By Denise Williams | News & Views

Cardiac rehabilitation as we know it today is a familiar and respected cog in the modern healthcare machine…but it was a long and hard-fought journey that brought it to this point. Past AACVPR President Barry Franklin, PhD, bore witness – his hair turning from black to “very” gray in the process, he laughs – as the profession expanded and evolved over the decades. He didn’t just watch from the sidelines as the future unfolded, however; he played an active part in the transformation. 

Back in the Day

A key shift in practice that Dr. Franklin is proud to have helped advance was the recognition of weight training as a valuable complement to cardiac rehab. He started his career in 1976, and by the time he joined his current facility – Detroit’s Beaumont Hospital – in 1985, some limited evidence had started to emerge on the likely benefits of resistance training in patients with heart disease. As one of the first in the field to incorporate the activity into cardiac rehab, he vividly recalls the deep-seated skepticism he and the Beaumont program endured. Vocal naysayers challenged the concept, questioned Dr. Franklin’s credibility and loudly proclaimed that allowing this fragile patient population to “pump iron” would backfire horribly.

But Franklin and Beaumont trusted in the science, which shows that weight training is safe and highly effective in the cardiac rehab setting. Dr. Franklin reports that, “Over the last 38 years, we’ve had zero complications during resistance training. What we have done is improve patients’ strength, body composition and functionality.” Indeed, study findings substantiate weight training as being as good as or better than aerobic exercise with respect to improvement in bone mineral density, strength, glucose metabolism and basal metabolic rate.

Pictured: 8 of AACVPR's first 10 presidents
Front row from left: Philip Wilson, EdD (1986), Linda Hall, PhD (1991), Kathy Berra, MSN (1987), Pat Comoss, RN (1992). Back row, from left: Mark Williams, PhD (1994), Reed Humphrey, PhD (1995), L. Kent Smith, MD (1989), Barry Franklin, PhD (1988)

More Changes

While knocking down the skepticism surrounding resistance training represents one example of how cardiac rehab has matured, it isn’t the only marker of progression. Dr. Franklin calls out a few more:

• Staffing. Cardiac rehab today is peppered with experts from across the healthcare spectrum. Clinical exercise physiologists work with RN clinicians, registered dieticians, clinical cardiologists, physical therapists with a cardiac rehab focus, psychologists and other specialists to create a collaborative, multidisciplinary team.
• Focus. The core of cardiac rehab has broadened beyond exercise physiology – which initially consisted primarily of walking. Although still at the heart of the profession, the “big picture” now captures medications and other pharmacotherapies combined with lifestyle modifications such as eating healthier and quitting smoking. The multifaceted approach, known as comprehensive cardiovascular risk reduction, delivers additional benefits than from exercise alone.
• Emphasis. Lifestyle modification has taken on greater importance in the specialty of cardiac rehab, thanks to evidence that behavior change is just as effective or even superior to drugs prescribed to cardiac patients. As an example, Dr. Franklin notes that tobacco users “typically lose 10-12 years of life,” highlighting the significant health benefits associated with smoking cessation.
• Scope. While cardiac rehab traditionally covered one type of patient – i.e., heart attack survivors – programs now receive reimbursement for a much broader population. Today’s participants include individuals who have angina, or chest pain on exertion; those who’ve had bypass surgery; angioplasty patients who do or do not have stents; people with heart failure with reduced ejection fraction and heart transplant recipients, among others.
• Environment. Research over the past decade suggests that some enrollees benefit from monitored home-based programs as much as they do from center-based, medically supervised sessions.

Turning Point 

Meanwhile, perhaps one of the most pivotal developments in the history of cardiac rehab, according to Dr. Franklin, was the mainstream acceptance and incorporation of the specialty into the contemporary medical care ecosystem. This movement, he says, was exemplified by the inclusion of cardiac rehab recommendations in the guidelines of influential associations, starting with AACVPR and its clinical journal, JCRP. The list has since grown to include the likes of the American Heart Association, the American College of Cardiology, the American College of Sports Medicine and the American Society for Preventive Cardiology.

No one agrees more with the tremendous importance of CR guidelines than Patricia Comoss, RN, BS, MAACVPR, who in 2021 marked half a century in the profession. She was AACVPR President in 1992, when the federal government granted the organization a million-dollar contract to generate the very first guidelines in cardiac rehabilitation. AACVPR worked primarily with what was then known as the Agency for Health Care Policy and Research for 3 years before finally issuing the recommendations in 1995.

