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Cardiac Rehabilitation and Exercise in

Secondary Prevention

Mnica Acevedo, Vernica Kramer,


Mara Jos Bustamante & Fernando
Yaez
Current Cardiovascular Risk
Reports
ISSN 1932-9520
Curr Cardiovasc Risk Rep
DOI 10.1007/
s12170-011-0190-4

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Curr Cardiovasc Risk Rep
DOI 10.1007/s12170-011-0190-4

Cardiac Rehabilitation and Exercise


in Secondary Prevention
Mnica Acevedo & Vernica Kramer &
Mara Jos Bustamante & Fernando Yaez

# Springer Science+Business Media, LLC 2011

Abstract Cardiac rehabilitation (CR) and exercise prescription in secondary prevention patients is a class I indication in
most clinical guidelines. CR programs not only include exercise
components but also provide comprehensive care and education about cardiovascular risk factors, cigarette smoking, and
behavioral interventions. However, CR programs are scarce or
inexistent in many developing countries; in the United States
and Europe, where they do exist, they are underused.
Keywords Exercise . Cardiac rehabilitation . Secondary
prevention

Introduction
Coronary heart disease (CHD) is the leading cause of death in
both men and women worldwide. Most success in the past
decade has been done in treating modifiable risk factors of
CHD, such as high blood pressure and dyslipidemia.
However, the treatment of those risk factors that depend more
on lifestyle modifications, such as overweight, obesity, and
physical inactivity, has been less successful.
M. Acevedo (*) : V. Kramer : M. J. Bustamante : F. Yaez
Preventive Cardiology and Cardiac Rehabilitation,
Division of Cardiovascular Diseases, Pontificia Universidad
Catlica de Chile, Santiago, Chile,
Lira 85, 1st floor,
Santiago, Chile
e-mail: macevedo@med.puc.cl
V. Kramer
e-mail: vkramer@med.puc.cl
M. J. Bustamante
e-mail: mjbustam@puc.cl
F. Yaez
e-mail: fyanez@med.puc.cl

Evidence from long-term epidemiologic studies supports


the concept that the fitness level of an individual is
inversely and strongly associated to cardiovascular and
total mortality in both healthy populations [1, 2] and in
secondary prevention patients [3]. The relationship is robust
and graded [2, 4] and independent of confounding risk
factors. Based on the striking data supporting the benefits
of exercise in reducing the risk of development and
progression of CHD, multiple health care agencies and
organizations worldwide have recommended regular physical
activity as a strategy to reduce the risk of CHD. Among these
organizations are the Center for Disease Control and
Prevention, the American Heart Association (AHA), the
American College of Cardiology (ACC), the National
Institutes of Health, the American College of Sports Medicine,
and the European Society of Cardiology (ESC). However,
despite the efforts devoted to promoting physical activity,
sedentary lifestyle is still highly prevalent in the United States,
Europe, and Latin America [5].

Exercise and Secondary Prevention


Due to the important progress in technology-based
diagnostic and therapeutic procedures in cardiovascular
disease (CVD) in recent years and the outstanding
advances in pharmacologic therapies, a greater number
of patients now survive acute cardiac events but retain a
burden of chronic conditions. In this regard, a supporting
approach that includes comprehensive risk factor intervention, besides the clinical visits and medications, is
most needed. Cardiac rehabilitation (CR) programs
include these important characteristics, incorporating also
the restoration of the quality of life and improvement of
functional capacity.

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The role of exercise in subjects with documented CHD


