Cardiovascular prevention and rehabilitation programmes are a multi-facet intervention that is offered to patients diagnosed with coronary heart disease. The programme is usually delivered over a 6-12-week period by a multi-disciplinary team focusing on the prescription and up-titration of cardio-protective medication, smoking cessation, diet, physical activity and psychological support.
What is a cardiovascular prevention and rehabilitation programme?
What is the evidence for cardiovascular prevention and rehabilitation?
What are the benefits of medical risk factor management?
What are the benefits of smoking cessation?
What are the benefits of a Mediterranean diet?
What are the benefits of physical activity?
What are the benefits of psychological support?
Cardiovascular disease (CVD) is a family of diseases including coronary heart disease (CHD), peripheral vascular disease and cerebral vascular disease, and it is the biggest cause of death worldwide.1 In 2015 an estimated 17.9 million people died from CVD, accounting for one-third of all global deaths.1 The percentage of deaths related to CVD differs between countries and social classes with low-and middle-income countries experiencing higher CVD rates.1 However, most CVDs can be prevented by addressing behavioural and medical risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, high alcohol consumption, hypertension, dyslipidaemia and hyperglycaemia.2
Using population-wide strategies such as the NHS Health Checks programme and cardiovascular prevention and rehabilitation (CPR) programmes, CVDs can be prevented in the primary and secondary care settings.
Secondary care interventions are aimed at empowering patients to make changes to their physical activity and dietary behaviours as well as enhancing education, providing psychological support and controlling medical risk factors in order to meet the targets in Table 1. This care package is commonly known as CPR, which is delivered by a multidisciplinary team. The aim of CPR programmes is to halt the progression of CVD and help the patient to return back to optimal physical and psychosocial function.
The evidence base that supports comprehensive CPR programmes is robust and is built on a background of research spanning over 30 years.3 This research has consistently shown that patients completing a CPR programme can significantly reduce their cardiovascular mortality risk and hospital re-admissions.3 Based on this evidence, every healthcare practitioner involved in the care of patients with CVD should actively promote CPR programmes. Therefore, the aim of this review article is to review the evidence behind a comprehensive CPR programme with a particular focus on medical risk factor management, smoking cessation, Mediterranean diet, physical activity and psychological support.
The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) define CPR as: “The coordinated sum of activities required to inﬂuence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease”.4
This definition is based on the six core components and six standards set by the BACPR4 (box 1 and 2), which should be delivered by a multi-disciplinary (box 3). There are many patient groups that benefit from a CPR programme and BACPR agree that the patients listed in box 4 will benefit from CPR.4
Referrals to CPR programmes generally come from cardiac wards, cardiac catheterisation laboratories, general cardiology/heart failure clinics and GPs. An assessment by a multi-disciplinary team should commence within 10 working days of receipt of the referral.4 The assessment should ideally include the following: medical risk factors (blood pressure, lipids and glucose), smoking status, dietary and physical activity behaviours, height, weight and waist, physical limitations, exercise capacity, quality of life and psychosocial health (anxiety and depression). Following the assessment, patients are usually discussed in an MDT meeting with a consultant cardiologist or a dedicated physician who leads on the prescribing and up-titration of the patient’s medication.
Following this review the patient enters into a programme that includes exercise, education and psychosocial support. The format of the programme can be delivered in a centre (hospital gym or leisure centre) or at home. It should be noted that home-based CPR is just as effective as centre-based programmes.5
The CPR programme typically runs for 6-12 weeks and patients attending a centre-based programme usually participate in a once or twice weekly supervised exercise session, which is followed by an educational workshop covering various topics, including cardiac medicines, medical risk factor management, healthy lifestyle change and stress management.4,6 Once the patients have completed the programme they are usually invited to attend an end-of-programme assessment. All data that is collected is recorded on the National Audit of Cardiac Rehabilitation database.6
A variety of meta-analyses have documented the beneficial effects of exercise-based CPR programmes in patients with CHD and/or with heart failure. In a recent Cochrane review (63 studies, n=14 486 participants), patients who had suffered an acute coronary syndrome and/or undergone coronary revascularisation, attending and completing exercise-based CPR programme was associated with an absolute risk reduction in CVD mortality from 10.4% to 7.6% when compared to usual care.3 However, the impact on reducing total mortality, recurrent myocardial infarction and repeat revascularisation was non-significant in this meta-analysis.3 Conversely, in previous meta-analyses total mortality was reduced by 13-26% and there was a 47% lower risk of re-infarction.7,8
These differences between previous and recent findings is probably due to the advances in coronary percutaneous interventions and medical therapies, which makes it difficult to tease out the effects of CPR on reducing all-cause mortality and re-infarction rates in cardiac patients. In terms of cost effectiveness, CPR has also been shown to reduce total hospital re-admissions by 25% and heart failure-related hospital re-admissions by 39%.3,9
Despite these positive findings, Powell et al10 refutes the benefits of CPR as they reported a neutral effect on all-cause and cardiovascular mortality and only a modest effect on reducing hospital re-admission in a meta-analysis including 22 exercise-based CPR studies (4,834 participants). The neutral effects of this study might have been influenced by the inclusion of the highly controversial RAMIT11 randomised control trial (RCT), which made up 37% (n=1813 patients) of their analysis.
