37528847 . 10.1016/j.eclinm.2023.102092 . 10388569 . free .
  64. Grace . Sherry L. . Taylor . Rod S. . Gaalema . Diann E. . Redfern . Julie . Kotseva . Kornelia . Ghisi . Gabriela . July 2023 . Cardiac Rehabilitation . JACC: Advances . 2 . 5 . 100412 . 10.1016/j.jacadv.2023.100412 . 2772-963X. free .
  65. Grace SL, Warburton DR, Stone JA, Sanderson BK, Oldridge N, Jones J, Wong N, Buckley JP . 6 . International Charter on Cardiovascular Prevention and Rehabilitation: a call for action . en-US . Journal of Cardiopulmonary Rehabilitation and Prevention . 33 . 2 . 128–131 . March–April 2013 . 23399847 . 4559455 . 10.1097/HCR.0b013e318284ec82 .