has been thoroughly investigated, with consistent findings
in respect to safety, improved functional capacity, and
reduction in all-cause and cardiovascular mortality [6]. CR,
as stated by the European Association of Cardiovascular
Prevention and Rehabilitation, can be viewed as the
clinical application of preventive care by means of a
professional multidisciplinary integrated approach for comprehensive risk reduction and global long-term care of
cardiac patients [7]. Accordingly, CR programs are
currently recommended (class I evidence) by the ESC,
AHA, and ACC in the treatment of patients with CHD and
chronic heart failure [8].
However, as in primary prevention, CR in secondary
prevention patients is underused, with only about one third
of coronary patients in Europe [7], 15%25% in the
United States [9], and less than 10% in Latin America [10]
referred to any form of CR. Possible reasons for underreferral include physicians skepticism over its benefits,
variation in access to CR programs in different regions,
preferences for exercise at home, and physicians primary
focus on revascularization procedures and pharmacologic
treatment over lifestyle-modification strategies [11]. Patient
factors might interfere as well. These can include an
unwillingness to commit to a 36-session CR program and/
or financial issues, among others. As an alternative to
traditional hospital or community center-based settings for
outpatient programs, other models of delivering exercise
training have been developed. These models include homebased programs for which a nurse is the case manager and
facilitates, supervises, and monitors patient care and progress
and community-based groups programs conducted by nurses
or exercise physiologists [12]. Programs are also offered via
the Internet as alternative methods for providing home-based
comprehensive risk factor modification and instruction for
structured exercise. Obviously, these latter methods can only
be offered to low-risk patients.
Although most candidates for CR programs are patients
following myocardial infarction (MI) or coronary artery
bypass graft (CABG) surgery, current use also includes
patients following percutaneous coronary interventions
(PCIs), heart or heart/lung transplantation recipients,
patients with stable angina or chronic heart failure,
peripheral arterial disease patients with claudication, and
patients after other surgical procedures such as heart valve
repair or replacement.

Key Components of Cardiac Rehabilitation


The main components of CR have been outlined by a
Scientific Statement from the AHA and the American
Association of Cardiovascular and Pulmonary Rehabilita-

tion [13] and the Cardiac Rehabilitation Section of the


European Association of Cardiovascular Prevention and
Rehabilitation [7]. Both highlight the integral role of CR
in the secondary prevention of CHD and are designed to
optimize cardiovascular risk reduction, promote healthy
behaviors, reduce cardiovascular disability, and foster an
active lifestyle for patients with CVD [6]. The core
components in most CR programs include 1) patient
assessment, 2) physical activity counseling, 3) exercise
training, 4) diet/nutritional counseling, 5) diabetes management, 6) weight control management, 7) lipid management,
8) blood pressure management, 9) smoking cessation, and
10) psychosocial management. In this review we mainly
focus on physical activity counseling and exercise training
components.

Physical Activity Counseling


Physical activity is defined as any body movement
produced by contraction of skeletal muscles resulting in
energy expenditure above the basal level, and as such, part
of lifestyle intervention. Assessments should also include
the readiness to change, self-confidence, barriers to increase
physical activity, and social support. Advice and support
according to patients age, comorbidities, preferences, and
goals, and referral to an exercise program should be done.
In most CHD patients, risk must be assessed by physical
activity history and exercise testing to guide the prescription (symptom-limited exercise testing in most cases). The
recommendation is a minimum 30 min of moderate
physical activity up to 60 min on most days of the week
or at least 34 times per week. At the beginning the
activities should be of low impact, with gradual increases
over time in activity duration and intensity. It is recommended to instruct the patients on the need for long-term
continuation of the exercise, as well as encourage them to
be involved in leisure activities and in group programs, as
many patients tend to revert to physical inactivity in the
medium-term follow-up. Increased participation in a regular
physical activity regimen has shown to improve psychosocial well-being, aerobic fitness, and all-cause mortality [14].

Exercise Training
Exercise training refers to the physical activity in which
planned, structured, and repetitive body movements are
performed to maintain or improve one or more attributes of
physical fitness [7]. Therefore, it is a structured intervention over a defined period of time. The risk of cardiovascular complications of exercise must be assessed before
initiation of exercise training using standardized methods to

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identify unstable patients. A symptom-limited exercise testing


