Issues in contemporary cardiac rehabilitation: a historical perspective.

Cardiac rehabilitation consists of exercise, psychosocial support and education and is prescribed most often for patients with coronary heart disease. Its purpose is to facilitate readaptation to normal life through the achievement of maximal functional capability and to reduce heart disease risk factors. It began historically with progressive ambulation after myocardial infarction and by 1980 became a standardized inpatient therapy performed according to a stepped procedure. Predischarge exercise testing was added and has become a meaningful contribution to the concept of risk stratification after an acute coronary event. Rehabilitation has subsequently become part of the outpatient environment and is delivered by multiple models. Meta-analyses have shown that rehabilitation reduces overall and cardiovascular deaths by about 20% and sudden death by about 37% during the year after an acute myocardial infarction. The significance of this, however, must now be modulated by the dynamic role of aggressive coronary intervention. Selection for such intervention has become an important adjunctive aspect of rehabilitation. Newer findings suggest that those stratified at low risk will benefit most by the modification of coronary risk factors, and that patients previously thought to be poor candidates for rehabilitation (such as those with significant left ventricular dysfunction and low work capacity) may experience substantial relative functional benefit. Beyond risk stratification, important contemporary issues include surveillance of patients after angioplasty, the effectiveness of rehabilitation in the attenuation or reversal of both native and vein graft atherosclerosis and consideration of such currently emphasized end points as quality of life and economic evaluation.