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CardiacRehabilitation
Author:VibhutiNSingh,MD,MPH,FACC,FSCAIChiefEditor:ConsueloTLorenzo,MDmore...

Updated:Aug12,2015

Overview
Background

Cardiacrehabilitationaimstoreverselimitationsexperiencedbypatientswhohave
sufferedtheadversepathophysiologicandpsychologicalconsequencesofcardiac
events.

Cardiovasculardisordersaretheleadingcauseofmortalityandmorbidityinthe
industrializedworld,accountingforalmost50%ofalldeathsannually.Thesurvivors
constituteanadditionalreservoirofcardiovasculardiseasemorbidity.IntheUnited
Statesalone,over14millionpersonssufferfromsomeformofcoronaryartery
disease(CAD)oritscomplications,includingcongestiveheartfailure(CHF),angina,
andarrhythmias.Ofthisnumber,approximately1millionsurvivorsofacute
myocardialinfarction(MI),aswellasthemorethan300,000patientswhoundergo
coronarybypasssurgeryannually,arecandidatesforcardiacrehabilitation.

Theimagebelowdepictscardiacrehabilitationafterbypasssurgery.

Phase1:Apatientwalkinginthehallwaywithaphysicaltherapistfollowingbypasssurgery.

Traditionally,cardiacrehabilitationhasbeenprovidedtosomewhatlowerrisk
patientswhocouldexercisewithoutgettingintotrouble.However,astonishingly
rapidevolutioninthemanagementofCADhasnowchangedthedemographicsof
thepatientswhocanbecandidatesforrehabilitationtraining.Currently,about
400,000patientswhoundergocoronaryangioplastyeachyearmakeupasubgroup
thatcouldbenefitfromcardiacrehabilitation.Furthermore,approximately4.7
millionpatientswithCHFarealsoeligibleforaslightlymodifiedprogramof
rehabilitation,asaretheeverincreasingnumberofpatientswhohaveundergone
hearttransplantation. [1]

Thisreviewaddressestheobjectives,indications,programcomponents,exercise
training,monitoring,benefits,risks,safetyissues,outcomemeasures,andcost
effectivenessofcardiacrehabilitation.

Objectives

Theidentificationofthepatientsatriskforacardiacevent'srecurrence(ie,risk
stratification)iscentraltoformulatinganappropriatemedical,rehabilitative,and
surgicalstrategytopreventsucharecurrence.Patientswhoareatlowormoderate
risktypicallyundergoearlyrehabilitation.Themajorgoalsofacardiacrehabilitation
programare:

Curtailthepathophysiologicandpsychosocialeffectsofheartdisease
Limittheriskforreinfarctionorsuddendeath
Relievecardiacsymptoms
Retardorreverseatherosclerosisbyinstitutingprogramsforexercise
training,education,counseling,andriskfactoralteration
Reintegrateheartdiseasepatientsintosuccessfulfunctionalstatusintheir
familiesandinsociety

Cardiacrehabilitationprogramshavebeenconsistentlyshowntoimproveobjective
measuresofexercisetoleranceandpsychosocialwellbeingwithoutincreasingthe
riskofsignificantcomplications.

Utilization

TheAgencyforHealthCarePolicyandResearch(AHCPR)theAmerican
AssociationofCardiovascularandPulmonaryRehabilitation(AACVPR),andthe
NationalHeart,LungandBloodInstitute(NHLBI)haverecognizedthewide
variationinawarenessandunderstandingoftheroleofcardiacrehabilitationamong
physicians,ancillaryhealthcareproviders,thirdpartypayers,andpatientswith
heartdisease.

Inthepast,itwasfoundthatonly11%ofpatientsparticipatedinsuchprograms
followinganacutecoronaryevent.However,thereisevidencethatparticipationhas
increased.Approximately38%ofUSpatientsand32%ofCanadianpatientswith
acuteMIwhowereinvolvedintheGlobalUtilizationofStreptokinaseandtPAfor
OccludedCoronaryArteries(GUSTO)trialwereenrolledincardiacrehabilitation
programs.

OutcomeMeasures
Currentcardiaccarehasalreadyreducedearlyacutecoronarymortalitysomuchso
thatfurtherexercisetraining,asan"isolated"intervention,maynotbeableto
causesignificantreductioninthemorbidityandmortality. [2]Nonetheless,exercise
traininghasthepotentialtoactasacatalystforpromotingotheraspectsof
rehabilitation,includingriskfactormodificationthroughtherapeuticlifestylechanges
(TLC)andoptimizationofpsychosocialsupport.Therefore,theoutcomemeasures
ofcardiacrehabilitationnowincludeimprovementinqualityoflife(QOL),suchas
thepatient'sperceptionofphysicalimprovement,satisfactionwithriskfactor
alteration,psychosocialadjustmentsininterpersonalroles,andpotentialfor
advancementatworkcommensuratewiththepatient'sskills(ratherthansimply
returntowork). [3,4]

Similarly,amongpatientswhoareelderly,suchoutcomemeasuresmayincludethe
achievementoffunctionalindependence,thepreventionofprematuredisability,and
areductionintheneedforcustodialcare. [5,6,7,8]Despitelimiteddata,oldermale
andfemalepatientsinobservationalstudieshaveshownimprovementintheir
exercisetolerancecomparabletothatofyoungerpatientsparticipatinginequivalent
exerciseprograms.Inaddition,thesafetyofexercisewithincardiacrehabilitation
programs,asstudiedinover4,500patients,iswellacceptedandestablished.

Cardiacrehabilitationservicesare,therefore,aneffectiveandsafeintervention.
Theseservicesareundoubtedlyanessentialcomponentofthecontemporary
treatmentofpatientswithmultiplepresentationsofcoronaryheartdiseaseand
heartfailure.

RelatedMedscapeReferencetopics:

AnginaPectoris(Cardiology)
AnginaPectorisinEmergencyMedicine
ComplicationsofMyocardialInfarction
MyocardialInfarction(Cardiology)
MyocardialInfarction(EmergencyMedicine)
MyocardialInfarctioninChildhood
UnstableAngina
VascularDiseasesandRehabilitation

RelatedMedscaperesources:

ResourceCenterHeartandLungTransplant
ResourceCenterHeartFailure

HistoryandDefinitionofCardiacRehabilitation
History

Inthe1930s,patientswithmyocardialinfarction(MI)wereadvisedtoobserve6
weeksofbedrest.Chairtherapywasintroducedinthe1940s,andbytheearly
1950s,35minutesofdailywalkingwasadvocated,beginningat4weeks.
Cliniciansgraduallybegantorecognizethatearlyambulationavoidedmanyofthe
complicationsofbedrest,includingpulmonaryembolism(PE),andthatitdidnot
increasetherisk.However,concernsaboutthesafetyofunsupervisedexercise
remainedstrongthisledtothedevelopmentofstructured,physiciansupervised
rehabilitationprograms,whichincludedclinicalsupervision,aswellas
electrocardiographicmonitoring.