should be done in most patients before enrollment in CR to
guide the level of supervision required for exercise training. In
general, the stress test should be performed 714 days after an
acute coronary syndrome or percutaneous coronary intervention (PCI). In those patients in whom a symptom-limited stress
testing cannot be done (eg, patients with severe left ventricular
dysfunction or recent surgical interventions) a sub-maximal
exercise evaluation and/or 6-minute walking test should be
considered. All the patients in CR programs should be warned
on the symptoms induced by effort. The exercise prescription
should include both aerobic and resistance training. It is
important to emphasize that in structured CR programs,
supervision should always include physical examination,
assessment of exercise-related symptoms or arrhythmias,
and monitoring of heart rate and blood pressure before,
during, and after exercise training. Expected outcomes after
CR are improvement in aerobic capacity, enhanced flexibility,
muscular endurance and strength, reduction of symptoms,
attenuated physiologic responses to physical tests, and
improved quality of life.
Exercise Training: Clinical Trial Data
Most of the data about exercise and secondary prevention
comes from patients with CHD. In 2001, the Cochrane
Database on Exercise-Based Rehabilitation for Coronary
Heart Disease reported, in more than 8000 patients, a 27%
reduction in all-cause mortality (odds ratio [OR] 0.73; 95%
CI, 0.540.98) for the exercise-only intervention. Total
cardiac mortality was reduced by 31% (OR 0.69; 95% CI,
0.510.94) and 26% (OR 0.74; 95% CI, 0.57, 0.96) in the
exercise-only and comprehensive cardiac rehabilitation
groups, respectively [15]. There was no effect on recurrent
nonfatal MI. This meta-analysis, however, included predominantly middle-aged and low-cardiovascular risk men.
A more recent review, including 48 trials with nearly 9000
patients, showed a 20% reduction in all-cause mortality and
16% decrease in cardiac mortality in CR compared to usual
care patients. Again, there were no significant differences in
the rates of nonfatal MI and revascularization between the
groups. Health-related quality of life improved to similar
levels with CR and usual care [14].
Clark et al. [16] identified 63 trials reporting on more
than 20,000 CHD patients. There was a 15% reduction in
all-cause mortality overall, with 13% reduction at 12 months
and 47% at 24 months. Also, there was a 17% reduction for
recurrent MI at a median of 12 months. Effects were similar
for programs that included risk factor education or
counseling with a structured exercise component, for
programs that included risk factor education or counseling
without an exercise component, and for programs that were
solely exercise-based.

But CR also benefits other secondary prevention patients.


A controlled trial of CR versus usual care after CABG surgery
with 10-year follow-up documented significantly fewer total
cardiovascular events for patients in CR (18% vs 35%), as
well as reduced hospital readmissions [17]. On the other
hand, it has been known for more than 30 years that exercise
training improves exercise tolerance in patients with chronic
stable angina by increasing the angina threshold and
delaying the onset of ischemia. Hambrecht et al. [18]
demonstrated, in a randomized controlled 12-month study,
the effects of exercise training versus PCI with stenting. In
101 male patients, exercise training was associated with a
higher event-free survival (88% vs 70%), better exercise
capacity, and reduced costs.
CR in heart failure patients still needs to be addressed. A
meta-analysis published in 2004 addressed exercise training in
2387 patients with stable heart failure. They reported an
improvement in functional capacity, a reduction in symptoms,
and a trend toward increased survival (OR 0.98; 95% CI, 0.61
1.32). There were no reports of deaths that were directly related
to exercise during more than 60,000 patient-hours of exercise
training [19]. The recent Heart Failure: A Controlled Trial
Investigating Outcomes of Exercise Training (HF- ACTION)
study [20] also provided contradictory results: 2331 medically stable outpatients with heart failure and reduced ejection
fraction were randomized to usual care plus aerobic exercise
training, consisting of 36 supervised sessions, followed by
home-based training, or to usual care alone; 65% of patients in
the exercise training group died or were hospitalized compared
to 68% in the usual care group (hazard ratio [HR] 0.93; 95%
CI, 0.841.02). Exercise adherence in this study decreased
from a median of 95 min per week during months 4 through 6
of follow-up to 74 min per week during months 10 through 12.
Cardioprotective Effects of Exercise Training
Exercise training produces several beneficial cardioprotective effects, among which are the improvement in exercise
tolerance, cardiac symptoms, blood lipids, psychosocial
risk factors such as anxiety and stress, reduction in cigarette
smoking, and as previously detailed, improvement in allcause and cardiac morbidity and mortality [6].
CR in the form of exercise alone has favorable effects on
cardiovascular risk factors [9, 21]. The most well-known
effects are on lipids, with an increase of 8%23% in highdensity lipoprotein (HDL) cholesterol and 5%26% in the
total to HDL cholesterol ratio. On the other hand,
triglyceride reduction is 22%, although no significant
reduction in LDL cholesterol is noticed with exercise alone.
Regular exercise also improves insulin sensitivity and
modestly reduces body weight by 0%2% in 3 months,
but fat mass decreases by 5%. The effects of improving
insulin sensitivity along with the modest weight reduction

