REVIEW

Efficacy of Cardiac Rehabilitation Services

With Emphasis on Patients After Myocardial Infarction
Philip Greenland, MD; and Joyce S. Chu, MD

During the 1970s, emphasis increased in clinical practice on

early ambulation and exercise-based rehabilitation after
myocardial infarction and other cardiac illnesses or procedures. This shift was based on the belief lhat exercise and
improved conditioning would improve prognosis. We examine the evidence supporting this assertion. Most of the reports on cardiac rehabilitation are about patients who have
coronary artery disease and a history of myocardial infarction. The review, therefore, is focused primarily on Ihe patient who has had a myocardial infarction. Effects of cardiac
rehabilitation, emphasizing exercise treatment and conditioning, are reviewed with regard to patient oulcomes, including changes in functional (work) capacity, psychosocial
functioning and health-related knowledge, risk factor modification, morbidity and mortality, and cardiac function. The
safety of cardiac exercise programs is reviewed, and the use
of telemetry monitoring is considered. We also discuss the
role of cardiac rehabilitation in categories of patients oiher
than those with myocardial infarction and the application of
newer approaches to rehabilitaiion such as programs based
in the patient's home.

for patients with stable angina pectoris, chronic arrhythmias, congestive heart failure, valvular heart disease, or other heart disorders. A nearly universal, central component of cardiac rehabilitation is a prescribed
regimen of physical exercise, primarily intended to improve functional work capacity and secondarily intended to increase the patient's confidence and wellbeing. Other interventions may include psychological
counselitig, dietary instruction for weight control,
blood lipid reduction, or both, vocational counseling,
and group support meetings. Intensity and duration of
exercise vary considerably among programs, and endpoints are widely disparate. Because the goals of rehabihtation can be exceedingly broad and open-ended, -A
critical review of the published articles on the benefits
and risks of cardiac rehabilitation services is needed to
define pohcies for selection of participants, and for
duration, frequency, and content of programs. This
review is organized according to disease categories
with primary emphasis on the role of cardiac rehabilitation after myocardial infarction. Program goals and
components are examined individually.

Annals of Internal Medicine. 1988:109:650-663.

From the University of Rochester School of Medicine and
Dentistry, Rochester, New York. For current author addresses, see end of text.

2. Methods

[Note that sections in this review are numbered so that

can be identilied with cross-references us supporting
dence in the article, "Cardiac Rehabilitation Services, "
lished in the Position Paper section of this i.^suc: see
671-673. The Editor]

they
evipubpases

1. Oardiac rehabilitatioti is defined as the process by

which patietits with cardiac disease are restored to
their optimal physical, medical, psychological, social,
emotional, vocational, and economic status (1). In the
i970s. widespread acceptance of exercise conditioning
for the patient with cardiac disease led to the development of many medically supervised, exercise-based rehabilitation programs. The emphasis on exercise and
early ambulation was a change in the care of patients
with cardiac disease (2), based on the belief that exercise and conditioning would improve prognosis. We
will examine the evidence that supports this belief.
Cardiac rehabilitation is frequently offered as a
comprehensive package of services for patients who
have had a myocardiaJ infarction, coronary artery bypass surgery, angioplasty, or heart transplantation, or
650

Annals of Internal Medicim; 15 October 1988

We used the MEDLARS database to identify articles

oti cardiac rehabilitation from 1976 through 1986. The
bibliographies of research papers or review articles
thus identified were also scatmed to facilitate review of
papers published before 1976 as well as papers referenced but not found in the computerized search. In
reviewing research reports, our primary focus was on
the quality of the data presented, including study design, sample size, pertinence of the endpoints, and
clarity of presentation of the intervention procedures.
3. Rehabilitation after Myocardial Infarction
3.1 Functional Capacity
Impairment in exercise capacity after myocardial infarction is due both to infarct-related damage to the
myocardium as well as to the deconditioning effects of
bedrest and physical inactivity. Gradual improvement
in physical exercise capacity after myocardial infarction typically occurs even in the absence of a formal
exercise training program. For example, Wohl and
colleagues (3) studied 50 patients (43 men and 7
women), aged 29 to 67 (mean, 52.8), a! 3 weeks, 6
weeks, 3 months, and 6 motiths after an uncomplicated myocardial infarction. Patients were encouraged to
engage in physical activity after hospitalization as tol(f) 1988 American College ol" Physicians

Table 1. Effects of Supervised Exercise Programs Shortly after Myocardial Infarction on Physical Work Capacity in
Controlled Studies (4-11)
Study (Reference)

DeBuskel al. (4)

Exercise
Control
Miller etal. (5)
Exercise
Control
Carson et al. (6)
Exercise
Coniroi
Hunget al. (7)
Exercise
Control
Wilhelmsen et al. {8)||
Exercise
Control

Patients

Work Capacity
afler Program

Capacity before Program

(Weeks after Myocardial
Infarction)

P Value

28
30

6.8 1.7 METS*(3)

6.7 + 1.4METS*(3)

Nol significant

61
34

6.5METS-(3)
6.0METS'{3)

Not significant

12.5 + 0.5 min (6)

11.5 0.5 min (6)

Not statedt

17.5 min
13.0 min

607 180

Nol significant

750 t64 kpm/min

i5I
152
23
30

114
88

10.4 2.2 METS*

8.9 2.0 METS*
8,5 METS'
7.0 METS"

P Value

Program
Lenglh

< 0.05

8 wk

< 0.001

8 wk

"Significant"

.1 mo

0.01

8wk

626 139 kpm/min

596 162
kpm/min (3)
'"20% increase in
cycle time from 3
mo-12 mo"
"No change in cycle
lime, 3-12 mo"

9 mo

lyr

Paterson et ai. (9)

High-intensity exercise

37

Low-intensity exercise

42

15% increase in VO2

max in highintensity group
after 1 yr.
No change in VO2
max after 1 year in
low-intensity
group

84
83

673 kg min -1(6)

635 kgmin-i(6)

Not significant

883 kg min '

673 kg min-'

< 0.001

8-9 wk

tl L/min (8)
U L/min (8)

Not significant

15 L/min
12 L/min

'Significant'"

4 mo

Marra et ai. (10)

Exercise
Control
Roman et al. (1 i)
Exercise
Control

93
iOO

A MET is a multiple of the resting energy expenditure; 1 = 3.5 mL O^/kg body weight
t Cycling.
X kpm/min = kiiopond meters/minute (kilogram-weight meter/minute).
BicyclingII Men only.