Inthe1950s,Hellersteinpresentedhismethodologyforthecomprehensive
rehabilitationofpatientsrecoveringfromanacutecardiacevent. [9]Headvocateda
multidisciplinaryapproachtotherehabilitationprogram.Hisapproachwasadopted
bycardiacrehabilitationprogramsthroughouttheworld.Despitemultipleadvances,
Hellerstein'soriginalideashavenotbeenimproveduponsignificantly.However,due
tochangingpatientdemographics,manymorepatientsnowhavetheopportunityto
receivethebenefitsofferedbycardiacrehabilitation.Multifactorialintervention,
includingaggressiveriskfactormodification,hasbecomeanintegralpartofpresent
daycardiacrehabilitation.

Definition

AccordingtotheUSPublicHealthService(USPHS),acardiacrehabilitation
programisdefinedasaprogramthatinvolvesthefollowing:

Medicalevaluation
Prescribedexercise
Education
Counselingofpatientswithcardiacdisease

Cardiacrehabilitationhastobecomprehensiveand,atthesametime,
individualized.Themaingoalsofacardiacrehabilitationprogramarenotedbelow.

Shorttermgoalsareasfollows:

"Reconditioning"thepatientsufficientlyenoughtoallowhim/hertoresume
customaryactivities
Limitingthephysiologicandpsychologicaleffectsofheartdisease
Decreasingtheriskofsuddencardiacarrestorreinfarction [10,11]
Controllingthesymptomsofcardiacdisease

Longtermgoalsareasfollows:
 Identificationandtreatmentofriskfactors
Stabilizingorreversingtheatheroscleroticprocess
Enhancingthepsychologicalstatusofthepatients

PhysiologyofExerciseandCardiovascularBenefit

Coronaryvasodilatationismainlydrivenbythebioavailabilityofnitricoxide(NO),
whichisproducedbytheactivitiesoftheendotheliallyderivedenzymeNOsynthase
andismetabolizedbyreactiveoxygenspecies.Thisfinetunedbalanceisdisturbed
inpeoplewithCAD.ThisformofimpairmentofNOproduction,alongwith
excessiveoxidativestress,resultsinthelossofendothelialcellsviaapoptosis.
Furtheraggravationofendothelialdysfunctionensues,whichtriggersmyocardial
ischemiainpersonswithcoronaryarterydisease(CAD).Inhealthyindividuals,an
increasedreleaseofNOfromthevascularendotheliuminresponsetoexercise
trainingresultsfromchangesinendothelialNOsynthaseexpression,
phosphorylation,andconformation.

Bythesametoken,exercisetraininghasassumedaroleinthecardiac
rehabilitationofpatientswithCAD,becauseitreducesmortalityandincreases
myocardialperfusion.Thishasbeenlargelyattributedtotheexercisetraining
mediatedcorrectionofcoronaryendothelialdysfunctioninpersonswithCAD.In
personswithCAD,regularphysicalactivityleadstoarestorationofthebalance
betweenNOproductionbyNOsynthaseandNOinactivationbyreactiveoxygen
species,therebyenhancingthevasodilatorycapacityinvariousvascularbeds.

Becauseendothelialdysfunctionhasbeenidentifiedasapredictorofcardiovascular
events,thepartialreversalofendothelialdysfunctionachievedbyregularphysical
exerciseappearstobethemostlikelymechanismbehindtheexercisetraining
inducedreductionincardiovascularmorbidityandmortalityinpatientswithCAD.

Theamountofexerciseintheyearbeforecardiacsurgeryhasbeenlinkedtothe
incidenceofpostoperativeatrialfibrillationduringrehabilitationaccordingtoastudy
byGiaccardietal.Theincidenceofatrialfibrillationduringrehabilitationwas
significantlyhigherinpatientswhoperformedlowintensityphysicalexercisethe
yearbeforesurgerycomparedwiththosewhoperformedmoderateintensity
exercise.Theoccurrenceofatrialfibrillationduringthepatients'hospitalstay,a
largerleftatrialvolume,andalowerleftatrialemptyingfractionwereindependent
predictorsofatrialfibrillationduringrehabilitation. [12]

Cardiacrehabilitationprogramsincludewalkingaspartoftheexerciseregimen. [13]
Gremeauxetalstudiedtheminimalclinicallyimportantdifferenceforthe6minute
walktestandthe200meterfastwalktestfor81patientswithacutecoronary
syndrome. [14]Resultsbeforeandafteran8weekcardiacrehabilitationprogram,
andatthe6thand12thsessions,werereviewed.Patientswereaskedtoratethe
changeintheirwalkingabilitybetweenthesetwotests.Physiotherapists,who
supervisedthetraining,alsogavetheirinput.Theminimalclinicallyimportant
differenceandmeanchangeinthe6minutewalktestdistancewas25mno
differencewasfoundinthe200meterfastwalktest.Theseresultsshouldhelp
physiciansinterpretthechangesmadebytheirpatientsinaclinicalcontextandalso
beusedinfurtherstudiesthatuse6MWDasameasure.

AstudybyBelletetalindicatedthatcardiacrehabilitationpatientsmayderivethe
samebenefitfromaprogramofonceweeklysupervisedexercisesessionsasthey
dofromaprogramoftwiceweeklysessions.Thestudyfoundthatimprovementsin
the6minutewalktestdistancewerethesameafter6weeksoflowtomoderate
intensitytrainingintheonceweeklyexercisegroup(115patients)asinthetwice
weeklygroup(254patients). [15]

AstudybyElDemerdashetalindicatedthatinpatientswithischemicheart
diseasewhoarenotsuitableforcardiacrevascularizationprocedures,acardiac
rehabilitationprogramcanreduceischemicburden.Inthestudy,40patientswith
ischemicheartdiseasewhowereunsuitableforpercutaneouscoronaryintervention
orcoronaryarterybypassgraftingparticipatedinaprogramthatincludedtwice
weekly,lowintensityexercise,aswellaspatienteducation,smokingcessation,and
nutritional,medical,psychological,andsexualcounseling.Theinvestigators
reportedareductioninthepatientsischemicburden,aswellasimprovementsin
thesubjectsfunctionalcapacityandhemodynamicandmetabolicprofiles. [16]

PatientSelectionandRiskStratification
PatientSelection

Cardiacrehabilitationencompassesshorttermandlongtermgoalsthataretobe
achievedthroughexercise,education,andcounseling.Patientsgenerallyfallinto
followingcategories:

Lowerriskpatientsfollowinganacutecardiacevent
Patientswhohaveundergonecoronarybypasssurgery
Patientswithchronic,stableanginapectoris
Patientswhohaveundergonehearttransplantation
Patientswhohavehadpercutaneouscoronaryangioplasty
Patientswhohavenothadprioreventsbutwhoareatriskbecauseofa
remarkablyunfavorableriskfactorprofile
Patientswithstableheartfailure
Patientswhohaveundergonenoncoronarycardiacsurgery
 Patientswithpreviouslystableheartdiseasewhohavebecomeseriously
deconditionedbyintercurrent,comorbidillnesses

Theshorttermgoalsofcardiacrehabilitationincludetherestorationofthephysical,
psychological,andsocialcondition,whilethelongtermgoalsinvolvethepromotion
ofhearthealthybehaviorsthatenabletheindividualtoreturntoproductiveand/or
joyfulvocationalandavocationalactivities.

