Cardiac rehabilitation services

Cardiac rehabilitation is a structured set of services that enables people with coronary heart disease (CHD) to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society.

The World Health Organization has defined cardiac rehabilitation as:

'the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible, physical, mental and social conditions, so that they (people) may, by their own efforts preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within secondary prevention services of which it forms only one facet'.^[1]

Cardiac rehabilitation is recommended in NICE clinical guideline 48 on myocardial infarction (MI): secondary prevention as an appropriate intervention for people following a hospital admission for MI. This supports the National service framework for coronary heart disease which sets the standard that:

'NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life'.

The National service framework for coronary heart disease established a goal that every hospital should ensure that more than 85% of people discharged from hospital with a primary diagnosis of acute MI or after coronary revascularisation are offered cardiac rehabilitation. It is also recommended in NICE clinical guideline 94 on unstable angina and non-ST-segment-elevation MI (NSTEMI). NICE clinical guideline 108 on chronic heart failure published in 2010 makes a new recommendation supporting cardiac rehabilitation for people with chronic heart failure.

There is evidence that exercise-based cardiac rehabilitation:

Traditionally the provision of cardiac rehabilitation has been described using phases 1 to 4 as mentioned in the National Service Framework for coronary heart disease (chapter 7). A more recent approach within the Department of Health's commissioning pack on cardiac rehabilitation describes cardiac rehabilitation along a best practice care pathway using stages 0 to 6 to reflect core stages in the cardiac rehabilitation pathway (see section 2 of this guide).

Cardiac rehabilitation should be offered as a comprehensive package, including exercise, education and psychological support. It should not be regarded as an isolated form or stage of therapy, but be integrated within secondary prevention services. Cardiac rehabilitation services are no longer exclusively hospital based; emphasis is placed on helping patients become active self-managers of their condition. This can involve hospital-, home- and community-based cardiac rehabilitation programmes. Evidence suggests that home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of life outcomes in acute MI and revascularisation patients^[5]. Collaboration between primary and secondary care services is vital in order to achieve the best cardiac rehabilitation outcomes.

Currently, many people who might benefit do not receive adequate cardiac rehabilitation. The National Audit of Cardiac Rehabilitation 2010 indicates that referral to cardiac rehabilitation was almost entirely restricted to people in one of three diagnostic groups: those who had sustained a heart attack (MI, 39%), elective angioplasty (percutaneous coronary intervention [PCI], 28%) or coronary artery bypass surgery (CABG, 76%). Only 1% of patients recorded in the audit had a diagnosis of heart failure. The extent, nature and cost of provision varies dramatically around the country, with some services developing in a haphazard way with no core funding and relying on charitable donations and time 'borrowed' from various hospital departments.

There are also marked inequalities in the way people access the available services. Women, minority ethnic groups, the elderly and people with more severe CHD are all under-represented among users of rehabilitation services^[6]. Furthermore, in many parts of the country those that are ready to start a rehabilitation programme may have to wait for several weeks^[7].