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GUIDELINES
French Society of Cardiology guidelines for cardiac
rehabilitation in adults夽
Recommandations de la Société française de cardiologie pour la pratique de la
réadaptation cardiaque chez l’adulte
Bruno Pavy a,∗, Marie-Christine Iliou b,
Bénédicte Vergès-Patois c, Richard Brion d,
Catherine Monpère e, François Carré f,
Patrick Aeberhard g, Claudie Argouach h,
Anne Borgne i, Silla Consoli j, Sonia Corone k,
Michel Fischbach l, Laurent Fourcade m,
Jean-Michel Lecerf n, Claire Mounier-Vehier o,
François Paillard f, Bernard Pierre p,
Bernard Swynghedauw q, Yves Theodose r,
Daniel Thomas s, Frédérique Claudot t,
Alain Cohen-Solal q, Hervé Douard u, Dany Marcadet v ,
Exercise, Rehabilitation Sport Group (GERS)
a
Service de réadaptation cardiovasculaire, centre hospitalier Loire-Vendée-Océan, BP 2,
44270 Machecoul, France
b
Hôpital Corentin-Celton, AP—HP, Issy-les-Moulineaux, France
c
Clinique Les Rosiers, Dijon, France
d
Centre Dieulefit Santé, Dieulefit, centre Bayard, Villeurbanne, France
e
Centre Bois-Gibert, Ballan-Miré, France
f
CHU de Rennes, Rennes, France
Received 22 January 2012; accepted 23 January 2012
Available online 16 April 2012
Abbreviations: CSP, Code de la Santé Publique; FCR, Follow-up care and rehabilitation; FSC, French Society of Cardiology; HF, Heart failure;
MET, Metabolic equivalent; NYHA, New York Heart Association; TEP, Therapeutic education programme; VT1, First ventilatory threshold.
夽 This text is an extract from the reference ‘‘Good Practice for Cardiac Rehabilitation in Adults in 2011’’, which is available on the
website of GERS (Groupe Exercice Réadaptation Sport of the French Society of Cardiology [Société française de cardiologie];
http://www.sfcardio.fr/groupes/groupes/exercice-readaptation-sport) and contains the complete bibliography, replacing the French
Society of Cardiology text of 2002, version 2, establishing recommendations for cardiac rehabilitation in adults.
∗ Corresponding author. Fax: +33 02 40 78 44 60.
E-mail address: [email protected] (B. Pavy).
1875-2136/$ — see front matter © 2012 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.acvd.2012.01.010
310
B. Pavy et al.
g
CCN, Paris, France
IFSI de Morlaix, Morlaix, France
i
Hôpital Jean-Verdier, AP—HP, Bondy, France
j
Hôpital européen Georges-Pompidou, AP—HP, Paris, France
k
Centre médical de Bligny, Briis-sous-Forges, France
l
Clinique Bordeaux-Nord, Bordeaux, France
m
Centre hospitalier des Armées, Marseille, France
n
Institut Pasteur de Lille, Lille, France
o
CHU de Lille, Lille, France
p
Clinique IRIS-Marcy l’Etoile, Lyon, France
q
Hôpital Lariboisière, AP—HP, Inserm, Paris, France
r
Centre William-Harvey, Saint-Martin d’Aubigny, France
s
Groupe hospitalier Pitié-Salpétrière, AP—HP, Paris, France
t
CHU de Nancy, Nancy, France
u
CHU de Bordeaux, Pessac, France
v
Clinique Bizet, Paris, France
h
KEYWORDS
Cardiac
rehabilitation;
Exercise training;
French guidelines;
Société française de
cardiologie;
Therapeutic
education
MOTS CLÉS
Réadaptation
cardiaque ;
Recommandations
françaises ;
Entraînement
physique ;
Éducation
thérapeutique
Background
‘‘Cardiovascular rehabilitation is the sum of activities
required to favourably influence the underlying causes of
the disease, as well as to ensure the patients the best possible physical, mental and social conditions, so that they may
by their own efforts, preserve or resume when lost, a place
as normal as possible in the life of the community’’ (World
Health Organization, 1993).
Rehabilitation in France is organized according to two
decrees and one circular letter [1—3]. Follow-up care and
rehabilitation (FCR) activities are now required. FCR for
cardiovascular pathology is officially recognized as an FCR
speciality with specific needs, which is subject to authorization by the Regional Health Authorities. Specialized FCR
centres for cardiovascular pathology must be able to manage
patients with cardiovascular problems, whatever the severity of the disease, either with conventional hospitalization
or ambulatory care. To fulfil this last obligation, the French
Society of Cardiology (FSC) recommends that a cardiologist
takes responsibility for, and coordinates, specialized FCR for
cardiovascular pathology.
The aim of rehabilitation in cardiovascular pathology is
to enable patients to adapt their life as best as possible
to their disease and to take responsibility for optimizing
their health status. Cardiovascular rehabilitation is based
upon the following three elements: exercise training and
education on long-term physical maintenance; therapeutic
optimization, which should be adapted to the state of the
patient and their way of life; specific therapeutic education,
which should be multidisciplinary and give the patient the
means to improve their prognosis by adapted behaviours.
The management of this approach must take into account
the patient’s psychological state, as well as social, familial
and vocational factors.
Cardiovascular rehabilitation is therefore a learning
period in order to put in place a new way of life in the long
term. It has proven effectiveness, which includes socioeconomics. It requires global patient management which must
be generalized and also developed.