Thecardiacrehabilitationprogramsbenefitwomenandmenequally. [17]Elderly
patientsalsocanderivesignificantbenefitfromrehabilitationprograms.

RiskStratification

Theriskstratificationprocessisveryvaluableforcardiacpatientsitservesasthe
basisforindividualizingtheprescriptionofexercisetrainingandforassessingthe
needandextentofsupervisionrequired.Theriskstratificationprocessisbasedon
theassessmentofthepatient'sfunctionalcapacity,onthepatient'seducationaland
psychosocialstatus,onwhetheralternativestotraditionalcardiacrehabilitationcan
beused,andonwhetherthepatientissufferingfrommyocardialischemia,
ventriculardysfunction,orarrhythmias.

Functionalcapacity

Thetermfunctionalcapacityreferstothemaximumabilityoftheheartandlungsto
deliveroxygenandtheabilityofthemusclestoextractit.Functionalcapacityis
measuredbydeterminingthemaximaloxygenuptake(VO2max)during
incrementalexercise.

Inmostpatients,aroughcalculationoffunctionalcapacitycanbeperformedby
usingmultiplesof1MET(metabolicequivalent,3.5mLO2uptake/kg/min).In
complicatedpatients,suchasthosewithsevereleftventricular(LV)dysfunctionand
congestiveheartfailure(CHF),thefunctionalcapacitycanbeascertainedwith
greateraccuracybyusingcardiopulmonaryexercise(CPX)testing.Mostcardiac
rehabilitationfacilities,however,arenotcurrentlyequippedforCPX.

Thefollowingfactorsinfluencefunctionalcapacity:

Age
Precardiaceventphysicalcapacity
Treatmentsandbedrestduringtheevent
Fluidvolume,suchasrelativedehydrationorvolumeoverloadinpatients
withCHF
LVdysfunction
Residualmyocardialischemia
Skeletalmuscleperformance,suchasdeconditioningorinthepresenceof
concurrent,noncardiacillness
Autonomicfunction,suchasdiabeticneuropathy
Peripheralvascularstatus
Pulmonarystatus
Othersystemicillnesses,especiallyorthopedicproblemslimitingflexibility
andlocomotion

Everyattemptshouldbemadetorecognizethepotentialeffectsofthesefactorson
functionalcapacityinordertominimizeriskoftheindividualizedreconditioning
programthatisbeingformulated.

Myocardialischemia

Symptomaticorasymptomatic(silent)myocardialischemiamaylimitthepatient's
exertionalcapacitybycausinglimitingangina,dyspnea,orfatigue.

Ventriculardysfunction

FixedLVdysfunctionordamagemaybepresentintheabsenceofangina.Patients
withLVdysfunctiondevelopearlydyspneaandeasilybecomefatigued.

Cardiopulmonaryexercisetestingpreferablyshouldbeperformedtodeterminethe
functionalcapacityinanobjectivemanner.

ExerciseintoleranceinpatientswithLVdysfunctionisduetoskeletalmuscle
hypoperfusionresultingfrominadequatecardiacoutputthatcanbebetterquantified
bymeasuringVO2max.

Arrhythmias

Ventricularirritabilityandcomplexventriculararrhythmiasrequireassessment
throughtheuseofsignalaveragedelectrocardiogram(ECG)orelectrophysiologic
studies.

Appropriatemedicalordevicetreatmentsshouldbeundertakenwheneverfeasible
priortobeginningphase2ofthecardiacrehabilitationprogram.

Veryclosesurveillanceisnecessaryinpatientswithsignificantcardiacarrhythmias
duringtheirexercisetrainingroutines.Concomitantrhythmmonitoringwith
telemetry,Holteroreventmonitoringshouldbeconsidered.Inmanycasesof
seriousarrhythmias,therapyremainscontroversialandthesafetyofisexercise
unclearsuchuncertaintiescomplicatethedecisionmakingprocess.
Patientswithsevereventriculararrhythmiasanduncontrolledsupraventricular
arrhythmiasshouldbeexcludedfromexercisetrainingunlessproperevaluationand
effectivetherapyhasbeeninstituted.Patientswithdevices,suchaspacemakers
anddefibrillators,shouldbecarefullymonitoredduringexercise.Rateresponsive
pacemakersarequitehelpfulevenforthosepatientswhoarecompletely
pacemakerdependent.Incaseofimplantablecardioverterdefibrillators(ICDs),
exercisetrainingcanbeprovidedaslongasunderlyingarrhythmiasarecontrolled
withpharmacotherapy.Heartrateshouldbekeptwellbelowthethresholdatwhich
theantitachycardiaalgorithmoftheICDbegins.

Educationalandpsychosocialstatus

Approximately2025%ofacutemyocardialinfarction(MI)patientsdemonstrate
severepsychologicalstressormajordepressiontheyalsoshowhighermorbidity
andmortality. [18]Clinicallysignificantdepressivesymptomsarefoundin4065%of
patientsafteranMI.

Exercisedoesprovidesomebenefit,butseverecasesmayrequirespecifictherapy
thathasbeenshowntoenhancethebenefitsderivedfromsubsequentcardiac
rehabilitation.

Thepromotionofselfefficacyandcontroloverone'sactivitiesisofparamount
importanceforboostingselfconfidence.

Coronarypronebehavior(CPB)isknownasacardiacriskfactor,butitseffecton
prognosisisunclear.SomedatasuggestthatthemodificationofCPBcanimprove
thecoronarydiseaseprognosis.

Initially,continuousECGmonitoringisrecommendedformostpatientsduring
cardiacrehabilitationexercisetraininghowever,cliniciansmaydecidewhetherto
usecontinuousorintermittentECGmonitoring.Aftertheinitialperiod,theuseof
electrocardiographydependsontheclinicaljudgmentofthesupervisingphysician.