erated, but no formal exercise rehabilitation program

was offered. Workloads were measured by serial bicycle exercise testing and reported in kiiopond meters/
minute (kpm/min) (kilogram-weight meter/minute). All testing, except the 3-week test, was discontinued at the onset of clinically limiting symptoms. Functional capacity increased spontaneously an average of
22% from 3 to 6 weeks after myocardial infarction in
the 25 patients with initial maximal tests and by a
total of 46% from 3 weeks to 6 months after myocardial infarction (from 334 kpm/min to 488 kpm/min).
DeBusk and associates (4) reported similar evidence of spontaneous improvement in physical exercise capacity in a group of 30 men studied by serial
exercise treadmill tests at 3, 7, and 11 weeks following
uncomplicated myocardial infarction. Patients were
less than 70 years of age (mean, 54) and were referred
from a university hospital and from community hospitals. Exercise capacity was defined at each testing by
the onset of cardiac symptoms or fatigue. Peak workload was estimated at each test on the basis of treadmill speed and grade and was reported in METS. (A
MET is defined as a multiple of the resting oxygen
consumption and is frequently used as a means of esti-

mating functional capacity in cardiac studies. One

MET is approximately equivalent to 3.5 mL of oxygen
per minute per kilogram of body weight.) Despite the
absence of a supervised program, 60% of the "no
training" group reported a return to an activity level
of that before the infarction by 11 weeks after infarction. Peak workload in the no-training group increased from 6.7 1.4 METS at 3 weeks to 8.2 1.9
METS at 7 weeks and to 8.9 2.0 METS at 11
weeks. Studies like these by Wohl and colleagues (3)
and DeBusk and colleagues (4) indicate that patients
without complications may achieve physical work capacity levels comparable to those of healthy sedentary
men.
A number of randomized and controlled studies
have addressed the question of whether a supervised
exercise training program improves physical work capacity more than would be expected spontaneously
(Table 1). The study by DeBusk and associates (4) is
worth detailed discussion because it is particulary well
designed and clearly presented. Patients after an uncomplicated myocardial infarction were randomly assigned to a gymnasium-trained group (n ^ 28) and
were compared to a no-trained group (n ^ 3 0 ) . A

Cardiac Rehabilitation

651

Table 2. Approximate Energy Requirements of Selected Activities (12) *

Category
Very light
< 3 METSt
< lOmL/kg.min
< 4 kcal

Light
3-5 METS
11-18 mL/kgmin
4-6 kcal

Moderate
5-7 METS
18-25 mL/kg mm
6-8 kcal

Heavy
7-9 METS
25-32 niL/kg min
8-10 kcal
Very heavy
> 9 METS
> 32 mL/kg.min
> 10 kcal

Seif-Care or Home
Washing, .shaving, dressing
Desk work, writmg
Washing dishes
Driving auto

Oceupalional

Recreational

Physiciil Condilioning

Sitiing (clerical.
assembly)
Standing (slore flerk,
bartender)
Driving truck
Operating era tie

Shulfleboard
Horseshoes
Bait casting
Billiards
Archery
Golf (cart)

Walking (2 niph)
Slatioiiary bicycle
(very low rcsisiancel

Cleaning windows
Raking leaves
Weeding
Power lawn mowing
Waxing floors (slowly)
Painting
Carrying objects (15-31) Ib)

Slocking shelves
(light objects)
Light welding
Light carpentry
Machine assembly
Auto repair
Paper banging

Dancing (social
and square)
Golf (walking)
Sailing
Horseback riding
Volleyball (6 man)
Tennis (doubles)

Walking (3-4 mph)

Level bicycling
(6-S mph)
Light calisthenics

Easy digging in garden

Level hand lawn mowing
Climhing stairs (slowly)
Carrying objects (30-60 Ib)

Carpentry (exterior
home building)
Shoveling dirt
Using pneumatic lools

Baciniinion
(competiiive)
Tennis (singles)
Snow skiing (downhill)
Light backpacking
liaskeibal!
Football
Skating (ice atid roller)
Horseback riding (gallop |

Walking (4.5-5 mpii]

Bicycling (9-10 mph)
Swimming (breast
stroke)

Sawing wood
Heavy shoveling
Climbing stairs (moderate speed)
Carrying objects (60-90 Ib)

Tending furnace
Digging ditches
Pick and sliovel

Canoeing
Mountaiti climbing
Fencing
Paddleball
Touch football

Jog (5 mph)
Swim (crawl stroke)
Rowing machine
Heavy calisthenics
Bicycling (12 mph)

Carrying loads upstairs

Carrying objects ( >TOIb)
Climbing stairs (quickly)
Shoveling heavy snow
Shoveling 10 min (16 Ib)

Lumberjack
Heavy laborer

Handball
Squash
Ski touring over hills
Vigorous bnsketbali

Running ( > 6 mph)

Ricycle ( > Ll mph or
up steep hill)
Kopejumping

Very lighl calisthenics

Reference 12, reprinted by permission of publisher.

t A MET is a multiple of the resting energy e?;penditure; 1 MET ^ approximately 3.5 mL Oj/kg body weight min.

smaller number of patients (n 12) was randomly

assigned to a home-trained status; however, these patients had less ischemia on exercise testing at 3 weeks
after myocardial infarction and were therefore not entirely analogous to patients in the other two groups.
Peak workload was similar at 3 weeks (before the
exercise programs) in all three groups ( 6 . 7 + 1 . 4
METS in no-trained patients; 6 . 8 + 1 . 7 METS in
gym-trained patients, and 7.3 + 1.1 METS in hometrained patients). At 7 weeks, all three groups
improved in functional capacity, and differences were
not statistically significant. By 11 weeks after infarction, there were statistically significant differences between groups, but differences were small and only
marginally significant clinically (Table 1). All three
groups in this study of patients without complications
showed physical work capacities at 11 weeks after infarction similar to those of healthy, sedentary, middleaged men (approximately 9 or more METS). Moreover, a work capacity of approximately 9 METS
should allow the majority of patients with cardiac disease to return to a variety of jobs by 11 weeks after
myocardial infarction (Table 2).
Table 1 summarizes the changes in functional capacity reported in randomized, controlled trials in patients after myocardial infarction. It is difficult to compare any one study to the others due to differences in
the exercise treatment programs, the role of nonexer652

Annals of Internal Medicine . 15 October 19SH

cise treatments such as counseling and risk factor reduction, time of enrollment after infarction, and exercise testing protocols used to assess changes in work
capacity. However, in Table 1, one notes striking similarities in work capacity outcomes among studies. In
every study reported, functional capacity improved
from prerandomization to posttherapy in all patient
groupswhether randomly assigned to special care or
usual care. In all studies, the exercise group had a
greater functional capacity after the intervention than
the control group. Although the differences are statistically significant, the magnitudes of the differences reported are relatively small (averaging 20% to 25%).
Table 2 lists the approximate energy requirements
of some selected self-care, occupational, recreational,
and physical conditioning activities. As noted, 10 or
more METS represent a very heavy workload, equivalent to demanding activities at home (for example,
shoveling snow) or at work (heavy labor). A workload of 7 to 9 METS is rated as heavy and translates
into activities such as sawing wood, carrying moderately heavy objects (60 to 90 ib), digging ditches,
climbing mountains, or jogging. Studies such as those
by DeBusk and associates (4) indicated that the average uncomplicated patient after myocardial infarction
may achieve a maximum capacity of 9 METS even
without participation in a formal exercise program.
Assuming that patients with cardiac disease should