FSC guidelines for cardiac rehabilitation in adults
Recommendation 1: exercise training
programme
Physiopathological basis [4—18]
Physical exercise induces beneficial effects in both primary
and secondary prevention. One metabolic equivalent ([MET]
3.5 mL/minute/kg of oxygen consumption) improvement in
functional capacity is followed by an almost 15% reduction
in mortality. The recognized beneficial effects are due to
intertwined mechanisms: reduction of systemic inflammation, sometimes subclinical, associated with these chronic
pathologies; antioxidant effects; antithrombotic effects;
neurohormonal effects; effects on remodelling and vascular function; and effects on muscular remodelling. These
favourable effects of training apply to: cardiovascular risk
factors; ageing; coronary artery disease; chronic heart failure (HF); and peripheral vascular disease.
Initial evaluation
Initial evaluation before cardiac rehabilitation is based, at
least, on the following [19—24]: clinical evaluation (history and physical examination); resting electrocardiogram;
transthoracic echocardiography; and exercise stress test
(see below). Attention must also be paid to indications from
other targeted examinations, including biological tests.
Exercise stress test
Exercise stress tests must fulfil the protocols and safety criteria for cardiological stress tests [21,25,26]. These tests
are often performed under medical treatment. The initial
test must be: maximal if possible or limited by the symptoms; in some cases limited by a maximal heart rate (i.e.
patients with implanted defibrillators); and in some cases
limited by a maximal arterial systolic pressure (i.e. following
aortic dissection or aortic aneurysm surgery).
Cardiorespiratory exercise stress test with analysis of
gas exchange should be performed whenever possible. This
allows evaluation of aerobic capacity (oxygen consumption
[VO2 ] max or peak) and determination of the ventilatory
adaptation threshold, which corresponds to the first ventilatory threshold (VT1).
An intermediary exercise stress test is indicated in case of
new symptomatology under exercise or a therapeutic modification that could affect the chronotropic function of the
heart, or to update prescriptions according to the patient’s
improved state of health. A final exercise stress test allows
an objective evaluation of the patient’s physical capacities
after rehabilitation.
A 6-minute walk test is used to evaluate the adaptation
of the patient to submaximal efforts typical of everyday life
[27—29]. A muscular strength test (e.g. determination of
maximal voluntary force) is useful for certain patients to
guide resistance training.
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60 minutes), using the large muscles of the body. The intensity of the training can be prescribed according to the data
shown in Table 1 [30—33].
Interval endurance training is characterized by alternating short-duration efforts of high intensity with periods
of active recuperation. Several combinations are possible,
with phases of high intensity (80 to 95% of maximal aerobic
power) lasting from 10 seconds up to 1 or 2 minutes and with
periods of active recuperation (20 to 30% of maximal aerobic
power) for 1 to 4 minutes [34].
Dynamic resistance training is performed for muscular
strengthening, with small weights, weighted wrist bands or
elasticised bands, or by using weight benches with adapted
equipment [35]; a succession of eight to ten different types
of movement are repeated 10 to 15 times at a low intensity
(30 to 50% of maximum strength). Two to three sessions lasting for 20 to 30 minutes are performed each week, adapted
to each context (recent sternotomy or implantation of pacemaker/cardiodefibrillator) [36].
Gymnastic exercises on the floor, on a bar or in water
optimize this reconditioning through workouts that include
the upper and lower limbs to improve coordination, flexibility, balance and strength of muscles and ligaments.
Breathing exercises complete the programme (tidal volume, control of air flow and ventilatory rhythm). These may
be performed individually or in training group sessions.
Electromyostimulation can be used alternatively or in
combination with exercise training for patients in very poor
physical condition or with HF [37].
Organization of training sessions
The training prescription must specify the type, intensity,
duration and frequency of the sessions. Each endurance session includes a warm-up period of 5 to 10 minutes, a training
period of 20 to 45 minutes and a cool-down period of at least
5 minutes. The optimal frequency of the sessions is three to
six per week. A minimum of 20 sessions is required to obtain
a significant improvement in functional capacity. In the most
unfit patients and in patients with HF, a larger number of sessions are often necessary. Later on, supplementary sessions
can improve compliance and allow exercise training advice
to be updated. The organization of this must be personalized
(i.e. number of sessions, frequency).
Regarding monitoring, a cardiologist must be present and
available close to the training rooms in order to immediately
intervene at the supervision team’s request. The presence
of at least one qualified person is required in each training
area during the sessions. The number of patients managed
during an endurance or gym session should be adapted to
ensure optimal supervision and patient safety.
Telemetric monitoring during the initial training sessions
is recommended. If necessary, heart rate monitoring is subsequently maintained according to medical advice. Brachial
artery pressure is monitored. Oxygen saturation monitoring
is sometimes appropriate.
Training modalities
Recommendation 2: education programme
This training includes endurance sessions and dynamic resistance sessions. Endurance training at a constant intensity
is characterized by prolonged submaximal exercise (20 to
The education program must be structured and include education about the disease, signs, nutritional education, help
312
B. Pavy et al.
Table 1
Prescription intensity in steady-state endurance training.
Training heart rate
If exercise stress test with VO2
If exercise stress test without VO2
Karvonen formula
HR at first ventilatory threshold (VT1)
THR = resting HR + [(max HR — resting HR) × K]
K = 0.6 if patient is without beta-blockers
K = 0.8 if patient is taking beta-blockers
Heart rate limit
If patient has angina
If implanted cardiodefibrillator
< 10 bpm under the threshold for angina
< 10 to 20 bpm under the pre-programmed triggering HR
Systolic arterial pressure < 160 mmHg
After aortic dissection
Patient’s sensations (respiratory, muscular)
Levels 12—14 on the 20-point Borg scale
Levels 4—6 on the 10-point VAS
Able to speak easily without becoming breathless
bpm: beats per minute; HR: heart rate; THR: training heart rate; VAS: visual analogue scale; VO2 : oxygen consumption.
in smoking cessation, management of antithrombotic treatment and prophylaxis of infective endocarditis.