Alternativeapproachestocardiacrehabilitation

Incarefullyselectedpatients,alternativestothetraditionalsupervised(groupor
individual)cardiacrehabilitationprogramhavebeenexamined.Thesealternatives,
whichareapplicableprimarilytoverylowriskpatients,includethefollowingoptions:

Homebasedcardiacrehabilitation(effectiveandsafe)
Exercisewithtranstelephonicmonitoring/surveillance

CardiacRehabilitationinPatientswithHeartFailure

Heartraterecovery(HRR)followingmaximalexercisehasbeenfoundtobea
predictorofallcausemortality.Ina2006study,Streuberandcolleagues
hypothesizedthataerobicexercisetrainingcouldimproveHRRinpatientswhohave
sufferedheartfailure,becauseathletesareknowntohaveacceleratedHRR,while
cardiacrehabilitationhasbeenshowntopositivelyeffectsuchrecoveryinpatients
withcoronaryarterydisease(CAD). [19]Theauthorsconductedaretrospectivestudy
of46patientswithheartfailurewhohadcompletedaphase2aerobiccardiac
rehabilitationprogramwithentryandexitmaximalstresstests.Theresults
indicatedthatinpatientswithheartfailurewhohavelowexercisecapacity,even
shorttermaerobictrainingcanaidHRR.

ExerciseTestingandExercisePrescription
Indications

Cardiacrehabilitationinitiallywasdesignedforlowriskcardiacpatients.Nowthat
theefficacyandsafetyofexercisehavebeendocumentedinpatientspreviously
stratifiedtothehighriskcategory,suchasthosewithcongestiveheartfailure
(CHF),theindicationshavebeenexpandedtoincludesuchpatients.Exercise
trainingbenefitspersonswiththefollowingcardiacconditions:

Recentmyocardialinfarction
Coronarybypass [20]
Valvesurgery [21]
Coronaryangioplasty
Cardiactransplantation [21]
Angina
CompensatedCHF

Exerciseprescriptiondependsontheresultsofexercisetesting,whichoften
includescardiopulmonaryexercise(CPX)testing.

ModificationsofExercise

Patientswithlimitationsduetochronicobstructivepulmonarydisease(COPD),
peripheralvasculardisease(PVD),stroke,andorthopedicconditionsstillcanbe
trainedintheexercisesthroughspecialtechniquesandadaptiveequipment(eg,use
ofarmcrankergometer).

Contraindications
Cardiacrehabilitationservicesarecontraindicatedinpatientswiththefollowing
conditions:

Severeresidualangina
Uncompensatedheartfailure
Uncontrolledarrhythmias
Severeischemia,LVdysfunction,orarrhythmiaduringexercisetesting
Poorlycontrolledhypertension
Hypertensiveoranyhypotensivesystolicbloodpressureresponsetoexercise
Unstableconcomitantmedicalproblems(eg,poorlycontrolledor"brittle"
diabetes,diabetespronetohypoglycemia,ongoingfebrileillness,active
transplantrejection) [22]

Insuchpatients,everyeffortshouldbemadetocorrecttheseabnormalitiesthrough
optimizationofmedicaltherapy,revascularizationbyangioplastyorbypasssurgery,
orelectrophysiologictestingandsubsequentantiarrhythmicdrugordevicetherapy.
Patientsshouldthenundergoretestingforexerciseprescription.

ExerciseTesting

Twoformsofexercisetestsareperformedinpatientsfollowinganacutecardiac
event:submaximalexercisetestingandsymptomlimitedexercisetesting.
Furthermore,CPXalsomaybeperformed,particularlyinpatientswith
cardiomyopathyorCHF,todetermineobjectivelythepatient'sexercisecapacity.

Submaximalexercisetesting

Inthisstrategy,thepatientsexerciseenoughtoachieve70%ofmaximumpredicted
heartratefortheirage(ie,70%of220minusageinyears).

Thistestiscommonlyperformedpriortodischargeandisfollowedbymaximal
exercisetesting68weekslater(whenpatientsaimtoachieve90%ofmaximum
predictedheartrate).

Symptomlimitedexercisetesting

Thepatientsexercisesoonafteracardiacevent.

Arepresentativeschedulemightbeginexerciseatintervals,suchas721days
followinguncomplicatedacutemyocardialinfarction(MI),310daysfollowing
angioplasty,or1428daysafterbypasssurgery.

Submaximalexercisetestingisnotnecessarilysaferthansymptomlimitedtesting.
Infact,thesubmaximalstrategymayhavecertaindisadvantagesitcanleadto
inappropriatelimitationinthepatient'sroutineactivitiesandexercisetrainingandto
asignificantdelayinthepatient'sreturntowork.Theuseofsubmaximalexercise
mayalsoresultinafailuretoelicitimportantfactorsinprognosis,suchasischemia,
cardiacdysfunction,andarrhythmia.

CPXtesting

Incrementalexerciseisemployed,usingmodifiedNaughtonprotocolfortreadmillor
modifiedprotocolsonabicycleergometer.

Concomitantminutetominutebreathanalysisandmeasurementofoxygen
consumptionandeliminationofcarbondioxideareperformedtodetermineVO2
max,whichisthemostobjectivemethodofdeterminingfunctionalcapacityin
patientswithcardiacdysfunction,valvulardisease,orrecentacutecardiacevent.

ModifiedBruceorNaughtonprotocolstypicallyareusedduringthetestingphase,
becausethestandardBruceprotocolhasbeenmodifiedtoavoidtooabruptan
increaseinMETs(by23METsperstage).

ThemodifiedNaughtonprotocolstartsatalowerMETworkloadandincreasesby1
METperstage,thusallowingbettertoleratedgradualprogressioninexerciseanda
moreaccurateassessmentofexertionalcapacity.

Theusualsymptomaticendpointsarefatigueandbreathlessness.

Severeabnormalitiesfoundonstresstestingmaycontraindicateexercisetraining
untiltheyhavebeencorrected.Lesssevereabnormalities,suchasthedevelopment
oftheabovesymptomsathighworkloads,maynotnecessarilycontraindicate
exercisetraininghowever,certainmodificationsandclosersurveillancemaybe
required,includingECGmonitoring.

SomereportshavequestionedearlyexercisetrainingfollowingacuteanteriorMI,
suggestingthatitmayleadtoabnormalscarformation.Nonetheless,evidenceis
strongthatmoderateexercisetrainingisnotassociatedwithworseningLVfunction
inpatientsfollowingacuteanteriorMI.

