Version May 2024
| Blood pressure management |
| Evaluation |
| Measure seated resting blood pressure on ≥two visits. |
| Measure blood pressure in both arms at program entry. |
| To rule out orthostatic hypotension, measure lying, seated, and standing blood pressure at program entry and after adjustments in antihypertensive drug therapy. |
| Assess current treatment and compliance. |
| Assess use of nonprescription drugs that may adversely affect blood pressure. |
| Interventions |
| Provide and/or monitor drug therapy in concert with primary healthcare provider as follows: |
| If blood pressure is 120 to 139 mmHg systolic or 80 to 89 mmHg diastolic: |
| • Provide lifestyle modifications, including regular physical activity/exercise; weight management; moderate sodium restriction and increased consumption of fresh fruits, vegetables, and low-fat dairy products; alcohol moderation; and smoking cessation. |
| • Provide drug therapy for patients with chronic kidney disease, heart failure, or diabetes if blood pressure is ≥130 / ≥80 mmHg after lifestyle modification. |
| If blood pressure is ≥140 mmHg systolic or ≥90 mmHg diastolic: |
| • Provide lifestyle modification and drug therapy. |
| Expected outcomes |
| Short-term: Continue to assess and modify intervention until normalization of blood pressure in prehypertensive patients; <140 mmHg systolic and <90 mmHg diastolic in hypertensive patients; <130 mmHg systolic and <80 mmHg diastolic in hypertensive patients with diabetes, heart failure, or chronic kidney disease. |
| Long-term: Maintain blood pressure at goal levels. |
| Lipid management |
| Evaluation |
| Obtain fasting measures of total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides. In those patients with abnormal levels, obtain a detailed history to determine whether diet, drug, and/or other conditions that may affect lipid levels can be altered. |
| Assess current treatment and compliance. |
| Repeat lipid profiles at four to six weeks after hospitalization and at two months after initiation or change in lipid-lowering medications. |
| Assess creatine kinase levels and liver function in patients taking lipid-lowering medications as recommended by NCEP. |
| Interventions |
| Provide nutritional counseling consistent with the Therapeutic Lifestyle Change diet, such as the recommendation to add plant stanol/sterols and viscous fiber and the encouragement to consume more omega-3 fatty acids, as well as weight management counseling, as needed, in all patients. Add or intensify drug treatment in those with low-density lipoprotein >100 mg/dL; consider adding drug treatment in those with low-density lipoprotein >70 mg/dL. |
| Provide interventions directed toward management of triglycerides to attain non-high-density lipoprotein cholesterol <130 mg/dL. These include nutritional counseling and weight management, exercise, smoking cessation, alcohol moderation, and drug therapy as per NCEP and AHA/ACC. |
| Provide and/or monitor drug treatment in concert with primary healthcare provider. |
| Expected outcomes |
| Short-term: Continue to assess and modify intervention until low-density lipoprotein is <100 mg/dL (further reduction to a goal <70 mg/dL is considered reasonable) and non-high-density lipoprotein cholesterol <130 mg/dL (further reduction to a goal of <100 mg/dL is considered reasonable). |
| Long-term: Low-density lipoprotein cholesterol <100 mg/dL (further reduction to a goal <70 mg/dL is considered reasonable). Non-high-density lipoprotein cholesterol <130 mg/dL (further reduction to a goal of <100 mg/dL is considered reasonable). |
| Diabetes management |
| Evaluation |
| From medical record review: |
| • Confirm presence or absence of diabetes in all patients. |
| • If a patient is known to be diabetic, identify history of complications such as findings related to heart disease; vascular disease; problems with eyes, kidneys, or feet; or autonomic or peripheral neuropathy. |
| From initial patient interview: |
| • Obtain history of signs/symptoms related to above complications and/or reports of episodes of hypoglycemia or hyperglycemia. |
| • Identify physician managing diabetic condition and prescribed treatment regimen, including: |
| - Medications and extent of compliance. |
| - Diet and extent of compliance. |
| - Blood sugar monitoring method and extent of compliance. |
| Before starting exercise: |
| • Obtain latest fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c). |
| • Consider stratifying patient to high-risk category because of the greater likelihood of exercise-induced complications. |
| Interventions |
| Educate patient and staff to be alert for signs/symptoms of hypoglycemia or hyperglycemia and provide appropriate assessment and interventions as per the American Diabetes Association. |
| In those taking insulin or insulin secretogogues: |
| • Avoid exercise at peak insulin times. |
| • Advise that insulin be injected in abdomen, not muscle to be exercised. |
| • Test blood sugar levels pre- and post-exercise at each session: if blood sugar value is <100 mg/dL, delay exercise and provide patient 15 g of carbohydrate; retest in 15 minutes; proceed if blood sugar value is >100 mg/dL; if blood sugar value is >300 mg/dL, patient may exercise if he or she feels well, is adequately hydrated, and blood and/or urine ketones are negative; otherwise, contact patient's physician for further treatment. |
