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(Circulation. 2007;115:2675-2682.)
© 2007 American Heart Association, Inc.

AHA/AACVPR Scientific Statement

Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update

A Scientific Statement From the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation

Gary J. Balady, MD, FAHA, Chair; Mark A. Williams, PhD, Co-Chair; Philip A. Ades, MD; Vera Bittner, MD, FAHA; Patricia Comoss, RN; JoAnne M. Foody, MD, FAHA; Barry Franklin, PhD, FAHA; Bonnie Sanderson, RN, PhD; Douglas Southard, PhD, MPH, PA-C

	Abstract

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The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation recognize that all cardiac rehabilitation/secondary prevention programs should contain specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance to these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular disease. This update to the previous statement presents current information on the evaluation, interventions, and expected outcomes in each of the core components of cardiac rehabilitation/secondary prevention programs, in agreement with the 2006 update of the American Heart Association/American College of Cardiology Secondary Prevention Guidelines, including baseline patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counseling and exercise training.

Key Words: AHA Scientific Statements • prevention • rehabilitation

Cardiac rehabilitation/secondary prevention programs are recognized as integral to the comprehensive care of patients with cardiovascular disease^1,2 and as such are recommended as useful and effective (Class I) by the American Heart Association (AHA) and the American College of Cardiology in the treatment of patients with coronary artery disease^3–5 and chronic heart failure.⁶ Consensus statements from the American Heart Association,¹ the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR),⁷ and the Agency for Health Care Policy and Research² conclude that cardiac rehabilitation programs should offer a multifaceted and multidisciplinary approach to overall cardiovascular risk reduction and that programs that consist of exercise training alone are not considered cardiac rehabilitation. The AHA and the AACVPR recognize that all cardiac rehabilitation/secondary prevention programs should contain specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular disease.⁸

This update to the previous statement⁸ aims to present current information on the evaluation, interventions, and expected outcomes in each of the core components of cardiac rehabilitation/secondary prevention programs in agreement with the 2006 update of the AHA/American College of Cardiology (ACC) secondary prevention guidelines,⁹ including baseline patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counseling and exercise training (Tables 1 and 2).^2,7,9–25 The most notable updates in the present statement are the changes in lipid goals and strategies to attain them and a new emphasis on ensuring that patients are taking the appropriate medications that have been shown to be of substantial benefit in reducing subsequent adverse cardiovascular events. Inherent to these recommendations is the understanding that successful risk factor modification and the maintenance of a physically active lifestyle is a lifelong process. Hence, incorporation of strategies to optimize patient adherence to lifestyle and pharmacological therapies is integral to the attainment of sustained benefits. It is essential to the success of any program that each of these interventions is performed in concert with the patient’s primary care provider and/or cardiologist, who will subsequently supervise and refine these interventions over the long term.¹⁰ These recommendations are intended to assist cardiac rehabilitation staff in the design and development of programs and to assist healthcare providers, insurers and policy makers, and consumers in the recognition of the comprehensive nature of such programs. In turn, insurance providers and third-party payers should provide adequate reimbursement for cardiac rehabilitation/secondary prevention programs such that comprehensive interventions delivered by a multidisciplinary team of professionals can be sustained. It is not the intent of this statement to promote a rote approach or homogeneity among programs but rather to foster a foundation of services on which each program can establish its own specific strengths and identity and effectively attain outcome goals for its target population. Presently, these core components are an integral part of the national program certification process established by the AACVPR (http://www.aacvpr.org/certification/). As such, programs certified by the AACVPR are recognized as meeting essential standards of care in keeping with the contemporary definition of cardiac rehabilitation as a secondary prevention program. The AHA and AACVPR encourage all cardiac rehabilitation/secondary prevention programs to meet the standards for AACVPR program certification.

View this table: [in this window] [in a new window]   TABLE 1. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: Patient Assessment, Nutritional Counseling, and Weight Management

View this table: [in this window] [in a new window]   TABLE 1. Continued

View this table: [in this window] [in a new window]   TABLE 2. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: Blood Pressure Management, Lipid Management, Diabetes Management, Tobacco Cessation, Psychosocial Management, Physical Activity Counseling, and Exercise Training

View this table: [in this window] [in a new window]   TABLE 2. Continued

View this table: [in this window] [in a new window]   TABLE 2. Continued

View this table: [in this window] [in a new window]   TABLE 2. Continued

Comprehensive and detailed guidelines on cardiac rehabilitation/secondary prevention programs have been published by the AACVPR⁷ and endorsed by the AHA. Detailed guidelines on specific risk factor modification are also available.^9,11–20 Specific details on management of patients with heart failure, valvular disease, arrhythmias, and other cardiovascular diagnoses in such programs are beyond the scope of this document and can be found in the AACVPR guidelines.⁷

	Disclosures

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View this table: [in this window] [in a new window]   Writing Group Disclosures

View this table: [in this window] [in a new window]   Reviewer Disclosures

	Footnotes

 
The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 11, 2006, and by the American Association of Cardiovascular and Pulmonary Rehabilitation on June 22, 2006.