ExercisePrescriptionandSurveillance

Phase2ofacardiacrehabilitationprogramisinitiatedbasedontheresultofthe
exercisetesting,andtheexerciseprescriptionisindividualized.Threemain
componentsofanexercisetrainingprogramarelistedbelow.
Theminimumfrequencyforexercisingtoimprovecardiovascularfitnessis3times
weekly.

Patientsusuallyneedtoallow3060minutesforeachsession,whichincludesa
warmupofatleast10minutes

Theintensityprescribedisinrelationtoone'stargetheartrate.Aerobicconditioning
isemphasizedinthefirstfewweeksofexercise.Strengthtrainingisintroduced
later.TheBorgscaleofRateofPerceivedExertion(RPE)isused.Patientsusually
shouldexerciseatanRPEof1315.

TheBorgscaleofperceivedexertionisasfollows:

6
7Very,verylight
8
9Verylight
10
11Light
12
13Somewhathard
14
15Hard
16
17Veryhard
18
19Very,veryhard
20Exhaustion

Exerciseinitiation

Exercisesessionsshouldbeginwith10minutesofwarmup,duringwhichlight
calisthenicsandmuscularstretchingareperformedtoavoidmuscleinjuryandto
bringaboutagradedincreaseinheartrate.Thiswarmupperiodisfollowedby40
minutesofaerobicexercise(eg,walking,jogging,bicycling)andafinal10minutes
ofcooldownperiodinvolvingmuscularstretching.Thecooldownperiodisvery
important.Gradualcooldownpreventsventriculararrhythmias,whichmayoccurin
patientswithcoronarydiseaseonabruptcessationofexercise.

Progression

Thepatient'speakheartrateisnoted.Thetargetis,subsequently,increasedby5
10%ofthepeakheartrateuntilthepatientisabletoexerciseat85%ofthepeak
heartrate.Mostpatientsareabletodosoby23months.Afollowuptreadmilltest
shouldbeperformedat48weeksafterthepatientstartstheprogram,andthe
resultshouldbeusedtofinetunetheexercisetraining.

Specialconsiderations

Inpatientswithmyocardialischemia,exercisetrainingstillcanbeperformedsafely.
Themaximalheartrateshouldbekept10beatsperminute(bpm)lowerthanthe
heartrateatwhichischemiaoccurred.ClosersurveillanceandECGmonitoringare
recommendedinpatientsfollowingmyocardialischemia.Patientswitharrhythmias
alsoneedECGmonitoring.PatientswithCHFrequireamuchmoremodified
exerciseprogram.

Also,inthosewithtype2diabeteswhohaveahypertensiveresponsetoexercise,
anincreasedleftventricularmass,andahigherriskofmortality,exercisetraining
anddietaryrestrictionsareadvised.Schultzetaldeterminedintheirstudythat,
after1yearoftheselifestylemodifications,patientssignificantlydiminishedtheir
exercisebloodpressurehowever,theircardiacsizeremainedthesame. [23]

PhasesofCardiacRehabilitation
Cardiacrehabilitationservicesaredividedinto3phases,asfollows:

Phase1Initiatedwhilethepatientisstillinthehospital
Phase2Asupervisedambulatoryoutpatientprogramspanning36months
Phase3Alifetimemaintenancephaseinwhichphysicalfitnessand
additionalriskfactorreductionareemphasized

Phase1:inhospitalphase

Thisprogrambeginswhilepatientsarestillinthehospital.

Phase1includesavisitbyamemberofthecardiacrehabilitationteam,education
regardingthediseaseandtherecoveryprocess,personalencouragement,and
inclusionoffamilymembersinclassroomgroupmeetings.Seetheimagesshown
below.
Phase1:Apatientwalkinginthehallwaywithaphysicaltherapistfollowingbypasssurgery.

Phase1and2:Educationandcounselingoneononewithpatientandfamily.

Someolderpatientsmayserveasvolunteersandsharetheirexperiencesabout
learningtolivewithheartdisease.

Teammembersincludecardiacnurses,exercisespecialists,physicaltherapists,
occupationaltherapists,dietitians,andsocialworkers.

Inthecoronarycareunit,assistedrangeofmotionexercisescanbeinitiatedwithin
thefirst2448hours.

Lowriskpatientsshouldbeencouragedtositinabedsidechairandtobegin
performingselfcareactivities(eg,shaving,oralhygiene,spongebathing).

Ontransfertothestepdownunit,patientsshould,atthebeginning,trytositup,
stand,andwalkintheirroom.Subsequently,theyshouldstarttowalkinthehallway
atleasttwicedailyeitherforcertainspecificdistancesorastoleratedwithoutbeing
undulypushedorheldback.Standingheartrateandbloodpressureshouldbe
obtainedfollowedby5minutesofwarmuporstretching.Walking,oftenwith
assistance,isresumed,withatargetheartrateoflessthan20beatsabovethe
restingheartrateandanRPEoflessthan14.Startingwith510minutesof
walkingeachday,exercisetimegraduallycanbeincreasedtoupto30minutes
daily.

Teammembersincludingthenurseeducator,dietitian,exerciserehabilitation
trainer,andphysicianshouldincorporateinthedischargeplanninganappropriate
emphasisonsecondarypreventionthroughriskfactormodificationandtherapeutic
lifestylechanges(TLC),suchasaspirinandbetablockeruseinallpatients,
angiotensinconvertingenzyme(ACE)inhibitoruseinpatientswithleftventricular
ejectionfractionoflessthan40%,smokingcessation,lipidmanagement,weight
management,andstressmanagement.Theymustalsoensurethatphase1
patientsgetreferredtoappropriatelocal,convenient,andcomprehensivephase2
programs.

Phase1.5:postdischargephase

Thisphasebeginsafterthepatientreturnshomefromthehospital.

Betterunderstandingofhowtokeepthehearthealthyandstrongisemphasized.
Teammembersworkwithpatientsandfamilymembers.

Teammemberscheckthepatient'smedicalstatusandcontinuingrecoverythey
shouldofferreassuranceasthepatientregainshealthandstrength.
Thisphaseofrecoveryincludeslowlevelexerciseandphysicalactivity,aswellas
instructionregardingchangesfortheresumptionofanactiveandsatisfyinglifestyle.

Riskreductionstrategiesareemphasizedagain.

After26weeksofrecoveryathome,thepatientisreadytostartphase2ofhis/her
cardiacrehabilitation.

Phase2:supervisedexercise

Patientswhohavecompletedhospitalizationand26weeksofrecoveryathome
canbeginphase2oftheircardiacrehabilitationprogram.

Thephysicianandcardiacrehabilitationstaffmembersformulatethelevelof
exercisenecessarytomeetanindividualpatient'sneeds(seeimagesbelow).

Phase2:Exercisetestingandtrainingonatreadmill.