not plan to work consistently at a workload exceeding

80% of their maximal capacity (13), a patient whose
maximal load is 9 METS should safely be able to perform workloads requiring 7 METS or less in occupational or recreational activities. Many occupational
and recreational tasks will therefore be within the limits of the uncomplicated patient by 11 weeks following
infarction, with or without a formal training program
(Table 2). Further, as shown in Table 1, the average
difference in capacity between program participants
and nonparticipants is approximately 20% to 25%.
This difference may be clinically important for some
patients, but should be of limited value in the patient
whose capacity exceeds 9 METS in the period shortly
after an uncomplicated infarction. Such a patient can
engage in heavy activities and may not need, or benefit
from, a modest increase in peak physical capacity (Table 2).
Intuitively, the patient who would benefit most from
an exercise training program in terms of functional
capacity would be the patient who is initially most
limited. Ironically, these patients are often excluded
from exercise programs or choose not to participate.
One study (14) reported that the greatest improvements in functional capacity in association with a cardiac exercise program were seen in patients who initially showed the lowest levels of physical fitness. In
this study, 146 patients with coronary artery disease
were randomly assigned to a year-long supervised exercise program or to a control (usual care) group.
Data on the 59 people completing the year of exercise
formed the basis for this report (14). Baseline clinical
characteristics, thallium exercise test findings, ejection
fraction results at rest and during exercise, medications, and intensity of the exercise training were all
examined by stepwise multivariate linear regression to
evaluate whether the outcome could be predicted using groups of these variables. Over 60 variables from
the categories listed were tested for an association with
outcome from the training program. Various measures
confirmed that exercise capacity improved over the 1
year, and the average estimated maximum oxygen
consumption increased by approximately 15%. Although the correlation was small, the best predictor of
improvement in exercise performance was a low initial
state of physical fitness. No variable or group of variables was highly predictive of physical improvement.
These data suggest that the usual practice of many
programs to select only the healthiest myocardial infarction survivors for program participation ironically
may exclude those who could benefit most.
Conclusions
a. A program of supervised physical exercise can be
expected to increase a patient's maximal exercise capacity after infarction by an average of 15% to 25%
over that which would occur spontaneously.
b. In the many predominantly sedentary patients
without complications whose recreational and occupational activities are of low intensity, resumption of premorbid activities can be achieved without participation in a formal cardiac rehabilitation program.

c. Patients with cardiac disease with significant limitation of maximal work capacity, for example, less
than 7 METS soon after infarction, may expect to
achieve meaningful improvement in work capacity by
participating in an exercise training program. The
15% to 25% greater improvement in work capacity
that may be expected to occur in an exercise program
is likely to be of greatest clinical benefit in such patients.
d. It is clear from the above conclusions that enrollment in cardiac rehabilitation should be based on
demonstration of a significant reduction in physical
work capacity before the initiation of exercise training.
Every candidate for cardiac rehabilitation should have
the following two assessments before enrollment: an
estimate of physical demands for bis or her expected
occupational and recreational activities after recovery
from the myocardial infarction, and an exercise test to
determine current physical work capacity (a measured
work capacity of 9 METS or greater should generally
preclude the need for supervised rehabilitation).
3.2 Changes in Psychosocial Function
Patients with cardiac disease commonly suffer significant psychological, vocational, and social disabilities.
Fifteen percent of patients do not return to work after
myocardial infarction, many of whom seem physically
capable of resuming employment (2). The economic
costs of myocardial infarction are estimated to be as high
as 30 billion dollars yearly, primarily due to vocational
disability. Family disruptions are also common (15).
Studies of the effects of cardiac rehabilitation on
psychosocial function have had inconsistent results.
The ideal study of psychosocial status would compare
outcomes in patients randomly assigned either to a
cardiac rehabilitation program or to a usual care condition. However, many of the enthusiastic reports of
the effect of exercise on psychosocial status outcomes
were not designed in this way. Positive outcomes in
most studies may, therefore, be difficult to interpret
(Table 3).
We identified only two studies in which a randomized, controlled design was used, the intervention was
thoroughly described, and the outcome quantified in
an objective manner. Stern and Cleary (23) reported
results from the National Exercise and Heart Disease
Project. Men, aged 30 to 64, who had had at least one
myocardial infarction 8 weeks to 36 months earlier
comprised the study pool. Patients were thus more
heterogeneous in length of time after myocardia! infarction than is typical of many cardiac rehabilitation
programs. Before randomization, all candidates participated in 6 weeks of low-level exercise in which they
performed at or less than 72% of age-predicted heart
rate in a program designed to help exclude the probable nonadherers. After the prerandomization phase,
subjects who attended most of the sessions were randomly assigned to a supervised exercise program three
times per week or to a control group status (that is,
they were not assigned to a supervised exercise program). Only 48% of exercise-assigned subjects were

Cardiac Rehabilitation

653

Table 3. Examples af Study or Design Problems in Psychosocial Outcome and Cardiac Exercise Programs after Myocardial
Infarction (16-22)
Study (Reference)
Raineri et al. (16)
Kavanagh et al. (17)

Schomer and Noakes (18)

Mayouet al, (19, 20)
Bengtsson (21)
Stern and Cleary (22)

Design
Exercise compared with usual care;
nonrandomized
44 depressed patietits 16-18 tno after
myocardial infarction; Minnesota
Multiphasic Personality Inventory
adtninistered before and after exercise
rehabilitation program
46 patients referred for cardiac
rehabilitation; 26 exercisers compared Io
20 dropouts
Randomized design-intervention; very lowintensity and poorly described in two
separate reports
Randomly assigned to multidisciplinary
counseling and exercise program
compared with usual eare
Compared exercise adherers to exercise
program dropouis before randomization
period of National Exereise and Hearl
Disease Project

still attending more than 50% of their scheduled sessions at 18 months after randomization, whereas 30%
of control subjects reported exercising regularly on
their own initiative. Baseline psychosocial measurements were similar between assigned groups, and no
differences were noted between the groups on various
psychosocial scales at the 6-month, 1-year, and 2-year
follow-up examinations. (All patients in both groups
were included in the follow-up, including dropouts
from exercise.) A modest increase in sexual activity by
the exercise group was found only at the 6-month test
period.
A second well-designed study was that of Erdman
and associates (24). Sixty-four patients were randomly assigned either to a hospital-based multidisciplinary
cardiac rehabilitation program (including supervised
exercise training plus teaching and counseling) or to a
physician-encouraged home exercise program. Outcome measures were assessed 3 months and 6 months
later. No significant difference was reported between
groups in return-to-work rate. Patients in the supervised program scored better on a scale measuring social inadequacy, but no other changes in psychological
measurements were statistically significant. A greater
number of group participants reported having stopped
smoking. Despite the excellent study design, the number of patients was small and size of effects that was
noted was unimpressive.
Conclusions
a. Anecdotal reports and uncontrolled studies frequently describe substantial improvements in psychological well-being in relation to cardiac exercise programs. However, in the few randomized, controlled
studies reported, the effect of exercise on psychological
well-being has been unimpressive.

654

Summary

Annals oflnternal Medieine - 15 October

Less anxiety in exercise group; groups not

comparable; design not randomized
Improvement in depression scores at 4 yrs
and improved hysteria and hypoehondriasis scores; no "usual eare" controls;
late after myocardial infarction
Nonrandomized: biased in favor of positive
outcome
Exercise group reported greater satisfaction
with care but no measurable psychosocial
improvement over other groups
Many dropouts and dropins; only 50%
follow up; no differences in outcome
Dropouts differed from adherers al baseline
(dropouts were of lower socioeconomic
class and fewer were married); dropouts
more likely to be depressed or anxious at
baseline; psychosocial changes over time
reported only in the exercise adherence
group

b. On the basis of available reports, an expected improvement in psychosocial well-being cannot justify
enrollment in cardiac exercise rehabilitation after
myocardial infarction.
c. Additional studies of this important aspect of
care after myocardial infarction are clearly indicated.