The RAMIT’s main limitations includes: an under-powered sample size, a large dropout rate in the CPR arm, no discussions relating to potential contamination to the control arm and the content of the CPR programme did not meet the current standards set by the BACPR.4
The prescription and optimisation of cardio-protective medication is key in meeting CVD risk factor targets (table 1) and improving all-cause and cardiac mortality. Patients with CHD are often prescribed multiple medications including anti-platelets, lipid lowering therapies, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers etc. In a recent survey across 24 European countries, 78% of patients with CHD were on anti-hypertensive medication and nearly 87% were on lipid lowering medication, nine out of 10 patients were on anti-platelet medication, four fifths on beta-blockers and three-quarters on ACE inhibitors or ARBs.12
However, despite these positive figures very few patients were meeting the risk factor targets.12 Therefore, it is paramount that CPR programmes are truly comprehensive and include a designated physician who can prescribe and up-titrate cardio-protective medication.
In support of this notion a recent meta-analysis demonstrated that CPR programmes that managed six or more risk factors reduced all-cause mortality by 37% and in those programmes that prescribed and monitored cardio-protective medications all-cause mortality was reduced by 75%.13
Cigarette smoking remains the leading cause of preventable death in the UK and it is estimated to be responsible for over 79,000 deaths per year and costs the NHS approximately £2.5 billion pounds annually.14 The INTERHEART study identified that current smokers are at three-times greater risk of non-fatal myocardial infarction compared with never-smokers.2 In support of this finding a recent meta-analysis reported a threefold increase in risk of sudden cardiac death among current smokers when compared to non-smokers.15
Due to the detrimental effects of smoking, every healthcare professional working in CPR should help patients to quit smoking. Simple advice given by a cardiac specialist nurse contributes towards a successful cessation rate in CHD patients admitted to hospital.16 Moreover, more formal smoking cessation programmes that focuses on behavioural support and pharmacological therapies are four times more effective than attempting to quit smoking unassisted and twice as successfully than stop-smoking medicines.17
Smoking cessation clinics can easily be incorporated into a CPR programme and can form part of the CVD risk assessment that is carried out during the initial assessment and the patient can be followed up with regular CO2 monitoring and behavioural support at the weekly exercise and educational sessions.
The Mediterranean diet is the most frequently studied dietary pattern in a CPR setting. The rationale for studying dietary patterns as opposed to single nutrients is based on the interactions between different nutrients during their absorption. Furthermore, by studying dietary patterns will give a better estimate of their combined effect on preventing CVD.
The Mediterranean diet consists of a high consumption of fruit and vegetables, whole grains products, pulses, fish and unsaturated fatty acids (oily fish and olive oil), a moderate consumption of alcohol, and a low consumption of processed foods, red meat, sweets and dairy products.
