By Todd M. Brown, MD, MSPH, FACC, FAHA, MAACVPR
Happy Cardiac Rehabilitation Week! This is a great time to celebrate all you do to help patients restore and improve their cardiovascular health. It is also a good time to reflect on the core components of what we deliver to our patients each day. I was recently fortunate to work with a team of experts to review and modernize the Core Components of Cardiac Rehabilitation, which has not been updated since 2007. The manuscript is currently live on the Journal of Cardiopulmonary Rehabilitation and Prevention (JCRP) website (https://journals.lww.com/jcrjournal/pages/default.aspx) and will be published in the March 2025 issue.
As you all know, cardiac rehabilitation helps patients live longer, improves their quality of life, and helps prevent recurrent cardiovascular events. As a result, numerous clinical practice guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend cardiac rehabilitation in patients with coronary artery disease, valvular disease, and heart failure. In addition, ACC, AHA, and AACVPR have issued performance measures promoting patient referral, enrollment, and adherence; improvements in functional capacity, depressive symptoms, and blood pressure; and the importance of tobacco cessation counseling.
The foundation for the Core Components of Cardiac Rehabilitation is the Social Security Act, which mandates that all cardiac rehabilitation programs include physician-prescribed exercise, cardiac risk factor modification, psychosocial evaluation, and outcomes assessment. In the updated scientific statement, our team first reviewed the scientific basis of each of the prior core components: patient assessment; nutritional counseling; weight management; blood pressure, lipid, and diabetes management; tobacco cessation; psychosocial management; exercise training; and physical activity counseling. Each one was deemed to still be integral to a cardiac rehabilitation program. But we felt that some expansion of these components was warranted.
What Is New About the 2024 Core Components?
First, we expanded the component of weight management to now encompass weight management and body composition. The change emphasizes the need to measure body composition beyond simply weight or body mass index. Other measures such as waist circumference, waist-to-hip ratio, and assessments of lean body mass complement the simple assessment of weight and body mass index. Improvements in body composition are associated with reduced cardiovascular risk, and assessment of these measures should be part of all cardiac rehabilitation programs.
Second, we separated exercise training into two separate components: aerobic exercise and strength training. A large body of literature has emerged since 2007 on the importance of strength training in combating frailty and in improving cardiorespiratory fitness and the functional independence of patients with cardiac disease. As such, the writing group felt that strength training had enough scientific evidence to represent its own component in addition to the component of aerobic exercise training, which remains a critical component of all cardiac rehabilitation programs.
Third, we added a new component of program quality. Outcomes assessment has always been a part of cardiac rehabilitation, but it previously focused on individual outcomes in patients who enrolled in and completed cardiac rehabilitation. However, in recognition of the fact that high-quality cardiac rehabilitation programs regularly monitor their processes and outcomes and continuously engage in quality improvement, we introduced this new component of program quality to emphasize the need to improve widely documented low enrollment and adherence rates and reduce health disparities in cardiac rehabilitation access. The recently published AACVPR performance measures on enrollment and adherence in cardiac rehabilitation are excellent metrics to judge the quality of your own programs.
What About Delivery?
Historically, cardiac rehabilitation has been provided in person, with patients traveling to the cardiac rehabilitation gym in a hospital or, less frequently, a physician office. But many programs and patients desire new methods to deliver these sessions. In the update to the core components, we follow the delivery models as outlined by the Million Hearts Cardiac Rehabilitation Think Tank. These new models include virtual (synchronous) sessions and remote (asynchronous) sessions. Virtual sessions describe those where cardiac rehabilitation professionals interact with patients for the entire duration of the session using real-time audio-visual communications technology, while remote sessions lack this real-time interaction. Hybrid programs are those programs that use more than one of these delivery methods: in-person, virtual, or remote.
New ways of delivering cardiac rehabilitation have the potential to improve equity in cardiac rehabilitation participation by meeting the needs of individual patients and by making cardiac rehabilitation a truly patient-centric intervention. However, I must underscore that these new ways to deliver cardiac rehabilitation must not change the foundation of what is delivered. Newer delivery models that do not adhere to the core components of cardiac rehabilitation are not cardiac rehabilitation and should not be viewed as an alternative to cardiac rehabilitation.
What’s Next?
Celebrate Cardiac Rehabilitation Week! Reflect on all you currently do to improve patient lives. And take a moment this week to download the new Core Components update and look for new ways to improve your programs.
Todd Brown, MD, MSPH, FACC, FAHA, MAACVPR, is a cardiologist and Professor of Medicine in the UAB Division of Cardiovascular Diseases, where he is medical director of the cardiac rehabilitation program. Dr. Brown is a past president of AACVPR and currently serves as Director-at-Large on the Board of Directors. Additionally, he is Editor-in-Chief of the Journal of Cardiopulmonary Rehabilitation and Prevention.