Structured therapeutic education programme
The ministerial decrees of 2nd August 2010 outlined the
specificities and authorization conditions for the therapeutic education programme (TEP) for patients [38,39], which
should conform to the quality criteria and the approaches
defined by the guidelines [40,41].
Cardiac rehabilitation centres allow integration of the
TEP into patient care. At these centres there are several
structured activities facilitated by a multidisciplinary team,
to help patients to become actively involved in control of
their risk factors and disease, and thereby work towards
cardiovascular prevention [42]. These collective group training sessions (Tables 2 and 3) are run by the medical and
paramedical rehabilitation teams. These teams must be
trained in the techniques of TEP and be competent for the
issues addressed. The group teaching should be complemented by individual sessions.
The organization of the TEP must be carefully planned
and coordinated, and regularly reviewed by multidisciplinary consultations.
Table 2
Nutritional education
Several nutritional factors are directly or indirectly implicated in the occurrence and progression of coronary artery
disease. A Mediterranean diet [43,44] and a high intake of
omega-3 long-chain polyunsaturated fatty acids [45,46] have
been proven by intervention studies to reduce cardiovascular morbidity and mortality.
It is important to establish a dietary survey (questionnaires applicable to French dietary habits and adapted to
prevention of cardiovascular events) [47,48], provide nutritional education (individual and/or collective), promote a
Mediterranean diet enriched in omega-3 for patients with
coronary artery disease (Table 4) and adapt counselling
according to the context (hypertension, diabetes, obesity,
HF, renal insufficiency, malnutrition).
Smoking cessation programme
Tobacco is a major cardiovascular risk factor and to stop
smoking is one of the most effective secondary prevention
measures [49—51]. Controlling this risk factor is therefore
part of all cardiovascular rehabilitation programmes.
In the initial assessment, tobacco consumption should be
completely and precisely documented. The patient must be
informed of the importance of stopping and must be offered
support during the process of stopping and in the prevention
Educational themes.
Collective group themes (suggestions)
The heart and its function
Cardiovascular risk factors
Pathologies (coronary artery disease, heart failure,
peripheral artery disease)
Cardiology investigations
Warning signs (angina, dyspnoea)
Self-assessment techniques (blood pressure, glycaemia)
Medications
Life-saving measures
Table 3
Practical workshops.
Theme
Examples
Nutrition
Reading labels
Choosing food at the
supermarket
Recognizing foods rich in salt,
sugar and fat
Physical activity
Managing endurance training
Travel, sexuality, driving
Managing daily-life activities
FSC guidelines for cardiac rehabilitation in adults
Table 4
Antiatheromatous diet.
Principles of Mediterranean diet adapted for coronary
artery disease patients
Advise consumption of
at least five portions of fruit and vegetables every
day
extra virgin olive oil, tea, cocoa and soya (rich in
polyphenols)
fish at least three times per week, including two
servings of oily fish
foods rich in ALA: nuts, nut oil, rapeseed oila
foods with a low glycaemic index
dry vegetables twice per week
two to three servings of fruits per day
foods rich in starch
fermented foods
foods rich in fibre
The consumption of wine and/or beer can be
maintained unless contraindicated (alcohol
dependence, pathological link to alcohol), limited to
one to two glasses per day, during meals
Reduce consumption of foods high in saturated fat
Restrict red meat (beef once or twice per week,
mutton/lamb once a month)
Replace butter with a margarine rich in omega-3
fatty acids
Restrict cheese to 30 to 40 g per day
Restrict cooked meats to 70 to 100 g per week
Restrict eggs to four to six per week
Avoid partially hydrogenated oils and palm oil
(pastries, cakes, biscuits, Viennese pastries, ordinary
margarines)
Reduce consumption of salt (especially in cases of
hypertension and/or heart failure)
ALA: alpha linolenic acid (an essential precursor of omega-3
polyunsaturated fatty acids).
a The daily consumption of two spoonfuls of rapeseed oil provides two-thirds of the recommended intake of ALA.
of restarting. Nicotine substitutes can be provided on leaving the intensive care unit immediately following myocardial
infarction [52]. Patches can be combined with oral forms to
eliminate the desire to smoke completely [53]. The substitution is then reduced over a minimum period of 3 months,
which can be prolonged if necessary. Behaviour and cognitive
therapies are based on learning self-control, management of
stress and self-affirmation techniques [54,55].
Anxiolytic/antidepressant treatments
Specific psychotherapy and/or medications to treat anxiety and/or depression may be essential in some cases. The
nurses in the multidisciplinary team have the important role
of listening to and motivating these patients [56—58]. Prolonged follow-up should be ensured, with close co-operation
with the cardiologist and treating physicians, who should be
made aware of the programme [59]. The patients should
have a prescription for products to help them to stop smoking and prearranged follow-up consultations when leaving
313
the rehabilitation centre. The medical report of the hospitalization addressed to the physician managing the follow-up
must include details of the treatments started and the
follow-up information. The multidisciplinary team should
integrate a consultation with a tobacco addiction specialist. Alternatively, a member of the medical or nursing team
should have received training about tobacco addiction.