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have been shown to reduce the risk of developing type 2


diabetes [22]. Moderate exercise also positively influences
blood pressure, with a mean reduction of 49 mm Hg in
systolic and diastolic blood pressure.
Exercise training also has positive hemodynamic effects for
CHD patients, as it produces a decrease in heart rate and blood
pressure and an improvement in peak oxygen uptake by 11%
36% (average of 20%), with the greatest improvement in the
most deconditioned patients [23]. Improved physical fitness is
also associated with reductions in submaximal heart rate,
systolic blood pressure, and rate-pressure product, decreasing
myocardial oxygen requirements during moderate to strenuous activities [23]. In addition, exercise training can also
increase coronary flow by improving coronary artery compliance or elasticity and endothelium-dependent vasodilatation
of the coronary arteries. Increased flow-mediated shear stress
is associated with enhanced synthesis, release, and duration of
nitric oxide [24]. Hambrecht et al. [25] demonstrated a
significant improvement in endothelium-dependent arterial
dilatation in patients with CHD and abnormal endothelial
function after 4 weeks of vigorous endurance exercise
training. Exercise training in that study improved
endothelium-dependent vasodilatation both in epicardial
coronary vessels and in resistance vessels [25]. Endurance
exercise also has anti-ischemic effects, reducing myocardial
ischemia in advanced CHD patients by decreasing the ratepressure product and myocardial oxygen demands during
physical activity, raising the ischemic or anginal threshold
[26]. Furthermore, exercise in advanced CHD patients may
produce ischemic myocardial preconditioning, a process by
which the tolerance of the myocardium to ischemia increases,
and thus reduces the risk of malignant ventricular arrhythmias
[23, 27]. Exercise also reduces sympathetic activity and
enhances parasympathetic activity, thus it may further
decrease the risk of sudden cardiac death [28].
Exercise training also has beneficial effects over inflammatory and hemostatic risk factors. Aerobic exercise is associated
with reduced C-reactive protein levels, which suggests that
exercise has anti-inflammatory effects [21, 29]. Strenuous
exercise, on the other hand, enhances fibrinolytic activity by
increasing the endothelial synthesis of tissue plasminogen
activator and reducing plasminogen activator inhibitor-1.
Exercise may also reduce fibrinogen levels [21].
Finally, from the patients point of view, the most
prominent effects of CR fall within psychological factors,
such as anxiety, emotional stress, lack of self-confidence,
depression, social isolation, and reported quality of life, all
of which improve significantly after CR [9].
Safety of Exercise Training
Several guidelines for prescribing aerobic and resistance
exercise for patients with CVD are available [23, 30, 31].

The main concern regarding CR programs has been the one


referring to exercise triggering sudden cardiac death.
However, the relative safety of medically supervised,
physician-directed CR programs that follow the international and approved guidelines previously mentioned is
very well established. Investigators have stated that
moderate, regular exercise is associated with a decreased
risk of cardiac mortality, and even the incidence of sudden
death associated with vigorous exercise is low. It has been
estimated that major cardiac events, including MI and
resuscitated cardiac arrest, occurred in 1 of 50,000100,000
patient-hours of supervised exercise, with 2 deaths reported
for 1.5 million patient-hours [6, 32]. However, it is
important to note that vigorous, high-intensity exercise
does increase the risk of MI. In this regard, contemporary
risk-stratification procedures for the management of CHD
have helped to identify patients who are at higher risk for
exercise-related cardiac events and who should require
more intensive monitoring and medical supervision within
the CR program [33]. Therefore, the adequate risk
stratification of patients, before their enrollment in CR, is
of utmost importance. Class A individuals are those who
are apparently healthy, with low cardiovascular risk with
exercise; Class B are the patients with stable CHD who are
at low risk of cardiovascular complications with vigorous
exercise; and Class C individuals are high-risk cardiovascular patients. High-risk patients are those who have had
multiple MIs or cardiac arrest, who are in New York Heart
Association (NYHA) class III or IVor who present with a
decreased aerobic capacity (ie, < 6 metabolic equivalents
[MET]), or those with inducible ischemia at the stress
testing. Class D patients are those with absolute contraindication of doing any exercise because of unstable
conditions. Patients in Class C should be enrolled in
medically supervised CR programs for at least 812 weeks
before referring them to home-based or community-based
CR centers.
Initiating an Exercise Program in Secondary Prevention:
Key Aspects
The risk of cardiovascular and orthopedic complications
increase as individual risk of CHD increases and as the
intensity of the exercise increases. Therefore and as
previously stated, any patient about to start a regular
exercise program should undergo some form of screening
to minimize complications. This is a must in secondary
prevention patients.
With respect to exercise prescriptions, the symptomlimited exercise test is conducted to provide far more
information than the simple presence or absence of
significant ST segment changes on the electrocardiogram
or exertional angina. The MET level, the rate-pressure