| • Encourage adequate hydration to avoid effects of fluid shifts on blood sugar levels. |
| • Caution patient that blood sugar may continue to drop for 24 to 48 hours after exercise. |
| In those treated with diet, metformin, alpha glucosidase inhibitors, and/or thiozolidinediones, without insulin or insulin secretogogues, test blood sugar levels prior to exercise for first 6 to 10 sessions to assess glycemic control; exercise is generally unlikely to cause hypoglycemia. |
| Education recommendations: |
| • Teach and practice self-monitoring skills for use during unsupervised exercise. |
| • Refer to registered dietitian for medical nutrition therapy. |
| • Consider referral to certified diabetic educator for skill training, medication instruction, and support groups. |
| Expected outcomes |
| Short-term: |
| • Communicate with primary physician or endocrinologist about signs/symptoms and medication adjustments. |
| • Confirm patient's ability to recognize signs/symptoms, self-monitor blood sugar status, and self-manage activities. |
| Long-term: |
| • Attain FPG levels of 90 to 130 mg/dL and HbA1c <7 percent. |
| • Minimize complications and reduce episodes of hypoglycemia or hyperglycemia at rest and/or with exercise. |
| • Maintain blood pressure at <130 / <80 mmHg. |
| Tobacco cessation |
| Evaluation |
| Initial encounter: |
| • Ask the patient about his or her smoking status and use of other tobacco products. Document status as never smoked, former smoker, current smoker (includes those who have quit in the last 12 months because of the high probability of relapse). Specify both amount of smoking (cigarettes per day) and duration of smoking (number of years). Quantify use and type of other tobacco products. Question exposure to second-hand smoke at home and at work. |
| • Determine readiness to change by asking every smoker/tobacco user if he or she is now ready to quit. |
| • Assess for psychosocial factors that may impede success. |
| • Ongoing contact: Update status at each visit during first two weeks of cessation, periodically thereafter. |
| Interventions |
| When readiness to change is not expressed, provide a brief motivational message containing the "5 Rs": Relevance, Risks, Rewards, Roadblocks, and Repetition. |
| When readiness to change is confirmed, continue with the "5 As": Ask, Advise, Assess, Assist, and Arrange. Assist the smoker/tobacco user to set a quit date, and select appropriate treatment strategies (preparation): |
| Minimal (brief): |
| • Individual education and counseling by program staff supplemented by self-teaching materials. |
| • Social support provided by physician, program staff, family and/or domestic partner; identify other smokers in the house; discuss how to engage them in the patient's cessation efforts. |
| • Relapse prevention: problem solving, anticipated threats, practice scenarios. |
| Optimal (intense): |
| • Longer individual counseling or group involvement. |
| • Pharmacological support (in concert with primary physician): nicotine replacement therapy, bupropion hydrochloride. |
| • Supplemental strategies if desired (eg, acupuncture, hypnosis). |
| If patient has recently quit, emphasize relapse prevention skills. |
| Urge avoidance of exposure to second-hand smoke at work and home. |
| Expected outcomes |
| Note: Patients who continue to smoke upon enrollment are subsequently more likely to drop out of cardiac rehabilitation/secondary prevention programs. |
| Short-term: Patient will demonstrate readiness to change by initially expressing decision to quit and selecting a quit date. Subsequently, patient will quit smoking and all tobacco use and adhere to pharmacological therapy (if prescribed) while practicing relapse prevention strategies; patient will resume cessation plan as quickly as possible when temporary relapse occurs. |
| Long-term: Complete abstinence from smoking and use of all tobacco products for at least 12 months (maintenance) from quit date. No exposure to environmental tobacco smoke at work and home. |
| Psychosocial management |
| Evaluation |
| Identify psychological distress as indicated by clinically significant levels of depression, anxiety, anger or hostility, social isolation, marital/family distress, sexual dysfunction/adjustment, and substance abuse (alcohol or other psychotropic agents), using interview and/or standardized measurement tools. |
| Identify use of psychotropic medications. |
| Interventions |
| Offer individual and/or small group education and counseling on adjustment to heart disease, stress management, and health-related lifestyle change. When possible, include family members, domestic partners, and/or significant others in such sessions. |
| Develop supportive rehabilitation environment and community resources to enhance the patient's and the family's level of social support. |
| Teach and support self-help strategies. |
| In concert with primary healthcare provider, refer patients experiencing clinically significant psychosocial distress to appropriate mental health specialists for further evaluation and treatment. |
| Expected outcomes |