Education on antithrombotic treatment
Because of the risks inherent in this treatment, patient education plays a crucial role in the correct use of antivitamin K
treatment [60] (Table 5). It is important to provide education
on the management of antivitamin K treatment (individual and/or collective), provide and/or update comments
in the patient’s anticoagulant record book and provide the
patient with record files containing details of antiplatelet
treatments. General practitioners should be informed of the
information and education provided to their patients.
Prophylaxis for infective endocarditis
The European recommendations of September 2009 [61,62]
currently restrict prophylactic antibiotic use to: three categories of patients at the highest risk of infective endocarditis
(carriers of prosthetic valves, those with a history of endocarditis and those with complete correction of cyanogenic
congenital heart disease); only one situation of risk (dental treatment affecting the gums or the periapical region or
accompanied by perforation of the buccal mucosa).
The patients concerned should be provided with information on prophylaxis, education concerning buccodental
hygiene and a specific treatment card.
Recommendation 3: psychosocial
management
Psychological management
Negative effect (anxiety, depression, propensity to anger
and hostility) is important among the risk factors for coronary artery disease [63]. The type D personality profile
(excessive negative effect and social inhibition) is associated with an increased risk of mortality or restenosis
after stent implantation [64,65]. Depression is predictive of
unfavourable outcomes in coronary artery disease patients
[66,67] and should be screened for, and integrated into, the
therapeutic objectives [68,69]. Following a cardiac rehabilitation programme significantly reduces mortality among
depressed patients with coronary artery disease [70]. Job
stress is a factor favouring progression of atherosclerosis and
is a precipitating factor in major cardiovascular events.
Screening for psychological risk factors should be done
using specific validated questionnaires (14-item Hospital
Anxiety Depression scale, shortened version of the 13-item
Beck Depression Inventory) [71,72].
314
Table 5
B. Pavy et al.
Education on antithrombotic treatments.
Anticoagulant medications
Antiplatelet agents
Knowledge of the name and dose
Indications and expected duration of treatment
Course of action when missed
Drug interactions
Notifying the presence of the treatment
Biological follow-up, target INR
Warning signs of overdose
Knowledge of the name and dose
Indications and expected duration of treatment
Course of action when missed
Drug interactions
Notifying the presence of the treatment
INR: international normalized dose.
Role of the psychologist or the consultant
psychiatrist
All cardiovascular rehabilitation programmes must
include support for professional reintegration, particularly
for patients in whom the clinical and/or psychological characteristics or the physical difficulty of the work are risk
factors for not resuming work.
A decision by the occupational physician of partial or
complete unsuitability for the current job can have substantial consequences for the patient and should only be taken
as a last resort.
All patients are encouraged to consult their occupational physician before returning to work in cases where
it will be necessary to temporarily or permanently adapt
their work (altered working hours, restructuring, changing
jobs, training course). Therapeutic part-time work offers an
opportunity to gradually return to work while allowing the
patient to follow an ambulatory rehabilitation programme
in parallel.
The presence of a psychologist in the cardiovascular rehabilitation team is highly desirable. It is essential that the
psychologist makes themselves available to all patients;
they participate in the TEP, inform patients on the role of
psychosocial factors and the notions of perceived stress,
detect eventual sexual dysfunction in patients and take part
in group meetings [73,74].
Non-pharmacological approaches may consist of patient
discussion groups complemented by individual interviews,
meditation exercises (yoga, relaxation sessions) and techniques to help to control stress [75—77].
Pharmacological approaches may comprise hypnotics,
which can be prescribed very occasionally on request, and
antidepressants, which are prescribed in cases of diagnosed
depression, panic attacks, symptoms of phobia and posttraumatic stress. The prescription of antidepressants should
be combined with a prolonged personal follow-up beyond
the rehabilitation period.
Recommendation 4: daily life
Return to work
Driving motor vehicles
Resuming work is one of the aims of cardiovascular rehabilitation and has personal as well as medicoeconomic
consequences [78,79].
Some studies on the factors influencing restarting work
after acute coronary syndrome confirm the poor predictive
value of clinical variables (20%) compared with demographic
and socioeconomic variables (45%) [80]. Depression during
the acute phase may also be a negative factor for resuming
work, independent of clinical and sociodemographic data
[81]. Furthermore, work perceived as restrictive (heavy load
and little decisional latitude) may be associated with an
increased risk of recurrence of cardiovascular events [82].
Stress management plays a determining role when resuming one’s professional life through the optimization of stress
capacity and, psychologically, through the positive selfimage generated by the patient.
The balance between the functional capacity of the
patient and their work can be evaluated using scales,
although this approach has limitations [83]. The results of
the exercise stress test, particularly the cardiopulmonary
exercise test, can be exploited to advise the patient and
the occupational physician. The physical difficulty of the
patient’s work can be assessed during ergonomic assessments or in on-site situations by ambulatory measurements
of blood pressure and heart rate.
Aptitude for driving is dependent on the risk of loss of
consciousness. The decree of 31st August 2010 modified
the decree of 21st December 2005, establishing the list of
medical conditions incompatible with driving light vehicles
(private) and heavy vehicles [84]. Drivers of light vehicles are not subject to a preliminary medical aptitude test
or regular examinations, whereas drivers of heavy vehicles —– mostly professional drivers —– are subject to tighter
regulatory constraints.
Any physician expressing restrictions about the patient’s
aptitude for driving must respect medical confidentiality and
should therefore try to convince the patient to contact the
medical commission of aptitude and provide all elements
relevant to making a decision. The opinion, with supporting arguments, of the rehabilitation service must be clearly
present in the patient’s medical file and, if the patient has
no objections, in the release documents. Consultation of the
tables specifying the aptitudes according to pathologies published in the French Official Journal is recommended before
all decisions.