3.3 Health Education after Myocardial Infarction

Cardiac rehabilitation programs commonly offer education about the heart, causes of myocardial infarction, cardiac risk factors, and other general teaching
designed to reassure patients with cardiac disease by
making them more knowledgable about their heart
condition. Few studies concerning this type of teaching after myocardial infarction have used an adequate
study design to allow for comparison of a special intervention against usual care. Four well-designed studies
were identified, Ott and coworkers (25) assessed
changes in quality of life using the Sickness Impact
Profile (SIP) for 258 patients after infarction in a randomized study. Three study conditiotis were used. A
control group consisted of patients receiving conventional medical and nursing management beginning
shortly after the heart attack. An exercise-only group
included patients who were given an exercise program
in the hospital and an exercise prescription supervised
at weekly out-patient visits. The exercise prescription
was progressive and individualized but only loosely
niotiitored. No group exercise sessions were required.
An exercise and teaching-counseling group was made
up of patients who were given the same exercise recommendations as the exercise-only group but, in addition, were given a teaching-counseling program about
risk factors and emotional adjustment after hospital

discharge during eight weekly clinic appointments.

The sessions covered a broad range of topics considered pertinent to the patient with cardiac disease.
Family and friends were encouraged to attend, and
individual problems were pursued on a personal basis
during appointments with a nurse. Follow-up evaluations were done on all patients at a centrally located
clinic 3 and 6 months after hospital discharge. There
were no significant differences at baseline among the
three randomized groups. The final SIP scores of the
exercise-only and control groups were similar. Modest, but statistically significant, differences in the exercise and teaching-counseling group were noted in comparison with control subjects. Psychosocial scales were
significantly improved at 3 months and several individual SIP items were significantly better at both 3 and
6 months after hospitalization. No differences were
found in rates of return to work.
A second well-designed study (26) on the effects of
a teaching-counseling program was reported by Pozen
and associates. One hundred and two patients were
randomly assigned either to receive usual care after
myocardial infarction or a series of counseling sessions
given by a nurse-rehabilitator. Sessions began while
patients were still in the hospital and continued at
weekly intervals after hospital discharge either by telephone or at clinic visits. The nurse-rehabilitator thus
supplemented routine physician and nursing care both
during and after hospitalization. The special counseling group had both a better return to work rate and
more favorable (patient-reported) cigarette smoking
status. Knowledge of heart disease was also significantly higher in the group receiving supplementary
teaching-counseling.
A later report (27) from a group of 11 Massachusetts hospitals reassessed the effect of a nurse-rehabilitator on the psychosocial outcome of patients after
infarction. One hundred and eight patients were randomly assigned either to a special teaching-counseling
intervention plus usual care or to usual care alone.
Most nursing visits took place at the patient's home,
and the average number of contacts was 6.3 + 2.8.
Baseline demographic, medical, psychological, and social characteristics were equivalent at entry into the
study. At 3 months after hospitalization, the interven- tion group scored significantly better on a distress
scale and a scale of family support. There were no
differences in work status. At 13 months after infarction, no significant differences between groups on any
of the study outcomes were seen. The study suggested
that spontaneous improvement in vocational and psychosocial outcomes is the rule and that special counseling programs, offered nonselectively, may not be
useful. Only modest differences in psychosocial adjustment were found and tended to favor the special intervention group.
A randomized, controlled trial of group therapy following myocardial infarction was reported by Rahe
and colleagues (28). Therapy consisted of group meetings every 2 weeks (four to six sessions), beginning
one month after hospital discharge. Issues covered included life stress, the contribution of physical and psy-

chological factors to coronary heart disease, coronaryprone behavior, home problems, and return to work.
Only 44 patients were randomized; 77% attended four
or more sessions. Follow-up began at 18 months and
continued for 3 to 4 years. Differences between the
groups were nonsignificant in virtually every dimension studied, including depression, anxiety, sexual
function, coronary disease knowledge, and change in
coronary risk factors. Medical outcomes were better in
the patients who had group therapy, but the number
of events was small and no significant differences were
found.
Conclusions
a. In some randomized, controlled studies, special
teaching or counseHng programs have produced modest improvements in psychosocial outcome compared
to usual care after myocardia! infarction. Other studies, however, have shown no benefit. The evidence that
teaching, counseling, or both, are helpful in cardiac
programs after infarction is not conclusive.
b. No significant improvement has been reported in
occupational status in well-designed assessments of
cardiac rehabilitation.
c. On the basis of reports, it is not justified to recommend special programs of cardiac education, teaching, or psychological support and counsehngover
and above usual supportive careas a routine measure after myocardial infarction. Certain patients, on a
selective basis, may require special teaching or counseling in addition to routine care based on psychological distress or special knowledge deficits.
3.4 Reduction of Morbidity and Mortality Secondary
to Cardiac Rehabilitation
An important question-^whether cardiac rehabilitation services can increase survival, particularly after
myocardial infarctionhas been difficult to answer
definitively for various reasons. First, and perhaps
most importantly, most studies have focused intervention efforts predominantly on low-risk patients. Because event rates in the control groups are quite low, if
the mortality benefit of intervention is relatively small,
as it has been in those studies showing such a trend, a
very large sample size is necessary to achieve statistical significance. For example, the annual mortality
rate in control group patients in two North American
studies has been approximately 2%. A 25% change in
this event rate over a 5-year period would require participation by nearly 4000 subjects to be statistically
significant, a number far greater than any study reported thus far. Of the eight major randomized trials
of exercise and cardiac rehabilitation after myocardial
infarction (6, 8, 10, 11. 29, 30-32), none showed a
statistically significant difference between treatment
and control groups in total mortality, and only one
reported a significant difference (a reduction) in cardiac mortality (31).
Table 4 sumtnarizes the principal characteristics of
the controlled and randomized trials that have reported
morbidity and mortality results. Most of these controlled
Cardiac Rehabilitation

655

Table 4. Main Features of Controlled. Randomized Trials Asses,sing Morhtclity or Mortality after Myocardial Itifarction in
Cardiac Rehabilitation Programs
SI iKiy
(Reference)

Patients
Randomly
Assigned

303

RechnilztT
etol, (20)

733

Shaw
el al. (.^0)

65 I

Willidi TISCU
cl al. ( 8 )

315

Kallio
et a!. ( 3 1 )

375

Marni
etal ( 1 0 )

167

Rt'msin
ct al. ( I D

193

Vermeulen
el al. (32)

i^H

Ken I a la
et al. (33)

2*38

Palaisi
er al. (34)

380

Bssential Trial Features

P Value
Mortality Rales
Rehabilitation Cnntrnl
PatJenIs
PjlienCs

intervention group exercised twn)

times per week for 12 wk
beginning approximately 6 wk
after niyocardial infarction:
dropoui rale in exercise group
was 3 1 %; mean follow-up = 2.1
yr,
Majority of patienls enrolled 2-12
mo after mynciirdial infarction
(median, 6.2 mo); rancioinly
assigned to a high- compared
with low-intenslty e.\ercise group;
high dropout rates same ( 4 5 % )
for bolh group,"-; mean follow-up.
2.i yr.
Patients randomly assigned up to 26
mo after myocardial infarciion;
rehabilitaiion and usual care
patients were eqiiivaleni.
'framing began i mo afier
myocardial infarction; e;<erciserehabililatioii only was compared
with usual care; 4'yr follow-up,
MullifacLorial intervention
(including e.\erci!ie) beginning
early after myocardial infarction
was compared wilh usual care;
3-yr follow-up,
Exercise rehabilitaiion compared
with usual care: low-risk patients,
randomly a,ssigned al 45 d after
myocardial infarction; average
follow-up = 55 mo.
Randomized during hospiiali/.aiiiin
to receive cardiac rehabiliialion
or usual care; exercise
rehabilitaiion three times per
week for 30 min heginning 2 mu
after niyoeaidial infarction;
average follow-np 55 mo.
Rehabilitation program b-fi wk
duration, beginning 4-6 wk after
myocardial mfaretion;
inlervention nol clearly described,
lirsi attempt at long-term followup made at 5 yrs alter myocardiai
infarciion.
Home rehabilitaiion compared wilh
usual care: not supcivisei!
rehabilitation,
Nol ,s(rictly randomized and groups
not comparable medically at
baseline.

