The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management

Abstract

Aim: This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades. Methods: A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s. Results: Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important. Conclusions: In light of these results, an emerging focus for CR, and in some cases "pre-habilitation", is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19. ä IMPLICATIONS FOR REHABILITATIONWith continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme. Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients. The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.

How to Facilitate Adherence to Cardiac Rehabilitation in Primary Health Settings for Ischaemic Heart Disease Patients. The Perspectives of Health Professionals

“…CR aims to provide cardiac patients with the best possible conditions mentally, physically and socially in order for them to resume or preserve a normal life (4). CR is a multi-faceted disease management programme that may reduce rehospitalisation, all-cause mortality, cardiac mortality and activity-related symptoms while improving functioning (5)(6)(7)(8).…”

Towards a framework for the scale-up of rehabilitation for patients with non-communicable disease in low-resource settings

“…Firstly, integration of rehabilitation care for multiple conditions simultaneously to address multimorbidity or converging burdens of disease. (24) Secondly, integration of rehabilitation care with other social domains that therefore can target social determinants of health. (25) Thirdly, integration of rehabilitation within primary care.…”

Historical Context of Cardiac Rehabilitation: Learning From the Past to Move to the Future

“…These programs started primarily as an inpatient model but eventually progressed to outpatient programs that involved supervised physical activity sessions requiring a low-level of oxygen demand ( 13 ). As identified by Buckley, the standard approach to “rehabilitation” at this time focused on exercise with only a few some programs addressing psycho-social care ( 22 ). In Canada, early research found that men with CHD could safely participate in supervised exercise programs after MI with a small group training for and completing the Boston Marathon ( 23 , 24 ).…”