Travel advice
Coronary artery disease is one of the most frequent causes
of hospitalization of Europeans abroad [85] and is the second
FSC guidelines for cardiac rehabilitation in adults
most frequent cause of death and repatriation of French citizens abroad [86]. Cardiac arrest is rare during flight. Since
January 2010, all planes passing over French territories must
be equipped with a semiautomatic defibrillator.
It is recommended to know the local health care structures prior to travelling (available at www.cimed.org), as
well as the time typically taken to provide care locally. Contraindications to air travel for the coronary artery disease
patient are [87]: coronary angioplasty or acute coronary syndrome less than 2 weeks prior to travel; coronary artery
bypass surgery less than 3 weeks prior to travel; unstable HF;
and uncontrolled supraventricular arrhythmia or ventricular
arrhythmia.
Some general precautions are recommended before travelling: obtain health insurance for medicalized repatriation,
covering the repatriation fees of patients with prior known
cardiovascular disease; have a summary of the patient’s
medical files translated into English if needed; have a
reference electrocardiogram trace; have the name (international non-proprietary name) of prescribed medication;
have a sufficient stock of medications to cover the journey;
have the necessary treatment readily available in the aircraft and be in possession of a prescription; ensure sufficient
time in airports (boarding, transit, etc.).
Trips to high altitude
An adapted physical condition and at least 4 weeks of clinical stabilization are required before considering physical
activity over 1500 to 2000 m, following a negative exercise
stress test [88,89].
315
contraindication is coprescription of nitrate derivatives,
which carries the risk of a major hypotensive episode.
Patients must be informed [95].
Cardiovascular rehabilitation favours the resumption of
a sex life following a cardiac event [96].
Physical activity in sedentary patients
The rehabilitation period is the time to start or restart physical activity. The benefits should be maintained by continuing
regular physical activity. The activities chosen should be
appropriate for realistic integration into the professional,
social and family life of the patient.
The objectives are as follows [97,98]: suggest new
behaviours (walking, using the stairs, reducing the time
spent in front of the television or the computer); encourage
the practice of physical activity tailored towards endurance
(walking, cycling, swimming), equivalent to 30 minutes of
walking per day (or 3 or 4 hours per week), of moderate intensity (breathing easily, ‘‘slightly difficult’’ on the
Borg scale), possibly in a heart rate target ‘‘zone’’; include
strength training (gym, aquagym) twice per week; ensure
regularity (support from family and friends, activity at a
club, indoor activities); advertise the Heart and Health Clubs
(www.fedecardio.com); avoid intense static efforts and bad
weather (cold, wind); report all unusual symptoms (pain,
dyspnoea, malaise); reduce or stop training in case of febrile
episodes [99].
Trips to tropical areas
There is no specific contraindication to vaccinations, but
prophylaxis for malaria should be adapted as appropriate
[90].
Sexual activity
Sexual health is a quality of life criterion according to the
World Health Organization and requires appropriate management. The cardiologist is involved because there is a very
strong statistical association between erectile dysfunction
and cardiovascular disease; this is due to endothelial dysfunction [91—94].
Sexual activity involves a moderate physical effort (2.5
to 3.3 METs), added to which there is a non-negligible emotional component. Sexual activity should not be limited if
the patient can achieve 60 watts on the bicycle or easily
climb two flights of stairs. The risk of triggering an acute
coronary syndrome following sexual activity is low, especially if the patient practices regular physical activity [93].
Several treatments for coronary artery disease have an
effect on erectile dysfunction. It is important to speak to
patients to reassure them and adjust the choice of treatments on an individual basis. Do not hesitate to work in
a network with the help of other specialists (to screen
for other possible causes: endocrine or urological). Specific inhibitors of type 5 phosphodiesterase, which are nitric
oxide donors for the treatment of erectile dysfunction,
have good haemodynamic tolerance and can be prescribed
for stable coronary artery disease patients. The only
Physical activity in physically active patients
A history of sport activity is a factor that should be systematically investigated at the start of the programme. This is
an excellent criterion favouring adherence to a training programme. It is, however, necessary to warn a patient who was
physically active that stopping physical activity for a few
weeks to a few months results in a loss of physical gains,
especially endurance [100], and that physical activity must
always be resumed progressively.
Resumption of regular exercise training at the start of
rehabilitation is often easier but the programme needs to
be monitored to ensure that it is reasonably adapted to the
current abilities of the patient. The training programme will
often be more intense than that used for inactive patients
of the same age. Evaluation at the start of rehabilitation is
essential to help select the appropriate sport and intensity
of training.
Previously published recommendations help to provide
advice to patients about the types of non-competitive activities appropriate to the pathologies concerned [88,101—107].
For patients wishing to resume competitive sport, specific
recommendations [108,109] are available to identify the
sports that can be practiced in competition, according to
the cardiovascular pathologies concerned; these are often
restrictive because it has been demonstrated that participating in competition is a factor that can increase the risk
of complications, particularly sudden death [110,111].
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Table 6
Class I
B. Pavy et al.
Levels of evidence and proof.
