Cardiac rehabilitation: why is it an underused therapy?

During the last decades, cardiac rehabilitation (CR) has evolved from a simple patient monitoring system for the safe return to normal physical activities to a multidisciplinary approach that focuses on patient education, individually tailored exercise training, modification of the risk factors, and the overall well-being of cardiac patients. The benefits of CR include reduction in mortality, symptom relief, smoking cessation, improvedphysical fitness, risk factormodification, and improved overall psychosocial well-being. 3 Unfortunately, CR still remains underutilized among patients with cardiovascular diseases mainly because of referral problems, poor enrolment and support, and various local reasons due to limited resources. A problem that healthcare systems are facing in all developed countries is the increase of the ageing population with various cardiovascular diseases and frailty. Coronary heart disease (CHD) is the most common type of heart disease, and it manifests as chest pain and myocardial infarction. Patients with cardiovascular diseases are a great challenge for secondary prevention measures, and recent research developments in CR have demonstrated that tremendous benefits can be derived from the optimal use of CR in patients recovering from an acute CHD event or heart failure (HF), as well as after cardiac surgery. A crucial point is to consider CR not as exercise trainingonly, but alsoasaprogrammebasedonthe individual’s requirements, aiming at the improvement of the quantity and quality of life by means of: reduction of the risk factors, such as smoking and cholesterol levels, modification of dietary habits, increase and maintenance of exercise training and its intensity, psychological support, and guidance on returning to work. The scope of contemporary CR could be shifted from exercise interventions to more comprehensive secondary prevention programmes with education and psychological support (Table 1). Multidisciplinary CR programmes should normally be started as soon as possible after a recent cardiac event during the hospitalization phase, continuing as a long-term treatment option with all necessary drugs and interventions. Despite its proven benefits, CR referral and participation rates have been very low compared with other evidence-based treatments. Earlier studies from multiple countries reported an average referral rate of 30% in Canada, the USA, and the UK, and a little higher at 50% in the rest of Europe. Differences in healthcare policies and delivery systems between countries and across hospitals may explain, at least in part, this variability. There are still differences in referral rates between European countries, and the exact reasons for underuse of CR in different EU countries and hospitals are not widely known. Although many patients do not receive CR currently, new home-based and individualized CR programmes have been increasingly introduced to widen access and participation in device-guided rehabilitation. In addition to recruitments problems, maintaining long-term adherence to CR is a key challenge, and therefore, interventions aimed at improvingpatient uptakeand long-termadherence toCRprogrammesshould be monitored and assessed. Indeed, exercise-based lifestyle modifications should be part of normal daily life. There are very few papers on comprehensive CR across the entire spectrum of indications for CR using a nationwide database. de Vries et al. have now assessed the effects of CR on survival in a large population of patients with an acute coronary syndrome (ACS) and patients that underwent coronary revascularization and/or heart valve surgery. Their new findings showed that receiving multidisciplinary CR in The Netherlands was associated with a substantial survival benefit in the first 4 years following an ACS or cardiac intervention. The survival benefit associated with CR was present regardless of age, type of diagnosis, type of intervention, and follow-up duration. In females, CR uptake was associated with a significant survival benefit at 2 years of follow-up only. Patients includedinCRprogrammes inTheNetherlandsareoffereda comprehensivemultidisciplinary rehabilitationwith a typicaldurationof 6–12 weeks, consisting of one or more group-based therapies (education, exercise training, relaxation therapy, and lifestyle modification therapy) supplemented by individual counselling when indicated (e.g. by a psychologist, dietician, or social worker). Reimbursement for outpatient CR after an ACS or cardiac intervention was provided by insurance companies on the condition that a patient is referred by a