Cardiopulmonaryexercisetestingtoobjectivelydeterminethefunctionalcapacityinpatients
withcongestiveheartfailurebeforetheybeginarehabilitationexerciseprogram.

Exercisetreatmentsusuallyarescheduled3timesaweekattherehabilitation
facility.

Constantmedicalsupervisionisprovidedthisincludessupervisionbyanurseand
anexercisespecialist,aswellastheuseofexerciseECGs.

Inadditiontoexercise,counseling,andeducationaboutstressmanagement,
smokingcessation,nutrition,andweightlossalsoareincorporatedintothisphase.

Phase2maylast36months.

Phase3:maintenancephase

Phase3ofcardiacrehabilitationisamaintenanceprogramdesignedtocontinuefor
thepatient'slifetime.Theexercisesessionsusuallyarescheduled3timesaweek.

Activitiesconsistofthetypeofexercisesthepatientenjoys,suchaswalking,
bicycling,orjogging.Aregisterednursesupervisestheseclasses.

ECGmonitoringusuallyisnotnecessary.

Themaingoalofphase3istopromotehabitsthatleadtoahealthyandsatisfying
lifestyle.

Phase3programsdonotusuallyrequiremedicalornursingsupervision.Infact,
mostpatientsparticipatein"phase3"equivalentexercisesattheexercisefacilities
inthecommunity(eg,YMCA,YWCA).

Sexualactivity
Commonsexualproblemsencounteredbycardiacpatientsincludeimpotence,
prematureordelayedejaculation,andreducedlibido(inmenandwomen).These
difficultiesmaybeduetomedications(eg,betablockers,diuretics),depression,or
fearsbythepatientandhisorherpartnerofprecipitatingacardiacevent.

Maximumheartrateduringsexualintercourseaverages120bpm,whichissimilar
toheartratesassociatedwithotherroutineactivitiesinandaroundthehouse.

Thehemodynamicresponseisgreaterwithanunfamiliarsexpartner,inunfamiliar
surroundings,aftereating,orafterconsumingalcohol.

Adaptinglessstrenuouspositionsforexample,usingasidetosidearrangement
ratherthanthemissionarypositioncanreducecardiacstress.

Patientsmaystartsexualactivity23weeksfollowinganuncomplicatedmyocardial
infarction.Theymustbeinstructedtoreportanyuntowardsymptomstothe
physicianortoamemberoftherehabilitationteam.

OutcomesofCardiacRehabilitationTraining
Cardiacrehabilitationprovidesmanybenefitsforpatients.Themostimportantof
thesearediscussedinthissection.

Improvedexercisetolerance

Cardiacrehabilitationexercisetrainingforpatientswithcoronaryheartdiseaseor
congestiveheartfailure(CHF)leadstoobjectivelyverifiableimprovementin
exercisecapacityinmenandwomen,regardlessofage. [17]Adverseoutcomesor
complicationsofexerciseareexceedinglyrare.Thenonfatalinfarctionrateis1
patientper294,000patienthoursthecardiacmortalityrateis1patientper784,000
patienthours.Thebenefitsareevengreaterinpatientswithdiminishedexercise
tolerance.Thisbeneficialeffectdoesnotpersistlongtermaftercompletionof
cardiacrehabilitationwithoutalongtermmaintenanceprogram.Therefore,exercise
trainingmustbemaintainedlongtermtosustaintheimprovementinexercise
capacity.

Controlofsymptoms

Inpatientswithcoronaryheartdisease,anginasignificantlyimprovesduringthe
cardiacrehabilitationexerciseprogram.Objectiveevidenceofimprovementin
ischemiahasbeenseenbyperformingintervalstressECGorradionuclidetesting.
Similarly,patientswithLVfailureordysfunctionshowimprovementinthe
symptomsofheartfailure. [24]Useofgasanalysis(CPX)hasshownthatpatients'
exertionaltoleranceimprovessignificantlywithexercisetraining.

Improvementinthebloodlevelsoflipids

Improvementsinlipidandlipoproteinlevelsareobservedinpatientsundergoing
cardiacrehabilitationexercisetrainingandeducation. [25]Exercisemustbe
combinedwithdietaryandmedicalinterventionsforrequiredlipidcontrol.

Effectonbodyweight

Exercisetrainingasasoleinterventionhasaninconsistenteffectoncontrolling
excessweight.Optimalmanagementofobesityrequiresmultifactorialrehabilitation,
includingnutritionaleducationandcounseling,behavioralmodification,andexercise
training. [26]

Effectonbloodpressure

Rehabilitationexercisetrainingasasoleinterventionhasminimaleffecthowever,
multifactorialinterventionhasbeenshowntohavebeneficialeffects.
Inconsistencieswiththistheoryremainunresolved.

Reductioninsmoking

Cardiacrehabilitationserviceswithwelldesignededucational,counseling,and
behavioralmodificationprogramsresultincessationofsmokinginasignificant
numberofpatients.Cessationofsmokingcanbeexpectedin1626%ofpatients.
Thisreductioniscombinedwiththespontaneouslyhighsmokingcessationrates
followingacutecoronaryevents.

Improvedpsychosocialwellbeing

Cardiacrehabilitationexerciseandeducationalservicesenhancemeasuresof
psychologicalandsocialfunctioning. [3,4]

Reductionofstress

Inmultifactorialcardiacrehabilitationprograms,improvementinemotionalstress
measurementsoccurs,asdoesareductionoftypeAbehaviorpatterns.This
reductionofstressisconsistentwithimprovementinpsychosocialoutcomesthat
occursinnonrehabilitationsettings.
Enhancedsocialadjustmentandfunctioning

Cardiacrehabilitationexercisetrainingimprovessocialadjustmentandfunctioning.

Returntowork

Cardiacrehabilitationexercisetrainingexertslessinfluenceonratesofreturnto
workthanonotheraspectsoflife.Manynonexercisevariablesalsoaffectthis
outcome(eg,prioremploymentstatus,employerattitude,economicincentives).

Reducedmortality

Scientificdatasuggestasurvivalbenefitforpatientswhoparticipateincardiac
rehabilitationexercisetraining,butitisnotattributabletoexercisealone.This
survivalbenefitisduetomultifactorialinterventions.Ametaanalysisofpost
myocardialinfarction(MI),randomized,controlledtrialsofexerciseshoweda25%
reductioninmortalityat3yearfollowup.Themagnitudeofthisbenefitisaslarge
asthatseenwiththepostMIuseofbetablockersorwiththeuseofACEinhibitors
inLVdysfunctionalongwithMI.Trialsthatinvolveexercisealonestillshowa15%
mortalityreduction.