The publication had two significant impacts, according to Comoss, who currently works as a cardiopulmonary rehab consultant out of Harrisburg, Pennsylvania. First, she says, it set the stage for scientific evidence to drive clinical practice. “It was the first collection of the research on cardiac rehab up to that date,” she notes, or about 20 years’ worth of data gathered since the discipline had been established. At the same time, Comoss adds, the AACVPR guidance laid the foundation for the association’s future advocacy movement. “The guidelines connected AACVPR to the federal government and, from there, we expanded our Washington contacts,” she elaborates. “Literally, that was the birth of our lobbying efforts.”

The publication of Clinical Practice Guideline, No. 17, Cardiac Rehabilitation by the U.S. Department of Health and Human Services was basically a “one and done” endeavor, Comoss notes, with the professional organizations directed to take it from there. AACVPR followed up some years later with its own set of recommendation, which it has periodically updated, she says.

Pictured: Guideline project leaders. 
Front row, from left: Tina Murray, RN, Nanette Wenger, MD, Dottie Seidman. Back row, from left: Erika Froelicher, RN, Pat Comoss, RN, L. Kent Smith, MD

Future of the Field

With so many improvements since cardiac rehab first hit the scene in the 1960’s, one might wonder what changes are still in store for the specialty and its stakeholders. Dr. Franklin has some thoughts, including:

• The need for licensure for clinical exercise physiologists, whom he says also should be given more robust training in order to help counsel patients on behavior change and modification.
• The need for long-term data, ideally through better randomized controlled trials, in order to evaluate the outcomes associated cardiac rehab as well as compliance and dropout rates among participants.
• The need for new models to further enhance referral to, enrollment in and long-term participation in cardiac rehab.
• The need to include more diverse populations in cardiac rehab studies. “Hispanic, African American and Native American populations are oftentimes most afflicted by cardiovascular disease and may benefit the most from research,” Dr. Franklin notes,” yet they seldom participate in these trials.
• The need to clarify the role, benefits and safety of high-intensity interval training (HIIT) in patients who have had a heart attack or other cardiac event.

Virtual CR

Importantly, both of our seasoned pros emphasize, there’s also the question of what to do about virtual cardiac rehab, which is positioned to potentially reshape the discipline. “We’ve learned that cardiac rehab, education and counseling could reasonably be done via Zoom calls and computers,” says Dr. Franklin. The format enjoyed wide adoption and utilization during the COVID-19 pandemic; but reimbursement is tied to public health emergency status, which is set to be lifted this year. Looking over the horizon, Dr. Franklin believes further exploration is necessary on the safety and efficacy of remote, or virtual, delivery models.

Comoss seconds that opinion, explaining her viewpoint that the value of in-person rehab should not be forgotten as the industry gravitates toward virtual. There’s no question, she concedes, that new models are needed today – never mind in the future – to address insufficient capacity as the number of referrals continues to climb. “We don’t have room,” Comoss states, but COVID and other factors have put hospitals in a position where they’re unwilling to invest in more staff and equipment – more everything – to expand physical rehab units. Therefore, she believes the future focus should be on expanding capacity, so that both providers and patients have more options. “The point is,” she concludes, “that we need to preserve those conventional programs or traditional models of brick-and-mortar cardiac rehab while at the same time we’re building new models. It should be a compatible combination, and the patient should have a choice of which rehab he or she wants to attend. Because we all know that the patient won’t stick to it if it isn’t something they like. If they can choose, that’s already a step in the right direction.” Dr. Franklin argues that it must be established which populations are most likely to benefit from facility-based rehab, virtual or remote programs or a combination of both; and Comoss doesn’t disagree on that point.

Accessible, Beneficial, Practical

She generally frames the capacity issue as a “good problem” to have, in that it is a reflection of the growing availability and acceptance of cardiac rehab compared to the early years. In those days, only a handful of academic hospitals and research centers offered the service; and many providers needed convincing of its worth. Like Dr. Franklin, Comoss also recalls the wall of skepticism that science slowly and methodically deconstructed over time. She also is proud of AACVPR’s role in converting the science into real-world applications. “While the research answers a lot of the ‘what’ and ‘why’ we should be doing things in cardiac rehab,” she explains, “AACVPR’s publication provides the ‘HOW,’ or the translation from science to practice.”

Dr. Franklin understands how some might believe that with the arrival of new treatments, including statins, beta blockers and angioplasty, cardiac rehabilitation has lost some relevance. In response, he cites a landmark study conducted a few years ago and other recent reports that determined the benefits of cardiac rehab are as important today or even more important than years ago. “My personal inclination is probably the benefits are even greater today because of advancements in research, education, expanded populations and so forth,” he reasons. “Consider this quote by renowned scientist Sir Isaac Newtown: If I can see further, it is by standing on the shoulders of giants.”