This article has been copublished in the May/June issue of the Journal of Cardiopulmonary Rehabilitation.

Copies: This document is available on the World Wide Web sites of the American Heart Association (www.americanheart.org) and of the American Association of Cardiovascular and Pulmonary Rehabilitation (www.aacvpr.org). A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0394. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the "Permission Request Form" appears on the right side of the page.

	References

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1. Leon S, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, Thompson PD, Williams MA, Lauer MS. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation [published correction appears in Circulation. 2005;111:1717]. Circulation. 2005; 111: 369–376.[Abstract/Free Full Text]
   
2. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CME, Dattilo AM, Davis D, DeBosk RF, Drozda JP, Fletcher BJ, Franklin BA, Gaston H, Greenland P, McBride PE, McGregor CGA, Oldridge NB, Piscatella JC, Rogers FJ. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agencies for Health Care Policy and Research, and the National Heart, Lung, and Blood Institute. AHCPR publication No. 96-0672. October 1995.
   
3. Antman EM, Anbe ST, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr; American College of Cardiology; American Heart Association; Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) [published correction appears in J Am Coll Cardiol. 2005;45:1376]. J Am Coll Cardiol. 2004; 44: 671–719.[Free Full Text]
   
4. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC Jr. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002; 40: 1366–1374.[Free Full Text]
   
5. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O’Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003; 107: 149–158.[Free Full Text]
   
6. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005; 112: 1825–1852.[Free Full Text]
   
7. American Association for Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, Ill: Human Kinetics Publishers; 2004.
   
8. Balady GJ, Ades PA, Comoss P, Limacher M, Piña IL, Southard D, Williams MA, Bazzarre T. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000; 102: 1069–1073.[Free Full Text]
   
9. Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute [published correction appears in Circulation. 2006;113:e-847]. Circulation. 2006; 113: 2363–2372[Free Full Text]
   
10. King ML, Williams MA, Fletcher GF, Gordon NF, Gulanick M, King CN, Leon AS, Levine BD, Costa F, Wenger NK. Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: a scientific statement from the American Heart Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005; 112: 3354–3360.[Free Full Text]
    
11. Sanderson BK, Southard D, Oldridge N. AACVPR consensus statement: outcomes evaluation in cardiac rehabilitation/secondary prevention programs: improving patient care and program effectiveness. J Cardiopulm Rehabil. 2004; 24: 68–79.[CrossRef][Medline] [Order article via Infotrieve]
    
12. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106: 3143–3421.[Free Full Text]
    
13. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ; for the Coordinating Committee of the National Cholesterol Education Program, endorsed by the National Heart, Lung, and Blood Institute, American College of Cardiology Foundation, and American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines [published correction appears in Circulation. 2004;110:763]. Circulation. 2004; 110: 227–239.[Abstract/Free Full Text]
    
14. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report [published correction appears in JAMA. 2003;290:197]. JAMA. 2003; 289: 2560–2572.[Abstract/Free Full Text]
    
15. Fiore MC, Bailey WC, Cohen SJ; for expert panel. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service. October 2000.
    
16. Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998; 158: 1855–1867.[Free Full Text]
    
17. American Diabetes Association. Standards of medical care for patients with diabetes mellitus [published correction appears in Diabetes Care. 2003;26:972]. Diabetes Care. 2003; 26 (suppl 1): S33–S50.[CrossRef][Medline] [Order article via Infotrieve]
    
18. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. American Diabetes Association. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006; 29: 1433–1438.[Free Full Text]
    
19. Thompson PD, Buchner D, Piña IL, Balady GJ, Williams MA, Marcus BH, Berra K, Blair SN, Costa F, Franklin B, Fletcher GF, Gordon NF, Pate RR, Rodriguez BL, Yancey AK, Wenger NK. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003; 107: 3109–3116.[Free Full Text]
    
20. Grundy SM, Pasternak R, Greenland P, Smith S Jr, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 1999; 100: 1481–1492.[Free Full Text]
    
21. American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. 7th ed. Baltimore, Md: Williams & Wilkins; 2006.
    
22. Piña IL, Apstein CS, Balady GJ, Belardinelli R, Chaitman BR, Duscha BD, Fletcher BJ, Fleg JL, Myers JN, Sullivan MJ. Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation. 2003; 107: 1210–1225.[Free Full Text]
    
23. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116: 682–692.[CrossRef][Medline] [Order article via Infotrieve]
    
24. Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, Eckel RH. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006; 113: 898–918.[Abstract/Free Full Text]
    
25. US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002; 136: 760–764.[Abstract/Free Full Text]
    

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This Article Free upon publication Abstract Full Text (PDF) All Versions of this Article: 115/20/2675    most recent CIRCULATIONAHA.106.180945v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Balady, G. J. Articles by Southard, D. Search for Related Content PubMed PubMed Citation Articles by Balady, G. J. Articles by Southard, D. Related Collections Secondary prevention Exercise/exercise testing/rehabilitation