There is evidence for or a general
consensus that a diagnostic
examination or a given treatment is
beneficial, useful and effective
Class II
There are conflicting data and/or
differences in opinion on the use or
efficacy of a treatment or procedure
Class IIa
The weight of evidence or opinions
lies in favour of usefulness/efficacy
Class IIb
The usefulness/efficacy is less well
established by evidence/opinions
Class III
There is evidence for or a general
consensus that a treatment or
procedure is not useful/effective
and in certain cases may be harmful
Proof A
Evidence based on several
randomized clinical trials or
meta-analyses
Proof B
Evidence based on a single
randomized clinical trial or large
non-randomized trials
Proof C
Consensus or opinion of experts
and/or small studies, retrospective
studies or registers
Recommendation 5: indications
The evaluation of indications takes into account the levels
of evidence (Class I to III) and proof (grade A to C) according
to the European recommendations (Table 6).
Coronary artery disease (medical)
The benefits of physical activity make a large contribution to
secondary prevention in all coronary artery disease patients
following myocardial infarction [112—115]. Rehabilitation of
the coronary artery disease patient reduces cardiac mortality by 26% and overall mortality by 20%.
After acute coronary syndrome (Class I, Level A)
In the absence of complications, a symptom-limited exercise
test under treatment can be performed 5 to 7 days after the
event; a maximal exercise test without treatment requires
a delay of 4 weeks [116].
The presence of stents should not delay the start of rehabilitation; the risk of stent thrombosis during training is very
low (estimated to be 0.08%) [117].
Training may be started after stabilization of the clinical condition, under supervision, with cardiac monitoring
during the initial sessions, with the aim of improving exercise capacity, which is a major prognostic factor [118]. A
sufficient number of sessions [119,120] is essential.
The control of risk factors should be initiated or updated.
Educational aspects (nutrition, tobacco) are essential for
this population, who are usually young and active. Return to
work should remain a priority [121,122]. Ambulatory rehabilitation should be promoted.
In stable angina or after angioplasty (Class I, Level
B)
Antiangina medication should be optimized, guided by the
exercise stress test, and the ischaemic and angina threshold
should be raised through well-managed training.
A symptom-limited exercise test under treatment can be
performed without delay after angioplasty [123], allowing
completely safe early training, which improves prognosis
and favours on-going activity at home [124]. The benefit is
proportional to the amount of training [125]. Ambulatory
rehabilitation should be favoured.
Cardiac surgery
Rapid management in a cardiac rehabilitation centre is
recommended. For patients recently operated on, close
surveillance of the clinical state allows earlier detection of
any infectious complications (infection of operative wounds,
unexplained febrile or inflammatory states).
The occurrence of pericardial effusion requires regular
re-evaluation until it has disappeared; there is a continuing
risk of secondary cardiac tamponade. The use of nonsteroidal anti-inflammatory drugs has no proven efficacy
[126,127].
All thromboembolic complications (postoperative
phlebitis, intraventricular thrombus) require temporary
cessation of training.
The effort and type of exercise must be adapted according to the sternotomy, the state of the operative wounds,
anaemia and postoperative pain.
Coronary artery surgery (Class I, Level B)
The surgical notes and report must be included in the
patient’s rehabilitation file.
At least three training sessions per week at a sufficient
intensity are required to improve exercise capacity [128].
Interval training seems to be more effective than continuous
training to facilitate continued activity at home [129].
Cardiac rehabilitation is one of the factors that favours
a return to professional life [130,131].
Valvular surgery (Class I, Level B)
It is recommended to offer all patients who have undergone valvular surgery an adapted training programme and
education on anticoagulants as early as the second week
postoperation [132]. Early rehabilitation is effective and
without risk after mitral valvuloplasty [133] or valvular replacement [134]. A combined training programme
(endurance and resistance) appears to be the best choice
[135]. The benefits in terms of exercise capacity are similar
to those seen in coronary artery disease patients who have
undergone surgery [136].
Surgery of the thoracic aorta (Class IIa, Level C)
Early rehabilitation following surgery for aortic dissection
is beneficial; at a moderate intensity, maintaining systolic
blood pressure under 160 mmHg, it is well tolerated [31]. A
FSC guidelines for cardiac rehabilitation in adults
similar protocol could be considered for patients with Marfan
syndrome (with or without surgery) and in all situations that
carry a risk of aortic dissection.
The risk of high exercise workload following surgery for
aortic aneurism, with or without valvular replacement, has
not been studied. The exercises are often limited according to the increase in blood pressure, although the value of
this has not been formally demonstrated. Each case must
therefore be evaluated according to its context.
317
importance for reducing rehospitalizations (often linked to
errors in diet or compliance to therapy).
The rehabilitation period allows adjustment of medical
treatments.
Heart failure with preserved ventricular function
(Class IIb, Level C)
Some studies have demonstrated the value of rehabilitation programmes in terms of quality of life, autonomy and
reduction of hospitalizations [152,153].
Preoperation period (Class IIb, Level C)
Education and/or rehabilitation before coronary surgery can
be offered to reduce the duration of hospitalization following surgery and limit postoperative complications—even
depression [137—140]. It is recommended that a rehabilitation programme be offered only to patients with multiple comorbidity factors (overweight, diabetes, sedentary
lifestyle, recently stabilized clinical state, unfavourable
social context) in preparation for coronary or valvular
surgery.
Cardiac resynchronization (Class I, Level B)
Heart failure
Ventricular assist device (Class IIa, Level C)
Heart failure due to systolic left ventricular
dysfunction (Class I, Level A)
Cardiac rehabilitation is part of the therapeutic arsenal
for use in patients with HF at stages II to III of the New
York Heart Association (NYHA) classification. The rehabilitation programme is based on the overall management of
the patient and should include at least an adapted exercise training programme, a TEP and optimization of other
therapies [141].