| Emotional well-being is indicated by the absence of clinically significant psychological distress, social isolation, or drug dependency. |
| Patient demonstrates responsibility for health-related behavior change, relaxation, and other stress management skills; ability to obtain effective social support; compliance with psychotropic medications if prescribed; and reduction or elimination of alcohol, tobacco, caffeine, or other nonprescription psychoactive drugs. |
| Arrange for ongoing management if important psychosocial issues are present. |
| Physical activity counseling |
| Evaluation |
| Assess current physical activity level (eg, questionnaire, pedometer) and determine domestic, occupational, and recreational needs. |
| Evaluate activities relevant to age, gender, and daily life, such as driving, sexual activity, sports, gardening, and household tasks. |
| Assess readiness to change behavior, self-confidence, barriers to increased physical activity, and social support in making positive changes. |
| Interventions |
| Provide advice, support, and counseling about physical activity needs on initial evaluation and in follow-up. Target exercise program to meet individual needs (see Exercise Training section of table). Provide educational materials as part of counseling efforts. Consider exercise tolerance or simulated work testing for patients with heavy labor jobs. |
| Consistently encourage patients to accumulate 30 to 60 minutes per day of moderate-intensity physical activity on ≥5 (preferably most) days of the week. Explore daily schedules to suggest how to incorporate increased activity into usual routine (eg, parking farther away from entrances, walking ≥2 flights of stairs, and walking during lunch break). |
| Advise low-impact aerobic activity to minimize risk of musculoskeletal injury. Recommend gradual increases in the volume of physical activity over time. |
| Caution patients to avoid performing unaccustomed vigorous physical activity (eg, racquet sports and manual snow removal). Reassess the patient's ability to perform such activities as exercise training program progresses. |
| Expected outcomes |
| Patient shows increased participation in domestic, occupational, and recreational activities. |
| Patient shows improved psychosocial well-being, reduction in stress, facilitation of functional independence, prevention of disability, and enhancement of opportunities for independent self-care to achieve recommended goals. |
| Patient shows improved aerobic fitness and body composition and lessens coronary risk factors (particularly for the sedentary patient who has adopted a lifestyle approach to regular physical activity). |
| Exercise training |
| Evaluation |
| Symptom-limited exercise testing prior to participation in an exercise-based cardiac rehabilitation program is strongly recommended. The evaluation may be repeated as changes in clinical condition warrant. Test parameters should include assessment of heart rate and rhythm, signs, symptoms, ST-segment changes, hemodynamics, perceived exertion, and exercise capacity. |
| On the basis of patient assessment and the exercise test if performed, risk stratify the patient to determine the level of supervision and monitoring required during exercise training. Use risk stratification schema as recommended by the AHA and the AACVPR. |
| Interventions |
| Develop an individualized exercise prescription for aerobic and resistance training that is based on evaluation findings, risk stratification, comorbidities (eg, peripheral arterial disease and musculoskeletal conditions), and patient and program goals. The exercise regimen should be reviewed by the program medical director or referring physician, modified if necessary, and approved. Exercise prescription should specify frequency (F), intensity (I), duration (D), modalities (M), and progression (P). |
| • For aerobic exercise: F=3-5 days/wk; I=50-80 percent of exercise capacity; D=20-60 minutes; and M=walking, treadmill, cycling, rowing, stair climbing, arm/leg ergometry, and others using continuous or interval training as appropriate. |
| • For resistance exercise: F=2-3 days/wk; I=10-15 repetitions per set to moderate fatigue; D=1-3 sets of 8-10 different upper and lower body exercises; and M=calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, or weight machines. |
| Include warm-up, cool-down, and flexibility exercises in each exercise session. |
| Provide progressive updates to the exercise prescription and modify further if clinical status changes. |
| Supplement the formal exercise regimen with activity guidelines as outlined in the Physical Activity Counseling section of this table. |
| Expected outcomes |
| Patient understands safety issues during exercise, including warning signs/symptoms. |
| Patient achieves increased cardiorespiratory fitness and enhanced flexibility, muscular endurance, and strength. |
| Patient achieves reduced symptoms, attenuated physiologic responses to physical challenges, and improved psychosocial well-being. |
| Patient achieves reduced global cardiovascular risk and mortality resulting from an overall program of cardiac rehabilitation/secondary prevention that includes exercise training. |
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