CaiiiJac Morbidity
(Nonfatal Myocardrai
hifaraion)
Rehabilitation
Patients

P Value

Conirol

21( 14)

NS'

I 1(7,3)

l l ) ( 6 6)

NS

15(4,0)

13(3.7)

NSt

3'V( 10.31

}}{<>.i)

NS

15(4.6)

2417.3)

NS

i?(4.6)

1 U3 3)

28(17.7)

35(22.3)

NS

25(15.H)

28(17.8)

41(2!,S)

56(24.9)

< 0.10

34(1S.1)

21(11,2)

6(7.4)

5(6.3)

NS

27(5 B
per yr)

NS

5(tS.Rl

NS

16(,1.6
peryr)

2(4,3)

5(0-1)

I6(.3.<)pcr
yrl

2(4.3)

')(i 1,2)

NS

NS

,- O.iO

NS

23(4,9
pcryil

NS

4(7,S)

NS

* NS = not significani,
+ Cardiac mortality only.

Studies showed a trend in favor of the special treatment

group, but as noted above, sample sizes have been small
and statistically significant differences have been unusual. Some investigators attempted to pool the data lo
increase the available sample size (35, 36). Data pooling
is often useful and valid in epidemiologic studies when
individual sample sizes are small (37), Sometimes referred to as meta-analysis. pooling generally requires
that each individual study asked the same question(s);
all patients, treated and untreated, were similar before
the study, and all patients within each group received

656

Annals of Internal Medicine 1 5 October

similar treatment; the mortality rate was cotistant over

the study period (35); and, perhaps most critical, the
intervention itself was uniform across studies- The last
requirement has clearly not been satisfied in studies of the
efficacy of cardiac rehabilitation because each rehabilitation effort has had unique elements. Thus, meta-analysis
is not appropriate lo help clarify this issue due to difleretices in interventions and in patient selection criteria
among studies.
It is worth noting that most controlled trials of cardiac rehabilitation exercise programs following myo-

cardial infarction have involved follow-up periods of 3

to 4 years or less. In addition, because compliance
with long-term exercise diminishes substantially with
time, analysis of data by the "intention to treat principJe" would mean, inevitably, that many patients randomly assigned to exercise did not really perform the
exercise prescribed due to drop-out. Other interventions directed at reducing cardiac morbidity or
mortality in patients with coronary disease or patients
prone to coronary disease, such as aspirin (38), betablocker (39), or lipid-lowering therapies (40, 41),
have required many years of treatment and follow-up,
as well as excellent compliance with treatment, to
show reduced morbidity or mortality. For example, no
diiference in cardiac event rates was noted in the Lipid
Research Clinics-Coronary Primary Prevention Trial
(40) until year 3 of follow-up, and a convincing difference was not seen until years 7 to 9 after the start of
treatment. Given the presumed pathogenetic mechanisms involved in altering the atherosclerotic process,
it is unlikely that relatively short-term programs of
exercise (less than 4 to 5 years, for example) would
substantially alter mortality or morbidity in patients
with coronary disease after myocardial infarction. It is
tempting to suggest that a prolonged, habitual increase
in physical activity after infarction could produce a
decrease in morbidity or mortality, as has been shown
in certain long-term studies of healthy people (42, 43)
or in men originally at high risk for coronary disease
as predicted by high levels of cholesterol, blood pressure, or cigarette smoking (44). Such an assertion,
however, currently cannot be supported by the existing data and remains, therefore, only a provocative
hypothesis.
Conclusion
Many randomized trials have shown a trend toward
reduced mortality in patients in rehabilitation after
myocardial infarction compared to usual care controls. Differences in mortality, however, have been
small, as have sample sizes, and no definitive evidence
exists that cardiac rehabilitation saves or prolongs
lives after myocardial infarction.
3.5 Effect of Cardiac Rehabilitation on Ventricular
Function, Cardiac Perfusion, or Collateral Circulation
In animal studies, exercise training has improved cardiac function, perfusion, or both. Moreover, in one
animal study (45), regression of atherosclerosis was
shown after a prolonged period of exercise conditioning. In humans, however, evidence that exercise can
improve cardiac function or perfusion has been more
elusive. Although studies (46) in patients with
coronary disease typically have shown that exercise
training increases exercise tolerance and the minimal
work required to induce angina, these improvements
have generally been attributed to adaptive changes in
the peripheral circulation rather than to primary cardiac effects. A randomized study by Paterson and associates (9) showed no evidence of improved cardiac
function after 6 months of high-intensity exercise in

patients with coronary disease, but showed a significant increase in stroke volume in patients who continued to train for 12 months or longer. No change in
stroke volume occurred in controls. A very well-designed experiment by Froelicher and coworkers (47)
studied changes in cardiac function and perfusion in
an exercise training program that lasted over 1 year in
a mixed population of patients with coronary disease,
one third of whom had had a recent myocardial
infarction. One hundred forty-six volunteers were randomly assigned either to a long-term program of supervised exercise or to usual care. Significant differences between the two groups were seen not only for
improved aerobic exercise capacity in the conditioned
group but also for thallium ischemia scores and ventricular function as measured by radionuclide ventriculography in patients without angina (47). The differences between exercise patients and controls were
relatively modest and did not occur in patients with
angina. A later report from the same research group,
using computer-analyzed thallium-201 circumferential
count profiles in 56 of the 146 patients described
above, showed strong evidence of improved cardiac
perfusion, apparently resulting from prolonged exercise training (48).
Ehsani and colleagues have produced substantial evidence over the past 10 years that, in addition to peripheral adaptations, long-term exercise training of
progressively increasing duration, frequency, and intensity can cause adaptations suggestive of improvement in myocardial ischemia and left ventricular function. For example, Ehsani and associates (49) showed
that a 12-month program of progressive and intense
exercise training resulted in less ST-segment depression at the same rate-pressure product in a group of
ten patients with coronary disease, nine of whom had
recently had a myocardial infarction. Other studies
from the same research group have shown that a similar 12-month exercise training period can result in
higher stroke volume and stroke work at comparable
heart rate and peripheral vascular resistance (50).
Other reports also showed an increase in ejection fraction from rest to exercise in patients with coronary
disease, after training (51), suggesting that endurance
training can improve left ventricular contractile function in certain highly motivated and selected patients
with coronary disease. The improvement in contractile
function seemed to reflect a reduction in the severity
of myocardial ischemia (51). The investigators suggested that their results, showing improvement in contractile status following exercise, conflict with earlier
reports because of lack of a sufficient training stimulus
in previous studies rather than differences in patient
populations.
Conclusions
a. Short-term exercise conditioning (6 months or
less) in patients with coronary disease has not been
found to improve myocardial performance or perfusion. Thus, a cardiac rehabilitation program of typical
duration is not likely to result in improved cardiac
function in itself.
Cardiac Rehabilitation