The precise evaluation of the physical capacities and limitations of each patient requires a cardiorespiratory exercise
stress test before starting reconditioning. The prescribed
training programme is personalized [142]. For more severe
cases (NYHA stage IIIb), it is advised that the programme be
started under supervision for inpatients, before considering
ambulatory management.
The duration of the training programme is often longer
than for patients without HF. A regular evaluation of exercise
performance is often necessary (e.g. ‘‘midterm’’ cardiorespiratory exercise test).
The training protocols for endurance use continuous
training and/or interval training approaches (this training
approach is particularly useful for the most frail patients)
[143]. These protocols are also combined with resistance
training using segmental muscular strengthening [144—146]
and can be complemented with respiratory training and/or
electromyostimulation. Other techniques improve compliance and quality of life (aquagym, Tai Chi, dance, etc.)
[37,147—149].
Subject to the application of an adapted protocol and
regular screening for any sign of decompensation, the
risks associated with training in these patients are very
low [150,151]. The benefits for prognosis appear to be
favourable; failures are linked to poor long-term adherence
[151].
Personal support throughout the training is useful. The
role of therapeutic education is significant [150], due to its
A comprehensive cardiac rehabilitation programme following cardiac resynchronization enhances the beneficial
effects of the device. Indeed, the peripheral improvements
associated with training are complementary to the central
improvements linked to cardiac stimulation, which explains
the increased gain in exercise tolerance [154,155].
Therapeutic education must be based upon ‘life with’ an
implanted device.
HF patients who have implanted ventricular assist devices
are very severe cases. This type of device is implanted either
as a bridge for cardiac transplantation or as destination therapy. In all cases, this is a particularly strong indication for
cardiac rehabilitation [156], and concerns several chronic
HF-related conditions. Patient education must also cover
managing the assist device and anticoagulants. This type
of complex rehabilitation requires centres specially trained
in the highly technical management, in close collaboration
with the surgical team.
Cardiac transplantation (Class I, Level B)
Cardiac rehabilitation of cardiac transplant patients has
specific features linked to surgery, immunology and psychosocial consequences; the rehabilitation should be
prolonged [157—159].
During the first 3 months, cardiac rehabilitation is regulated by surveillance and possible complications; the start of
training should be light and progressive, guided by the cardiorespiratory exercise test and the sensations of the patient
(due to denervation, heart rate is not the best supervision
variable) [160].
The education of the patient must cover anti-rejection
treatments, prevention of complications due to immunosuppression and cardiovascular risk factors.
Psychological management and social and professional
support are particularly important in this context.
After 3 months, based on improvements in the patient,
the cardiac rehabilitation programme can become more conventional.
Peripheral vascular disease (Class I, Level A)
Physical exercise improves rheology, endothelial function, extraction of oxygen and muscular metabolism. The
development of collateral arteries is accompanied by a
redistribution of blood flow towards the most active muscles
318
and increases metabolism of fatty acids by the leg, thereby
optimizing the use of oxygen delivered to the tissues.
Training reduces the consumption of oxygen and improves
walking power [161,162]. Supervised cardiac rehabilitation
has an effect on the pain threshold, distance, duration and
speed of walking.
Indications for rehabilitation in obstructive peripheral
vascular disease are [163]: patient asymptomatic with
ankle-brachial index less than 0.9; intermittent claudication; permanent chronic ischaemia; and follow-up of
revascularization (endovascular or surgical).
The patient undergoes an initial functional evaluation:
walking distance limits (pain/claudication) and speed of
walking; familiarization with low-load ergometers; clinical
criteria for disadaptation; and assessment of comorbidities.
In cases of very limited walking ability, the exercise stress
test can be performed with an arm ergometer, favouring discontinuous protocols with a very slowly progressing increase
in workload [164].
Walking on the flat or on a treadmill is the basic exercise to be performed three to five times per week. The
speed and duration during the session should be varied and
adapted to the capacities of the patient. Some authors
advise alternating phases of rapid walking, generating moderate claudication, with phases of recuperation over a total
duration of 50 minutes [165,166]. Walking in hot water is
beneficial if the condition of the skin allows this.
Analytical exercises of the lower limbs should be
included, focusing on eccentric contractions against low
resistance and involving muscles from the feet to the
base of the legs, combined, if necessary, with drainage of
oedema, reflexology massage and passive mobilization (musculotendinous retractions).
A supervised programme lasting for 1 to 3 months must be
followed by a daily walk of at least 20 minutes to maintain
the benefits [165].
Therapeutic education and treatment of risk factors are
essential in this very-high-risk population [163,167].
Specific cases
Amputee patients should be given a specialized adapted
workload in a centre equipped for fitting the appropriate
prosthesis. Following revascularization surgery, the operative wounds must be considered when designing gym
programmes; regular training on the bicycle ergometer
should be avoided in cases of arterial anastamoses in the
groin.
Other indications
Implanted automatic defibrillators (Class IIa, Level
B)
Indications for implanting automatic defibrillators are subject to specific recommendations. Patients often have
another indication for cardiac rehabilitation (ischaemic cardiopathy, HF) but some patients receive the implantation
only to manage arrhythmias. These patients are suitable for
rehabilitation management with the aim of restoring selfconfidence during physical activity and providing a specific
therapeutic education [168—170].
B. Pavy et al.
A preliminary exercise test in the training programme
allows the exercise programme to be personalized. The programmed triggering heart rate for the defibrillator must be
known to train the patient at 10 to 20 beats per minute
below this threshold.