Thescientificevidencepertainingtotherelationshipbetweencardiacrehabilitation
exercisetrainingandmortalityalsoincludesscientificreportsthathaveappearedon
theUSNationalInstitutesofHealthWebsite.Amongthedatainthesereportswas
thefinding,throughrandomizedtrial,that3yearcoronarymortalityandsudden
deathratesweresignificantlylower(P<.02)inpatientswho,aftersuffering
myocardialinfarction,underwentmultifactorialcardiacrehabilitation,starting2
weeksafterhospitaldischarge.Thisbeneficialoutcomepersistedatthe10year
followup.

ThelargercenterfromamulticenterEuropeantrialofexerciseonlyrehabilitationin
males(postMI)reportedsignificantmortalityreductionintherehabilitationgroup(P
<.01).

Pathophysiologicmeasures

Whencombinedwithintensivedietaryintervention,withorwithoutlipidlowering
drugs,exercisetrainingmayresultinthelimitationofprogressionorinthe
regressionofangiographicallydocumentedcoronaryatherosclerosis.

ExercisetraininginpatientswithheartfailureandcompromisedLVejectionfraction
producesfavorablehemodynamicchangesintheskeletalmusculature.Therefore,
cardiacrehabilitationexercisetrainingisrecommendedfortheimprovementof
skeletalmusclefunctioning.However,suchtrainingdoesnotseemtoimprove
cardiachemodynamicfunctionorcollateralcirculationtoanysignificantdegree.

Patientsfollowingcardiactransplantation
Followingorthotropiccardiactransplantation,rehabilitationexercisetrainingis
recommendedtoimprovepatients'exercisetolerancemeasurements. [21]

Elderlypatientsandwomen

Coronarypatientswhoareelderlyhaveexercisetrainabilitycomparabletothatof
youngerpatientsparticipatinginsimilarrehabilitationprograms.Elderlypatients
(maleandfemale)showcomparableimprovements.Unfortunately,referralsto
cardiacrehabilitationaremadelessfrequentlyforelderlypatients,particularlyfor
elderlywomenparticipationincardiacrehabilitationalsoislessfrequentamongthe
elderly.Nocomplicationsoradverseoutcomesforelderlypatientshavebeen
describedinanystudy.Elderlymaleandfemalepatientsshouldbeencouragedto
participateincardiacrehabilitation.

Patientsondialysisandfollowingcoronaryarterybypassgrafting
surgery

Patientswhoareonrenaldialysisareathighriskforcardiacdeathandhavealarge
burdenofcardiovasculardiseaseandcardiovasculardiseaseriskfactors.Cardiac
rehabilitationcanpromoteimprovedsurvivalofnondialysispatientsaftercoronary
arterybypassgrafting(CABG)surgeryandiscoveredbyMedicare, [20]butno
studieshaveinvestigatedwhetherdialysispatients'survivalafterCABGmaybe
improvedasafunctionofcardiacrehabilitation.

Ina2006studybyKutnerandcolleagues,itwasfoundthat,incomparisonwith
dialysispatientswhodidnotundergocardiacrehabilitation,therewasa35%risk
reductionforallcausemortality,aswellasa36%riskreductionforcardiacdeath,in
dialysispatientswhohadcardiacrehabilitationfollowingCABGthefindingswere
independentofsociodemographicandclinicalriskfactors,suchasrecent
hospitalization. [27]Inthestudy,10%ofpatientsreceivedcardiacrehabilitationafter
CABG,lessthanhalftheestimatedshareofpatientsinthegeneralpouplationwho
suchrehabilitation.Womenandblackpatientsaged65orolder,alongwithlower
incomepatientsofallages,weresignificantlylesslikelytoreceivecardiac
rehabilitationservices.ThisobservationalstudysuggeststhatfollowingCABG,
cardiacrehabilitationincreasesadialysispatient'slikelihoodofsurvival.
CardiacRehabilitation:Risks,Safety,andCost
Issues
OverviewExercisetraininginvolvescertainrisks,especiallyinpatientswith
undiagnosedorundertreatedmyocardialischemia,ventriculararrhythmias,orLV
dysfunction.Theintensityofexercisemustbekeptbelowthelevelofexerciseat
whichtheabnormalitieswereelicitedduringtheriskstratificationandtestingphase.

SelectionofPatients

Theproperselectionofpatientsisofparamountimportancebeforephase2or
phase3exerciseprogramsarebegun. [28]Patientswithcertaincharacteristicsareat
ahigherriskandthereforerequireallattemptsatcorrectionofthehighrisk
conditionpriortoexercisetraining.Patientsalsomustbemonitoredwithcontinuous
electrocardiographyandbesupervisedclosely.Highriskfactorsincludethe
following:

SevereLVdysfunction,LVejectionfraction(EF)lessthan30%,congestive
heartfailure(CHF),andhistoryofcardiogenicshock
Severeexerciseinducedischemia(suchasanginaataworkloadoflessthan
5METs),STsegmentdepressionofgreaterthan0.2mVonanECG,
multipleperfusiondefectsonexercisenuclearstresstesting,ormultiple
dyskineticLVsegmentsonstressechocardiography
Complexventriculararrhythmias,suchasnonsustainedventricular
tachycardia(alessthan30secondrunofventriculartachycardia[VT])atrest
orwithexerciseorahistoryofprevioussuddencardiacarrest(SCA)
Hypotensiveresponsetoexercise(ie,dropinsystolicpressureofmorethan
20mmHgatincrementalexertion)
Lowfunctionalcapacity(ie,peakworkloadoflessthan5METs,functional
capacitydeterminedbyCPXtestingwithreducedpeakoxygen[VO 2max]
consumption)
Patient'sinabilitytoselfmonitorhis/herheartrate

Forsomepatients,therisksofexercisemayoutweighthebenefits.Inthese
instances,patientsshouldbecounseledagainstexercisetraining,andtheirmedical
managementmustfirstbeoptimizedwiththoroughsupervision.

Surveillance

Highriskpatients,constitutingapproximately1525%ofallpatientsreferredfor
cardiacrehabilitation,requirethemaximumlevelofsupervisionandsurveillance,
includingcontinualECGmonitoring.Thegroupofhighriskpatientsdescribed
aboveconstitutesthebulkofsuchpatients.

Intermediateriskpatientsneedsomewhatlessintensesurveillance.Thelevelof
supervisionneededincludesunmonitoredexercisetrainingingroupsinthepresence
ofhealthprofessionalswhoarecertifiedinadvancedcardiaclifesupport(ACLS).

Verylowriskpatientscanexercisesafelyandindependentlyoncetheyhavelearned
howtomonitortheirpulseratesandareabletorecognizewarningsigns.Such
patientshavegreaterthan8METsofexercisecapacitywithoutsymptomsorsigns
ofangina,heartfailure,orarrhythmias.