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product at the onset of ST changes or symptoms, along with


the heart rate and blood pressure response to exertion, the
peak METS, and/or the onset or exacerbation of arrhythmias, are all key parameters to be considered when doing
and exercise prescription. Also, in secondary prevention
patients, it is important to consider the medications on the
exercise response. In this regard, although to determine the
prognosis of CHD it is desirable that patients withhold betablockers and nitrates prior to the stress test, to evaluate the
hemodynamic and chronotropic response during exercise it
is preferable to have patients taking all the medications as
normally prescribed prior to the graded stress test [34].
Another important aspect to have in mind when interpreting
the initial stress test is that most standard normograms used
to estimate the peak functional capacity from time and
workload are based on young and healthy individuals
without medications and exercising without holding into
the treadmill bars. Therefore, a significant over-prediction
of functional capacity can occur in the older and sicker
patient. Peak functional capacity can be overestimated by
up to 31% if patients are allowed to pull or hold onto the
front handrail. Therefore, it is recommended that the patient
walks trying to only slightly touch the handrail. If this is not
possible, in the everyday practice, one should subtract at
least 1 MET from the peak functional capacity to calculate
the prescription. When the patient is ready to begin the CR
program, the specific components of the program can be
addressed [35]. Every activity session should be composed
of a warm-up period, conditioning, and a cool-down period.
The warm-up period starts the exercise session and includes
static and range-of-motion stretches as well as low-level
aerobic activity at 25%40% of the patients functional
capacity. This period should last 515 min and is intended
to avoid orthopedic injuries and allow the hemodynamic
and physiologic adaptations to exertion. The conditioning
period, which is the most important, should address six key
factors to complete the exercise prescription:
1. Frequency: recent guidelines recommend that exercise
be done on most days of the week for cardiovascular
benefits, overall risk reduction, and weight management. In general, activity must be performed at least
3 days per week. At lower levels of fitness, the
frequency of activity may be increased to 57 days/
week to achieve a higher caloric expenditure.
2. Intensity: this is the hardest area to prescribe. It has
been recommended that the exercise be performed at a
moderate intensity. The general approach is to set the
intensity between 50% and 80% of peak oxygen
consumption, or 40%85% of METS predicted, or of
a peak heart rate or 40%60% of heart rate reserve
([peak heart rate resting heart rate] x 0.6 + resting
heart rate). But intensity can also be determined based

3.
4.

5.

6.

on a subjective approach, according to the patients


perception of exertion. This method is called the Rating
of Perceived Exertion (RPE) scale or Borgs scale [36].
The scale provides numeric values according to the
level of exertion perceived by the patient for a given
activity. There are two scales: the older, linear 620
point scale based on the relationship between heart rate
and perceived exertion, and the newer, logarithmic
scale ranging from 0 to 10. Both are used and correlate
well with the relative level of exertion.
Mode: the recommendation is aerobic or rhythmical
activity, repetitive in nature and using large muscle
groups, satisfying the intensity requirement.
Duration: at least 2030 min (preferably 4560 min).
One of the goals of most exercise programs is to
increase the weekly caloric expenditure, targeting
2000 kcal/week. Also, shorter accrued sessions (a
minimum of 15 min per time) can be performed,
achieving the same benefits than longer sessions. Rate
of progression will depend on the patients past history,
level of conditioning, comorbidities, and age.
Compliance: the key to an exercise training program is
that the physical activity is performed in the long-term.
The compliance rate in CR programs in United States is
50%75% after 6 months.
Finally, the activity session concludes with a cool down
period of between 3 and 10 min, during which the body
transits from the vigorous conditioning period to rest.
This period should not be terminated abruptly, but
gradually. This prevents venous pooling, hypotension,
and an abrupt catecholamine surge that may cause
arrhythmias.