657

Table 5. Ri.sk Pactor Modification in Randomized Trials of Cardiac Rehabilitation

Study (Reference)

Trial Features

Risk Factor Changes Reported

Kallioetal. (31)

Multidisciplinary intervention beginning 2

wk after myocardial infarction

Vermeulen et al. (32)

Intervention unclear from report

Carson et al. (6)

Intervention: 12 wk exercise twice a week

Oberman et al. (52)

National Exercise and Heart Disease

Project; primarily an exercise program
without other specific risk factor
reduction components

WilhelniHen et al. (8)

Training began 3 mo after myocardial

infarction

Marraetal. (10)

Exercise four times a week for 7-9 wk

Intervention group had lower body weight,

serum cholesterol, triglycerides, systolic
and diastolic blood pressures; smoking
decreased 50% in both groups
Lower cholesterol in intervention group; no
difference in other risk factors
Smoking decreased in both groups; no
changes in body weight or cholesterol;
triglycerides, lower in exercise group
No change in smoking; blood pressure,
small decrease in diastolic blood pressure
in exercise group over control;
triglycerides, slightly lower in exercise
group; cholesterol, slightly increased in
both groups
Cholesterol and triglycerides decreased in
botb groups (difference = not
significant); systolic blood pressure
slightly lower in exercise group compared
to control
No difference between groups in smoking
and cholesterol; triglycerides significantly
lower in exercise group

b. Longer term, high-intensity, progressive exercise

traitiing, on the other hand, may improve myocardial
performance in highly motivated patients with coronary disease. Studies showing these results have involved small numbers of carefully selected patients
who participated in supervised exercise training for
prolonged periods on a nearly daily basis for 12
months or more. Thus, cardiac improvement is possible but will not commonly be attained.
3.6 Risk Factor Modification duritig Cardiac Exercise
Programs
Many survivors of myocardial infarction could theoretically benefit from organized attempts to help them
stop smoking, lower their blood Iipids, and control hypertension or other standard cardiac risk factors. In
randomized trials of cardiac rehabilitation after infarction, several investigators have studied whether cardiac risk factors are more favorably affected by special
interventions. As noted earlier, studies of cardiac rehabilitation interventions have not been uniform, and
frequently, reports do not adequately describe
intervention efforts other than the exercise program
itself. Table 5 summarizes the randomized trials and
the effects on risk factors that have been noted (6, 8,
10, 31, 32, 52).
Conclusions
a. The study by Kallio (31), using a multifactorial
intervention, showed substantial changes in risk factors in the special intervention group. Other studies
(not multifactorial, typically exercise only) have
shown less impressive or no risk factor changes.
b. On the basis of the data presented in Table 5, an
exercise program alone seems unlikely to produce better risk factor outcomes when applied to unselected
patients following myocardial infarction.
658

Annals of Imeniai MeJic-ine IS Ocloher I9SH

3.7 Safety of Cardiac Exercise Programs

Surveys of large numbers of programs and reviews
from individual programs have studied the safety of
cardiac exercise programs. A recent report by Van
Camp and Peterson (53) described the cardiac risks in
51 303 patients who exercised between 1980 and 1984
in 167 randomly selected cardiac rehabilitation programs that were surveyed by questionnaire. Program
directors were asked to report and describe adverse
events that occurred during supervised exercise. Patients exercised an estimated 2 251 916 hours. Twentyone persons had a cardiac arrest; 18 were resuscitated.
In addition, eight nonfatal myocardial infarctions
were reported. Cardiac arrests, thus, occurred at a rate
of 8.9 per million patient-hours of exercise (one per
111996 patient-hours). Myocardia! infarctions occurred at a rate of 3.4 per million hours (one per
293 990 patient-hours); and fatalities were reported at
a rate of 1.3 per million hours (one per 783 972 patient-hours). The investigators found no statistically
significant difference in the frequency of adverse
events among programs of varying size or extent of
elect rocardiographic monitoring; however, conclusions are considered tentative because of lack of information regarding differences in patient characteristics
that may exist among programs of differing design and
character. The authors concluded that current cardiac
rehabilitation practices permit the delivery of prescribed, supervised exercise to patients who have cardiovascular disease with a low risk for cardiovascular
complications.
In a previous survey of the safety of cardiac rehabilttation, higher event rates were reported although
absolute event rates were also low. Haskell (54) surveyed 30 cardiac programs from 1960 to 1977 concerning adverse evetits. He found a cardiac arrest rate
approximately four times that of the Van Camp and

3.8 Role of Telemetry Monitoring in Cardiac

Programs

exercise testing or an above average exercise performance. Because these factors need not be managed by
continuous ECG monitoring, the authors suggested
using individual patient counseling regarding risks, as
well as supervision, instead of routine telemetry (55).
In contrast to the conclusion of Hossack and Hartwig, others have advocated the use of continuous ECG
monitoring on a routine basis in exercise programs
because neither entry exercise testing (59, 60) nor
Holter monitoring (61) is a good predictor of exercise-induced arrhythmias or ischemic ECG changes
that occur during cardiac exercise programs. Several
reports suggested that telemetry in cardiac rehabilitation revealed unexpected abnormalities leading to adjustments in medication or exercise prescription before
continuation of the exercise program (58, 59, 62, 63).
In assessing these conclusions, one notes that the complexity or severity of the ECG abnormalities detected
ranged from life-threatening but uncommon (for example, ventricular tachycardia) to possibly unimportant yet very common (for example, exercise-induced
premature ventricular depolarizations). Since entirely
normal persons can experience ventricular ectopic activity daily (64), the importance of detecting ventricular ectopic activity in cardiac rehabilitation programs
is uncertain. No study has been done in which patients
were randomly assigned either to a supervised (but
nontelemetered) program or to a program using both
supervision and telemetry. Because the complication
rates in cardiac rehabilitation seem low, a prohibitively large study would be required in order to detect a
reduction in complication rates attributable to telemetry monitoring.

