JS-CME-2: REDUCTION IN CARDIOVASCULAR MORBIDITY AND MORTALITY BY CARDIAC REHABILITATION: WHAT'S THE EVIDENCE?

Abstract

The Japanese Society of Cardiac Rehabilitation defines cardiac rehabilitation (CR) as follows. Cardiac rehabilitation refers to a long-term, multifaceted, comprehensive program designed to optimize a cardiac patients physical, psychological, social, and vocational status, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic or heart failure processes, thereby reducing recurrence, rehospitalization and mortality and enabling patients to live comfortably and actively. CR programs include medical assessment, prescribed exercise training, coronary risk factor modification, patient education, counseling and optimal medical therapy for individual patients, which are provided by a multi-disciplinary team in a coordinated manner. Comprehensive CR consists of continuous multidisciplinary team medical care centered on exercise therapy and disease management. Comprehensive CR improves exercise tolerance and physical function in most heart diseases. Improvements in subjective symptoms and QOL are also observed in many heart diseases. Concerning long-term prognostic improvement effect, it is observed in coronary artery disease and heart failure. Reduced readmissions are also observed in heart failure patients. Mechanisms for improving the long-term prognosis of patients with coronary artery disease and heart failure include: 1) improvement of coronary risk factors, 2) improvement of vascular endothelial function and systemic anti-arteriosclerosis/anti-inflammatory effects via suppression of oxidative stress, 3) improvement of autonomic nerve function, 4) increase in skeletal muscle mass and associated various myokine actions. Based on the above-mentioned evidence, all clinical guidelines of the Japanese Circulation Society, AHA, and ESC strongly recommend participation in CR as class I (evidence and/or general agreement that a given procedure or treatment is effective and useful) for patients after acute myocardial infarction. In post-CABG patients, American and European guidelines recommend CR as Class I. As for chronic heart failure, exercise therapy is strongly recommended as class I in all heart failure clinical guidelines in Japan, Europe, and the United States. However, a clinical problem is the low rate of CR participation in patients with heart disease. This tendency is particularly conspicuous in Japan. Furthermore, an increase in the number of elderly heart failure patients with frailty is also a major issue. There is a need to create a system that supports patients through a community network throughout the acute, recovery, and maintenance phases.