Resistance Exercise
Resistance training refers to training designed to increase
strength, power, and muscle endurance by lifting weight
[7]
Exercise programs have emphasized dynamic lowerextremity exercise. However, mild to moderate resistance
training can provide an effective method for improving
muscular strength and endurance, preventing and managing
several medical conditions, modifying cardiovascular risk
factors, and enhancing psychosocial well-being. Also, this
type of exercise has demonstrated to attenuate the ratepressure product for any load that is lifted [30]. Strength
training is especially important for the frailest patients who
may have difficulty performing aerobic training because of
leg weakness. CHD patients should perform this training
with caution, and close monitoring of adverse cardiovascular signs and symptoms should be pursued. Unfortunately,
there is a lack of data on resistance exercise training

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studies. The current general recommendations for training


regimes include using 30%40% of the 1-repetition maximum
for the upper body and 40%50% of the 1-repetion maximum
for the lower body exercises, with 1215 repetitions in 1 set
repeated two to three times weekly [7, 35].

Barriers to Participation in Cardiac Rehabilitation


As previously mentioned, the participation of coronary
patients in CR is scarce.
Although few prospective studies have reported on the
potential barriers to CR participation, some of the obstacles that
have been mentioned are lack of physician referral, lack of health
insurance, low education level, depression, social deprivation,
low socioeconomic status, dependent spouse at home, lack of
transportation, lack of motivation, reduced self-efficacy, and
perception of CR as inconvenient or unnecessary [3740].
In a prospective study by Dunlay et al. [41] among 179
subjects presenting with acute MI, 132 were referred to CR
and 115 participated. CR participants were younger than
non-participants and more frequently were men. Some of the
characteristics associated with CR participation were STelevation MI, presence of reperfusion therapy, in-hospital
care by cardiologist, and referral to CR. The most important
psychosocial predictors of participation included the perception of CR as important and necessary, a better health
perception prior to the MI, the ability to drive, and postsecondary education. On the other hand, diabetic patients
and those with a prior MI or having previously attended a
CR program were less likely to participate. When all the
predictors were entered in a model, four factors emerged as
independent predictors of CR participation (c statistic of
0.898): age, reception of reperfusion therapy, referral to CR
while in the hospital, and perceived need of CR. Worcester et
al. [42] made a similar analysis but differentiated by gender.
They concluded that three factors were significant and
independent predictors of non-attendance among men,
namely age, diagnosis, and ability to drive. Among women,
the only significant and independent predictor was age.
When promoting patient uptake and adherence in CR,
Davies et al. [43] reports there is some evidence suggesting
that interventions involving motivational communications,
such as letters, telephone calls, and home visits, as well as
case-management by nurses, may be effective in increasing
participation in CR. Individually tailored approaches are
recommended to increase the likelihood of success.

Cost-Effectiveness of Cardiac Rehabilitation


CR has proven to be cost-effective in both trials and
systematic reviews. Hambrecht et al. [18] have even

reported that a 12-month program of regular physical


activity is more cost-effective than PCI. The costeffectiveness, however, seems to depend on the patients
cardiac risk level, the reason for referral, and the patients
demographic characteristics [44, 45, 46]. Hall et al. [47],
for example, compared formal CR after MI to early return
to normal activities without CR, with the latter being more
cost-effective in low-risk patients. Furthermore, it has also
been suggested that CR is more cost-effective for men than
for women [48]. The cost-effectiveness is also influenced
by the perspective of the analysis, as shown by Oldridge et
al. [49], who reported that cardiac rehabilitation is costeffective from a community perspective and highly costeffective from the perspective of patients.
In economic terms, Briffa et al. [50] reported an
Incremental Cost Utility Ratio of $45,000 per quality of
life-year saved when comparing comprehensive CR relative
to standard care, although with large variations in the
sensitivity analysis.

Conclusions
CR and exercise are key components of secondary
prevention programs in patients with cardiovascular disease.
Physical activity not only confers cardiovascular benefits,
such as the improvement in exercise tolerance, cardiac
symptoms, blood lipids, and reduction in cigarette smoking,
but also promotes a better quality of life. Unfortunately, there
is still a need for more randomized trials to clearly confirm the
role of exercise therapy alone or as part of CR in reducing
cardiac mortality in CHD and heart failure patients. Health
agendas must advocate for CR programs to be included in the
care of all CHD patients.

Disclosure No conflicts of interest relevant to this article were


reported.

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