The cardio-protective benefits of the Mediterranean diet were first identified back in the late 1950’s when the Seven Countries study demonstrated a significant difference in CVD mortality between northern Europe and the southern Mediterranean Europe.18
In support of these findings a recent RCT has demonstrated a lower risk of CVD events over a five-year period with a relative difference of 30% and an absolute difference of 1.7 to 2.1 percentage points in patients at high-risk of CVD following a Mediterranean diet supplemented with either extra-virgin olive oil or nuts compared to a control group following a low-fat diet.19
The terms physical activity and exercise are sometimes used interchangeable in the literature even through exercise is planned and structured and physical activity represents any bodily movement that raises the bodies expenditure that above rest.20,21
The benefits of physical activity in CHD patients are well established in reducing CVD risk factors. Risk factors benefiting from physical activity, include a reduction in hypertension,22,23 hypercholesetremia,24 insulin resistance,25 inflammatory markers,26 and psychological factors.27 Moreover, regular exercise training has been shown to halt and regress atheromatous plaques within the coronary arteries and it has also been proven to be more effective than angioplasty with a significantly greater “event-free” survival rate.28,29
Many CHD patients enter a CPR programme with borderline or clinically significant levels of anxiety and depression.6 Anxiety and depression are usually assessed by the 14-item self-assessment Hospital Anxiety and Depression Scale (HADS).30 The HADS is validated for detecting states of depression and anxiety and a cut-off score of over 8/21 is used to identify clinically significant symptoms of mild/moderate anxiety and depression.31 There are several treatment options for treating anxiety and depression.
In addition, some CPR programmes have a designated Clinical Health Psychologist who can offer several therapies including motivational interviewing, cognitive behavioural therapy, mindfulness and acceptance and commitment therapy. The effects of psychological treatments on CHD patients have recently been reported in a meta-analysis including 35 studies (n=10,703). Generally, the quality of evidence was low to moderate and there was no risk reduction overserved for total mortality, non-fatal MI and revascularisation procedures with psychological therapies compared to usual-care.33 However, there was a 21% reduction in cardiac mortality in patients who received psychological interventions.33
CVD is caused by multiple risk factors that can be effectively managed through lifestyle change and medical management. In a secondary-care setting, patients with CHD should be routinely offered the opportunity to participate in a CPR programme. Such programmes are led by a multi-disciplinary team, which offer interventions that will help empower patients to quit smoking, make changes in their diet and increase their physical activity behaviours.
In addition, psychological support has also been shown to reduce cardiac anxiety and depression. The combined effect of all these interventions along with the prescription and up-titration of cardio-protective medication has a significant impact on reducing all-cause mortality, cardiac mortality and hospital re-admissions in patients with CHD.
Tim Grove, Senior Physical Activity Specialist, Chartered Scientist, Cardiac Health & Rehabilitation Service, Imperial College Healthcare NHS Trust
Conflict of interest: none declared
4. BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation,of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR). 2017. http://www.bacpr.com/resources/8BZ_BACPR_Standards_and_Core_Components_2017.pdf (accessed March 2018).
8. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. American Heart Journal 2011; 162: 571–84
9. Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014 Apr 27;(4):CD003331. doi: 10.1002/14651858.CD003331.pub4.
11. West RW, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012; 98: 637–44
12. Kotseva K, Wood D, De Bacquer D, et al: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol 2016; 23(6): 636–48
13. van Halewijn G , Deckers J , Tay HY, et al. Lessons from contemporary trials of cardiovascular prevention and rehabilitation: a systematic review and meta-analysis. Int J Cardiol 2017; 232: 294–303
15. Aune D, Schlesinger S, Norat T, Elio Riboli E. Tobacco smoking and the risk of sudden cardiac death: a systematic review and meta-analysis of prospective studies. Eur J Epidemiol 2018; 33(6): 509–521
18. Menotti A, Puddu PE. How the Seven Countries Study contributed to the definition and development of the Mediterranean diet concept: a 50-year journey. Nutr Metab Cardiovasc Dis 2015; 25(3): 245–52
19. Estruch R, Ros E, Salas-Salvadó J, et al for the PREDIMED Study Investigators* Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra Virgin Olive Oil or Nuts. N Engl J Med 2018; 378
21. Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR). ACPICR Standards for Physical Activity and Exercise in the Cardiac Population available at http://acpicr.com/publications (2015 (accessed September 2018)
24. Kodama S, Tanaka S, Saito K, et al. Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol: a meta-analysis. Archives of Internal Medicine 2007; 28; 167(10): 999–1008
28. Hambrecht R, Niebauer J, Marburger C, et al. Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. Journal of American College of Cardiology 1993; 22(2): 468–77
29. Hambrecht R, Walther C, Möbius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004; 109(11): 1371–78