Alternativeapproachestothetraditionalsupervisedcardiacrehabilitationprograms
havebeenevaluatedandfoundtobereasonablysafe.Theseoffsite,self
monitoredortelemetrymonitoredprogramsareapplicableprimarilytoverylowrisk
patientsandinclude(1)homebasedcardiacrehabilitation(effectiveandsafe)and
(2)exercisewithtranstelephonicsurveillance.

Safety

Supervisedexercisetrainingprogramshaveextremelygoodsafetyrecords,despite
theinherentpotentialforcardiovascularcomplicationsduringexercise.Noneofthe
morethan3dozenrandomizedcontrolledtrialsofcardiacrehabilitationexercise
testingandtraininginpatientswithcoronaryheartdisease,involvingover4,500
patients,showedanyincreaseinmorbidityormortalityinrehabilitationcompared
withcontrolpatientgroups.

A19801984surveyof142UScardiacrehabilitationprogramsreportedalowrate
ofnonfatalmyocardialinfarction(MI1caseper294,000patienthours)andcardiac
mortality(1caseper784,000patienthours).Atotalof21episodesofcardiacarrest
occurred,withresuscitationsuccessfullyperformedin17oftheseepisodes.
Therefore,thesafetyofexercisewithincardiacrehabilitationprogramsiswell
acceptedandestablished.

AnalysisofCostEffectiveness

Cardiacrehabilitation,aclinicallyeffectiveinterventionforcoronaryheartdisease,
hasbeensubjectedtopreliminarycostanalyses. [6,29]InaUSstudy,arandomized,
8weektrialofrehabilitationbeginning6weeksfollowingMIshowedacost
effectivenessof$9,200perqualityadjustedlifeyear.Subsequently,asimilar
analysisshowedacosteffectivenessofonly$4,950peryearoflifesaved.In
contrast,cholesterolloweringforsecondarypreventionhasacosteffectivenessof
$9,630peryearoflifesaved,thrombolytictherapyforacuteMIhasaC/Eof
$32,700peryearoflifesaved,andbypasssurgeryhasacosteffectivenessof
$18,700forayearoflifesaved.

InSweden,acomprehensivecostanalysisofcardiacrehabilitation,performedon
patientsfollowingMIorbypasssurgery(witha5yearfollowup),showedthat
rehospitalizationsdecreasedfrom16to11daysthestudyalsoshowedahigher
rateofreturntowork(53%versus38%).Overall,cardiacrehabilitationprograms
resultedincostsavingstotheSwedishsystemof$12,000perpatient.

Researchthereforeindicatesthatcardiacrehabilitationisnotonlyclinically
effective,butiscosteffectiveaswell.Cardiacrehabilitationcomparesfavorably
withothermedicalinterventionsperformedcommonlyinpatientswithcoronary
heartdisease.

Conclusion
Cardiacrehabilitationisanimportantcomponentofthecurrentmultidisciplinary
approachtothemanagementofthepatientswithvariouspresentationsofcoronary
heartdisease.Cardiacrehabilitationinvolvesexercisetraining,education,
counselingregardingriskreductionandlifestylemodification,and,frequently,
behaviorinterventions.

Thegoalsofcardiacrehabilitationservicesaretoimprovethephysiologicand
psychosocialconditionofpatients.Physiologicbenefitsincludetheimprovementof
exercisecapacityandthereductionofriskfactors(eg,cessationofsmokingand
loweringoflipidlevels,bodyweight,bloodpressure,bloodglucose),withthe
exercisecomponentprovidedthroughrehabilitationpossiblyreducingthe
progressionofatherosclerosis.Psychologicalimprovementsincludethereductionof
depression,anxiety,andstress.Alloftheseimprovementsenablethepatientto
acquireandmaintainfunctionalindependenceandtoreturntosatisfactoryand
appropriateactivitythatbenefitsthepatientandsociety.

Forexcellentpatienteducationresources,visiteMedicineHealth'sHealthyLiving
Center.Also,seeeMedicineHealth'spatienteducationarticlesChestPain,
CoronaryHeartDisease,HeartAttack,WalkingforFitness,andResistance
Training.

ContributorInformationandDisclosures
Author
VibhutiNSingh,MD,MPH,FACC,FSCAIClinicalAssistantProfessor,DivisionofCardiology,Universityof
SouthFloridaCollegeofMedicineDirector,CardiologyDivisionandCardiacCatheterizationLab,Chair,
DepartmentofMedicine,BayfrontMedicalCenter,BayfrontCardiovascularAssociatesPresident,Suncoast
CardiovascularResearch

VibhutiNSingh,MD,MPH,FACC,FSCAIisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Cardiology,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanMedicalAssociation,Florida
MedicalAssociation

Disclosure:Nothingtodisclose.

Coauthor(s)
DouglasDSchocken,MD,FACC,FACPCourtesyProfessor,DepartmentofGerontology,UniversityofSouth
FloridaCollegeofArtsandSciencesProfessor,DepartmentsofMedicineandEpidemiologyandBiostatistics,
UniversityofSouthFloridaMorsaniCollegeofMedicine

DouglasDSchocken,MD,FACC,FACPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Cardiology,AmericanCollegeofPhysicians

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.

RichardSalcido,MDChairman,ErdmanProfessorofRehabilitation,DepartmentofPhysicalMedicineand
Rehabilitation,UniversityofPennsylvaniaSchoolofMedicine

RichardSalcido,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPainMedicine,
AmericanAcademyofPhysicalMedicineandRehabilitation,AmericanAssociationforPhysicianLeadership,
AmericanMedicalAssociation,AcademyofSpinalCordInjuryProfessionals

Disclosure:Nothingtodisclose.

ChiefEditor
ConsueloTLorenzo,MDMedicalDirector,SeniorProducts,CentralNorthRegion,Humana,Inc

ConsueloTLorenzo,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPhysical
MedicineandRehabilitation

Disclosure:Nothingtodisclose.

Acknowledgements
RobertStameyPatientCareDirector,BayfrontMedicalCenter
RobertStameyisamemberofthefollowingmedicalsocieties:AmericanCollegeofSportsMedicine

Disclosure:Nothingtodisclose.

KarenWilliams,MDMedicalDirector,RehabilitationSpecialist,BayfrontRehabilitationServices,Bayfront
MedicalCenter

KarenWilliams,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPhysicalMedicine
andRehabilitation,AmericanMedicalWomen'sAssociation,AmericanSpinalInjuryAssociation,FloridaMedical
Association,FloridaSocietyofPhysicalMedicineandRehabilitation,andSouthernMedicalAssociation

Disclosure:Nothingtodisclose.

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