We investigated the evidence that supervised exercise

programs, especially those using electrocardiographic
(ECG) telemetry monitoring, are safer than less intensively monitored or supervised programs. Cardiac
exercise programs commionly use continuous ECG telemetry for 12 weeks or longer after myocardial infarction. In the Van Camp and Peterson study (53), 58%
of the programs reported use of continuous ECG telemetry throughout the program; 34% employed intermittent ECG monitoring; and the remaining 8% of
programs monitored all patients continuously for at
least 3 sessions and then advanced patients to intermittent monitoring. Intuitively, cardiac telemetry appears to provide a "safety net" for the patient with
cardiac disease by allowing detection of arrhythmias
and ST-segment changes and instant checking for
compliance with heart rate prescription (58). In Haskell's report of cardiovascular complications in cardiac rehabihtation (54), he found a significantly lower
cardiac event rate in the 2 programs (out of 30) that
used continuous ECG monitoring. The later study by
Van Camp and Peterson (53) did not substantiate this
finding. Hossack and Hartwig (55) noted that cardiac
arrest occurred in 25 out of 2464 patients in their supervised programs in Seattle and found that noncompliance with exercise prescription heart rate during exercise was one of several predictors of cardiac arrest.
Other predictors were, as noted earlier, the presence of
marked ST-segment depression during pre-enroUment

Conclusions
a. The longer one performs ECG monitoring in the
patient with cardiac disease the greater the likelihood
of detecting some abnormality including ventricular
ectopy and silent ischemic changes (60, 61). Whether
these ECG abnormalities are clinically meaningful in
cardiac rehabilitation settings requires further study.
b. On the basis of small numbers of cases (55), certain patients may be at greater risk for a serious cardiac event during exercise sessions, including patients
with ischemic ECG changes on exercise testing or serious underlying cardiac disease (65), or those who exceed the heart rate limits of their exercise prescription
(55). Such relatively unusual patients are logical candidates for more intensive monitoring than the average
patient with coronary disease in exercise rehabilitation.
c. The role of graduated telemetry monitoring, that
is, initial continuous monitoring followed by a progression to intermittent monitoring, requires further
study, in particular, determining the predictive capacity of data derived early in the patient's exercise course
of serious arrhythmia or unexpected ischemia later in
the patient's course.
d. Little evidence currently substantiates the need
for continuous ECG monitoring during exercise in all
patients with cardiac disease. Although telemetry

Peterson study (53) and a fatality rate approximately

seven times higher. Neither the Haskell survey (54)
nor the Van Camp and Peterson study (53) is sufficiently detailed to assess the quality of the data
presented. Reports from individual programs have
generally noted low event rates in supervised cardiac
programs (55-57). In a study by Hossack and Hart-^
wig (55) from a large supervised exercise program in
Seattle, participants who had ischemic electrocardiographic changes during entry-assessment exercise testing and participants who tended to exceed their prescribed exercise heart rate limit were more likely to
have a cardiac arrest. Victims of cardiac arrest had
also generally performed at higher than average exercise capacities. No other studies have identified highrisk characteristics predictive of myocardial infarction
or cardiac arrest during exercise programs for patients
with cardiac disease.

Conclusion
Based on the infrequency of reports of adverse events,
as well as the low rates of complications noted in several large surveys, supervised cardiac exercise programs appear to be safe for the average patient following infarction. Additional information about the types
of patients at greatest risk for exercise-related complications would be useful to help stratify patients requiring more prolonged or intensive m,onitoring.

Cardiac Rehabilitation

659

monitoring intuitively seems useful, its vaiue over supervision alone remains to be proved in an appropriately designed and controlled experimental study. In
the absence of valid empirical evidence, it is reasonable
to propose limiting telemetry monitoring to high-risk
patients.
Lacking data on which to base decisions regarding
telemetry in cardiac exercise programs, the American
College of Cardiology has suggested guidelines for selective use of electrocardiographic monitoring (66).
Telemetry is advised for patients with any of the following characteristics:
a. severely depressed left ventricular function (ejection fraction under 30%);
b. resting complex ventricular arrhythmia (Lown
type 4 or 5);
c. ventricular arrhythmias appearing or increasing
with exercise;
d. systolic blood pressure decreasing with exercise;
e. previous cardiac arrest;
f. after myocardial infarction complicated by congestive heart failure, cardiogenic shock, or serious
ventricular arrhythmias;
g. severe coronary artery disease and marked exercise-induced ischemia (ST-segment depression
> 2mm);
h. inability to self-monitor heart rate due to physical or intellectual impairment.
The American College of Cardiology (66) recommendation is as follows:
Hardwire or telemetry ECG monitoring is considered a
safety net and has sometimes been prescribed indiscriminately. Probably not more than 20-25% of patients in
rehabilitation programs require ECG monitoring with
the present ability to stratify patients into low, medium
and high risk groups. Data are lacking regarding the
risk of complications or death to the patient in supervised exercise programs with ECG monitoring, as compared to supervised exercise programs without ECG
monitoring. Until further data are available, it is recommended that identifiable high-risk (patients be ECG
monitored as well as supervised.

3.9 Frequency and Duration of Cardiac Exercise

Programs
Frequency and duration of cardiac rehabilitation depend largely on the goal of the intervention. If the goal
is to improve functional capacity, one can refer to
studies of the training effect in patients with cardiac
disease as a guide to program intensity, duration, and
frequency (78). Table 1 summarizes several studies
that showed improved functional capacity occurring
as soon as 8 to 12 weeks after myocardial infarction.
As noted earlier, improvement can occur spontaneously and can be augmented by an exercise program. Such
programs generally require the patient to exercise a
minimum of two times per week for at least 30 minutes per session. In DeBusk's studies in uncomplicated
patients (4), work capacity was examined at 3, 7, and
11 weeks after infarction during an 8-week exercise
program. The study showed that an additional incre660

Annals oflnternal Medicine IS October 198S

ment in work capacity occurred between 7 and 11

weeks although the magnitude of improvement was
somewhat less than that which occurred between 3
and 7 weeks after infarction (the first 4 weeks of training). Studies of patients without coronary disease have
shown that a plateau effect in functional capacity begins to occur within 6 to 10 weeks in an exercise program consisting of three sessions per week for 30 to 60
minutes per session (67). Exercise intensity is typically limited to 70% to 85% of maximal exercise capacity. Fewer sessions per week or shorter sessions may
produce no exercise capacity improvement; more frequent or more prolonged sessions may compensate for
decreased exercise intensity but may do so at the expense of more orthopedic complications or lower adherence to the exercise program.
When one deals with the patient in cardiac rehabilitation, it is advisable to set individual goals for exercise
capacity based on initial exercise capacity and expected
future workload. In light of studies of exercise training,
a program consisting of three sessions per week for 8 to
12 weeks, 30 to 60 minutes per session, with exercise
aimed at 70% to 85% of maximal workload should
maximize the opportunity for most patients to achieve
individual workload or training goals, or both. Some
patients may achieve training or workload goals earlier
(or later) than 8 to 12 weeks; thus a monitoring system
to detennine time of exit from a supervised training
program should be routinely established in all cardiac
exercise programs. A patient who achieves functional
goals earlier than 8 to 12 weeks could be discharged
sooner, whereas some patients may benefit from more
prolonged exercise training, especially if training intensity is low due to baseline functional limitations. An exit
goal of 9 METS may be appropriate for many patients
with cardiac disease {see Section 3.1).
Traditionally, cardiac rehabilitation exercise programs have emphasized aerobic activities, such as
walking, jogging, cycling, or rowing. Resistance
strength exercises like weight lifting have usually been
avoided in patients with cardiac disease because of
concerns about adverse hemodynamic effects of isometric loading. Recently, a few studies have shown the
apparent safety and benefits of circuit weight training
as an adjunct to traditional aerobic exercise conditioning in cardiac rehabilitation settings (68, 69). Kelemen and colleagues studied a group of 20 stable patients in an outpatient cardiac rehabilitation program
(69). Patients were carefully selected to avoid highrisk subjects. Intervention subjects performed a series
of resistance exercises on circuit weight machines for
20 minutes followed by a 20-minute walk-jog aerobic
routine. Exercise training was conducted three times
per week for 10 weeks. A control group played volleyball for 20 minutes in place of the circuit weight training. No cardiovascular complications were noted in
this selected group. The experimental subjects significantly increased treadmill time by 15%, whereas control subjects did not change. Strength increased by
24% in weight-trained patients but no change was
seen in controls. Because many patients with coronary
disease return to vocational or other activities requir-

