Dive into the Sixth Edition of the AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention


Dive into the Sixth Edition of the AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention

Editors Jonathan K. Ehrman, PhD, FACSM, FAACVPR; and Patrick D. Savage, MS, FAACVPR, recently sat down with News & Views to discuss the upcoming AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Program, slated to be released in March 2020. This is the sixth edition of the guidelines, the most up-to-date and definitive resource for developing inpatient and outpatient cardiac rehabilitation programs. Along with the new Guidelines, we asked Ehrman and Savage their thoughts on the future of cardiac rehabilitation and standards in the field. 

AACVPR: What would you say were some of the biggest updates in this edition?

Jonathan K Ehrman and Patrick D. Savage: There is a focus on methods to increase the traditionally low participation rates in cardiac rehabilitation (CR). With increased participation comes an increasingly varied and diverse patient population.  Since the release of the 5th Edition of the Guidelines, systolic heart failure has been approved as an eligible diagnosis. Along with this brings higher acuity patients, including those with a left ventricular assist device, for example. Interventions employed in CR need to accommodate an evolving patient demographic and, yet, be scientific and evidenced based. The 6th Ed. of the Guidelines provides updated recommendations and guidelines for the treatment and care of this increasingly diverse patient population.  In particular, sections on heart failure, valvular heart disease, older patients, and peripheral arterial disease have been expanded. Exercise training has always been the cornerstone of cardiac rehabilitation. Reflecting this prominent role, the 6th Edition of the Guidelines has dedicated an entire chapter to physical activity and exercise training and prescription. Other chapters that have been revised significantly or re-written entirely included Nutrition Guidelines and Behavioral Modification for Risk Factor Reduction. Importantly, all chapters and sections have been updated to reflect contemporary regulatory and practice guidelines. 

Even in the past 5-10 years, there have been huge strides in cardiac rehabilitation research. How have you seen the standards and guidelines change?

JE & PS: 
The list of qualifying diagnosis for participation in CR has expanded as we continue to understand the tremendous benefits of exercise training and lifestyle modification. The scientific literature clearly supports the efficacy of participating in CR as a means of risk factor reduction and for the prevention recurrent cardiovascular events. From a programmatic perspective, minimizing the time between hospital discharge and enrollment in early outpatient CR is associated with more favorable outcomes. Therefore, programs need to develop policies and procedures to expedite referral to and enrollment in CR. Also, there has been greater attention toward developing an exercise prescription to optimize patient outcomes. Higher intensity interval training and higher caloric exercise training are examples of adapting the exercise prescription to specifically target an individual’s goal and objectives. The 6th Ed. of the Guidelines provides CR professionals the most up-to-date evidence based research and practice guidelines so as to be responsive to changes in clinical practice to optimize patient outcomes. 

AACVPR: What do you think is a big issue that’s on the horizon in the field?

JE & PS:Going forward, a significant challenge is the widespread underutilization of CR services. This includes a needed focus on patients from traditionally underrepresented groups such as individuals of lower socio-economic status, racial and ethnic minorities, women, and the elderly. Mobile and other health-related technology is advancing rapidly and has enormous potential for cardiovascular disease prevention and management.  Also, alternatives to the traditional CR model need to be considered.  Hybrid models of hospital and home-based CR programs, for example, may provide a safe and effective means to increase accessibility to CR-related services.

The secondary prevention model employed in CR also allows for program transition into the management of other chronic diseases that have similar underlying pathophysiology. Many chronic diseases, including coronary artery disease, some types of cancers, hypertension, obesity, diabetes, and peripheral vascular disease, have a common underlying pathophysiology. The preventive and rehabilitative aspects of CR programs can be adapted to address six lifestyle-related risk factors—smoking, hypertension, obesity, type 2 diabetes, unhealthy diet, and sedentary lifestyle.

AACVPR: Why do you think the AACVPR guidelines hold such weight in the field?

JE & PS: Cardiac rehabilitation is a complex, multifaceted and multidisciplinary intervention. It is a challenge to integrate the many and varied aspects of CR programming together to deliver comprehensive CR services. Also, federal regulations affecting reimbursement and program design continue to influence how CR services are delivered.  It is very difficult for busy clinicians to stay current with all the regulatory requirements, research and clinical practice guidelines. The Guidelines cover the scope of practice for CR programs and is an essential resource to help CR professionals meet program structure and delivery challenges. The Guidelines provide CR professionals with the latest tools and information to successfully start new programs or update and enhance existing ones. Obviously, the high quality contents of the Guidelines is the results of the efforts of the contributing authors.  The contributors to the Guidelines are leaders in the field of CR and secondary prevention, cardiovascular risk reduction, reimbursement, and public policy.  No other text provides this comprehensive information about CR from beginning to end.

AACVPR: Anything else you’d like to add?

JE & PS:Starting with the First Edition (released in 1991), the Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs have been an invaluable resource for CR professionals. While significant updates are included, it is important to acknowledge that the 6th Ed is part of an evolutionary process. Each successive edition of the Guidelines has been built on the work of previous editors and contributors. There are some items that are a mainstay of the guidelines while others are ever evolving. We have attempted to capture and convey these in an informative and practical manner.