Best Practice Guidelines Services for Cardiac ...

1 Best Practice Guidelinesfor Cardiac Rehabilitationand secondary PreventionPRODUCED BY THE HEART RESEARCH CENTRE ONBEHALF OF DEPARTMENT OF HUMAN Services VICTORIAH umanServicesVictoriaBackground to Heart Research Centre and authorsThe Heart Research Centre was established in 1989 with three year seeding fundingfrom the National Heart Foundation of Australia. It became an independent centre in1993 and is now affiliated with The University of Melbourne and La Trobe Heart Research Centre conducts research into Cardiac rehabilitation and theprevention of heart disease, especially their psychological, behavioural and socialaspects.

2 The Centre also conducts training programs for health Alan Goble is a practising clinical cardiologist, with a longstanding interest incardiac rehabilitation . He is a member of the Expert Advisory Panel onCardiovascular Diseases of the World Health Organisation, and a member and past-chairman of the Council on rehabilitation and prevention of the World HeartFederation. He is Chairman of the Board of the Heart Research Marian Worcester has a doctorate in social and preventive medicine and aMaster s degree in criminology.

3 She has a particular interest in psychologicalresponses to acute illness and social support. She has been Director of the HeartResearch Centre since its Best Practice Guidelines for Cardiac rehabilitation and secondary Preventionare dedicated to the late Dr John Shaw, former director of the National HeartFoundation of Australia, for his support of the Heart Research Centre, and tocardiologists, Dr Robert Goodwin and Dr W Anthony Seldon for their contributionsto the development of Cardiac rehabilitation in Practice GUIDELINESFOR Cardiac REHABILITATIONAND secondary PREVENTIONHEART RESEARCH CENTREP rincipal AuthorsAlan J Goble, MD, FRCP, FRACPM arian U C Worcester, PhD.

4 MAProduced on behalf of Department of Human Services VictoriaBEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONiiBest Practice Guidelines for Cardiac rehabilitation and secondary PreventionGoble AJ & Worcester MUCH eart Research CentreACN 060 479 763A company limited by guaranteeLygon Court, 333 Drummond Street, Carlton, Victoria 3053 AustraliaPO Box 607, Carlton South, Victoria 3053 AustraliaTelephone (613) 9347 5544 Facsimile (613) 9347 6964 Email Website ~heart/Published by Department of Human Services VictoriaApril 1999 ISBN.

5 0 7311 5258 1 Designed by Outsource Design (03) 9645 5220 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONiiiFOREWORD xiiiFOREWORDxivINTRODUCTIONxvPREFACExviE XECUTIVE SUMMARY xviiiCHAPTER 11 Development of the Best Practice GuidelinesIntroduction1 Terms of reference2 Clinical Practice Guideline of the United States Agency forHealth Care Policy and Research3 Development of the Best Practice Guidelines3 Evidence from meta-analyses5 Strength of evidence rating systems5 United States Agency for Health Care Policy and Research6 National

6 Health and Medical Research Council of Australia6 Consultative Committee7 Survey of current programs in Victoria8 Focus groups with health care providers8 Comparative study of four model programs8 CHAPTER 29 Cardiac rehabilitation and secondary prevention : definitionsCardiac rehabilitation9 secondary prevention10 Phases of Cardiac rehabilitation11 Inpatient rehabilitation (Phase 1)11 Ambulatory outpatient rehabilitation (Phase 2)11 Maintenance (Phase 3)12 CONTENTSBEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONivCHAPTER 313 Cardiac rehabilitation and secondary prevention .

7 Historical backgroundUnited States of America13 Australia14 Europe15 United Kingdom15 Asia15 Participation in programs16 CHAPTER 417 The burden of cardiovascular diseaseCHAPTER 523 Recent Practice Guidelines and policy statementsScientific review23 United States Agency for Health Care Policy and Research23 Other Guidelines and statements23 American Association of Cardiovascular and Pulmonary Rehabilitation23 British Association of Cardiac Rehabilitation23 American College of Sports Medicine24 British Cardiac Society24 American Heart Association24 American College of Physicians24 rehabilitation Systems in Europe24 European Society of Cardiology24 National Heart Foundation of Australia25 World Health Organisation25 CHAPTER 627 Review of Clinical Practice Guideline No 17 Cardiac rehabilitation (1995)

8 US Agency for Health Care Policy and ResearchExercise training29 Education, counselling and behavioural interventions30 Organisational issues30 CHAPTER 731 Exercise training in Cardiac rehabilitationMeta-analyses31 Ambulatory (convalescent) Cardiac rehabilitation trials32 Longterm exercise studies where exercise training alone is comparedwith standard medical care32 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONvLongterm multifactorial interventions compared with standard medical care32 Comparisons of high and low intensity exercise training32 The benefits of exercise training33 Physical performance33 Exercise tolerance33 Muscular strength34 Symptoms34 Psychological functioning35 Social adaptation and functioning35

9 Return to work36 Major risk factors37 Lipids37 Smoking habit37 Body weight38 Blood pressure38 Subsequent exercise habits39 Morbidity, recurrent events, hospital readmissions and mortality40 Conclusions41 CHAPTER 842 The amount of exercise trainingIntensity of exercise training42 Categorisation of exercise intensity44 Low intensity exercise44 Moderate intensity exercise45 High intensity exercise45 Measuring exercise intensity46 Heart rate46 Determination of training heart rate from exercise stress test46 Determination of training heart rate from formula47 Formula-based percentage of maximal heart rate48 Formula-based percentage of heart rate reserve48 Perceived

10 Exertion49 Frequency of exercise sessions and duration of program49 Frequency of sessions50 Duration of program51 Home exercise programs52 Continued exercise beyond convalescence53 Eligibility for exercise programs55 Exclusion from exercise training55 BEST Practice Guidelines FOR Cardiac rehabilitation AND secondary PREVENTIONviCHAPTER 957 Risk stratificationHigh risk groups57 Technological assessment of risk58 Clinical assessment of risk58 Conclusions59 CHAPTER 1060 Conducting exercise programsSite of exercise program60 Safety protocols61 Equipment62 Content of exercise classes62 Staffing63 Staff to patient ratio64 Exercise testing before exercise training64 Patient assessment before entry to the program65 Time of starting the exercise program66 Monitoring during exercise sessions66 Exercise testing after exercise training67 High intensity exercise training68 CHAPTER 1169 Exercise programs for specific groupsPatients with heart failure and transplantation69 Patients with pacemakers and implantable cardioverter