ing upper body strength, exercises such as those described by Kelemen and associates (69) may be useful. The studies in this area are relatively small and
few in number, and the benefits versus risks of circuit
weight training are not yet conclusive.
Conclusions
a. The standard recommendation of an exercise
training program lasting 8 to 12 weeks, 30 to 60 minutes per session, three to five times per week is based
on studies taken from the exercise physiology literature.
b. Many uncomplicated patients with coronary disease will attain their personal workload goals in less
than 8 to 12 weeks after enrollment in cardiac rehabilitation. A capacity of 9 METS is one suggested exit
criterion (see Section 3.1).
c. A supervised exercise program that exceeds 8 to
12 weeks cannot usually be justified on the basis of an
expected continued improvement in functional capacity. Supervised cardiac rehabilitation beyond the attainment of a plateau in functional capacity must be
justified on the basis of safety requirements or unusual
dependency needs of the individual.
3.10 Home Training Programs
DeBusk and colleagues (70) have shown the feasibility and apparent benefit on functional capacity and
training effect of a home-based exercise program in a
selected group of uncomplicated patients soon after a
myocardial infarction. Transtelephonic ECG monitoring was used as an additional safety measure in these
studies. This approach has only been used so far in
uncomplicated patients with minimal physical work
limitations. Such patients may not require any supervision at all, although there may be some reassurance
value of the transteiephonic monitoring. Too little evidence is available presently to define the role of home
training programs in coronary patients.
4. Other Categories of Patients Who May Benefit
from Cardiac Rehabilitation
4.1 Patients with Angina Pectoris
Redwood and coworkers (71) showed that patients
with stable angina could markedly improve their exercise performance after a 6-week program of intensive
aerobic exercise training. Improved exercise time on a
bicycle ergometer, maximal oxygen consumption, time
to onset of angina, and other measures of clinical improvement were well documented in this study and
have been substantiated in other studies (72). Thus,
aerobic exercise training can be of some value in the
patient with angina. Logically, the patient with angina
can also benefit from antianginal drugs, revascularization procedures, smoking cessation, and other risk factor interventions as well. In this country, exercise
training, despite its documented potential benefit in
patients with stable chronic angina, has not been considered a primary therapeutic method. The literature.

although relatively limited, supports a conclusion that

cardiac rehabilitation can be recommended for the patient with anginal symptoms who fails to benefit adequately from the other currently available antianginal
treatments. The role of exercise in maximizing function, as opposed to improving function, requires further study given radical changes in medical and surgical treatments for chronic anginal syndromes in the
past 15 years4.2 Patients with Severe Left Ventricular Dysfunction
In the 1970s, patients with severely depressed left ventricular function were not considered candidates for
exercise training (cardiac rehabilitation) due to safety
concerns and the uncertainty of benefit from exercise
training. In a small series of patients with coronary
disease who had ejection fractions ranging from 13%
to 26%, Conn and colleagues (73) reported that exercise capacity improved by an average of 20%, measured by treadmill exercise duration, after a supervised
exercise training program ranging from 4 to 37
months (mean duration, 12 months). No morbidity or
mortality occured during training in this small group
of patients (n = 10). Surprisingly little additional research has been done in this area. Based on the limited
data, it seems that selected patients with severely depressed left ventricular function can participate in an
exercise conditioning program and may achieve a clinically meaningful training effect. Although severe left
ventricular dysfunction need not be considered a
contraindication to exercise conditioning or cardiac
rehabilitation in an otherwise appropriate candidate,
the benefits and risks in this patient population are
presently poorly defined.
4.3 Patients after Coronary Artery Bypass Surgery
Observational studies suggest that patients who had
coronary artery bypass surgery may improve physical
work capacity while participating in a supervised exercise rehabilitation program (74, 75). Few controlled
studies have been done (76), and we identified only
one randomized, controlled trial (77) of the effects of
a supervised exercised program compared to usual
community care in a selected, small series of stable
patients following bypass surgery. This study included
some patients whose surgery had been done many
months or even years earlier. The exercise program
patients improved their functional capacity by 15% to
20% more than the controls after I year of training.
This level of improvement is similar to that reported
in other patients with coronary disease (Table 1 and
Section 3.1).
Conclusions
a. As in the patient after myocardial infarction or
the patient with angina, exercise training can increase
functional capacity in the patient who is recovering
from coronary revascularization surgery.
b. Most patients who have had successful and uncomplicated surgery can be expected to recover to preCardiac Rehabilitation

661

operative functional level with usual postoperative

care and should not require routine participation in a
supervised cardiac rehabilitation program. A postoperative exercise capacity of 9 METS or greater should
enable the surgical patient to recover with usual medical and postoperative care alone.
c. Additional studies, in patients with exercise capacity under 9 METS, comparing supervised programs with home-based or unsupervised programs, are
necessary to establish the role of routine supervision in
this patient subpopulation. In the meantime, we suggest that a patient whose exercise capacity remains
low (below 7 METS) and who cannot achieve adequate workload for vocational or recreational demands can be considered a candidate for a period of
supervised exercise in the period soon after surgery,
analogous to that suggested in the period soon after
infarction,
4.4 Elderly Patients and Cardiac Rehabilitation
No randomized, controlled trials have examined the
effects of supervised cardiac rehabilitation compared
to usual care in the elderly. Observational studies suggest that the elderly patient can achieve a modest
training effect during a cardiac rehabilitation program
following coronary surgery or infarction (78). Exercise training studies (78-80) in healthy, stable, elderly
patients showed a training effect similar to that observed in younger patients.
Conclusion
The elderly patient with cardiac disease should be
treated similarly to younger patients with such disease.
Indications and contraindications for cardiac rehabihtation are identical for older and younger patients.
4.5 Other Cardiac Conditions
Cardiac rehabilitation programs have been offered to
almost all types of patients with coronary disease, including those who have had coronary angioplasty, cardiac valve replacement, or cardiac transplantation. Because the adaptive responses to aerobic conditioning
are primarily considered to be peripheral rather than
cardiac (46), it may be logical to extend cardiac exercise programs to these patients as well. The primary
goals of treatment in many such patients would include improved functional capacity and psychological
wellbeing, similar to those in the patient with coronary
disease. However, randomizxd trials in these other patient groups are lacking and use of cardiac rehabilitation is. therefore, empiric.
Acknowtedgmanl^: The authors and ihe American College of Physicians
thank the many reviewers of this manuscript mcludiiig representatives of
the .American College of Cardiology and Ihe American Heart Associalion.
Rtfqiiesrs for Rcprinrs: Philip Greenland, MD, Box bl"^. University of
Rochester Medical Center, Rochester, NY 14642,
Current Author Addroiscs: Dr. Greenland: Box bl'i. University of
Rochester Medical Center. Rochester. NY 14642,
Dr, Chu: 10 Rustic Road. Branford. CT 06405,

662

Annals of Internal Medicine - 15 October 1988

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