Gym training and/or training of the upper body should
be undertaken only with care during the weeks following
implantation to prevent any complications at the surgical
site or device leads.
Congenital cardiopathies in adulthood (Class IIa,
Level C)
The aim of cardiac rehabilitation is to improve postoperative
functional capacities, resulting in a more or less complex
change in cardiac function from the cardiopathy, and to
improve cardiac function and associated problems.
The training programme must take into account the
presence of HF, arrhythmias, the degree of pulmonary hypertension and any exercise desaturation.
High cardiovascular risk (Class I, Level A)
In terms of primary prevention [171,172], all patients at
high cardiovascular risk should be given treatment and support for the behavioural changes that are required, including
education and dietary advice, help in smoking cessation and
promotion of regular physical activity.
Support of cardiac rehabilitation allows these difficultto-achieve goals to be fulfilled without assistance. Ambulatory care is the rule for this indication.
Recommendation 6: contraindications
Screening for complications
Complications observed in cardiovascular rehabilitation are
usually independent of exercise training. Previous studies
have demonstrated that the risk under supervised exercise is low [173—178]. The multicentre registry developed
by the Exercise, Rehabilitation and Sport Group (FSC)
has evaluated over 25,000 patients referred to cardiac
rehabilitation under the required safety conditions and
has followed up the occurrence of serious clinical events
(death, infarction, cardio-circulatory arrest or any event
requiring resuscitation) during the hour following exercise. The risk for this cohort was exceptionally low and no
deaths were recorded per 0.74 million hours of exercise
[179].
Training sessions should be performed under the continuous surveillance of a rehabilitation team trained for
emergencies. The presence of a cardiologist in the room is
not mandatory but a cardiologist should be present in the
area and be able to intervene immediately at the request of
the supervision team in case of emergency.
Outdoor activities, under supervision of a rehabilitation
team trained for emergencies, should be performed and regularly tested according to a written protocol; this protocol
should include warning and evacuation procedures and rapid
access to a defibrillator (portable automatic or semiautomatic device). The types and modalities of outdoor activities
should be prescribed by the cardiologist.
FSC guidelines for cardiac rehabilitation in adults
Table 7
Formal contraindications to exercise training.
Unstable acute coronary syndrome
Uncompensated heart failure
Severe uncontrolled ventricular arrhythmia
Intracardiac thrombus with high risk of embolism
Moderate-to-severe pericardial effusion
Recent episode of thrombophlebitis with or without
pulmonary embolism
Severe and/or symptomatic obstruction to left
ventricular outflow tract
Any inflammatory pathology and/or progressive
infection
Severe and symptomatic pulmonary artery hypertension
Incapacity to perform physical exercise
Contraindications
The contraindications to the prescription of a cardiac training programme are similar to those for a cardiac exercise
stress test; they are not frequent and often temporary
(Table 7).
Some patients may refuse all of or part of the rehabilitation programme; their desire as well as the clear information
given by the doctor on the benefit/risk ratio of rehabilitation
should be noted in the patient’s medical records. Discussion
between the parties involved decides what follows.
Some physical or psychological disabilities in a patient
may require an adjustment of the programme according to
the facilities at the centre.
Recommendation 7: specific populations
Women
Women referred to cardiac rehabilitation are on average 10
years older than men; the most frequent risk factors are
hypertension, diabetes and increased tobacco use [180].
There are several barriers to cardiovascular rehabilitation: under prescription; lack of family support or domestic
help; fear of non-adapted training, especially in older
patients; and comorbidities, especially musculoskeletal disease [181].
The beneficial effects of cardiovascular rehabilitation on
morbidity and mortality reported in recent meta-analyses
[182,183] also apply to women (although this population is
underrepresented). Although their exercise capacities are
significantly lower than those of men of similar age and
training habits (by 25% to 35% on average), the improvement
in exercise tolerance after cardiac rehabilitation is significant, especially if initial capacities are low (< 5 METS) and
for patients aged over 75 years.
Diabetic patients
Between 20 and 30% of the overall population undergoing cardiac rehabilitation are diabetic [184]. These patients
have a higher frequency of associated cardiovascular risk
factors, polyvascular injuries and comorbidities; they are
319
often overweight and poorly conditioned to physical exercise [185].
Patients with poor glucose tolerance (1.10 g/L
< glycaemia < 1.26 g/L) should be warned of their high
cardiovascular risk and the development towards diabetes.
Regular physical activity [186] significantly improves the
diabetic patient’s glycaemic control, leading to an average
reduction in glycated haemoglobin of 0.6% and a reduction
in degenerative complications of diabetes [187]; it is also
accompanied by a reduction in visceral fat and subcutaneous
adipose tissue. In addition, glycaemic control plays a major
role in wound healing in postoperative patients. Reduction
of glycaemia is correlated with the number of endurance
exercise sessions; this effect is extended after the end of the
session. The effects of endurance training on glycaemic control are limited over time (about 30 hours) showing evidence
of the need for regular physical activity [188].
The presence of complications of diabetes (retinopathy,
nephropathy, neuropathy) does not contraindicate training,
but in the presence of proliferative retinopathy very intense
efforts should be avoided.
Activity in water is preferred because the discomfort linked to joint problems and overweight is reduced
[189—191].
Optimal control of blood pressure combined with glycaemic balance improves prognosis [192].
Blood glucose should be checked before exercise in every
patient with diabetes. In addition, blood glucose testing
should also be performed at the end of and 4 to 6 hours
after each physical activity session in patients treated with
insulin or insulin secretagogues (sulphonureas or glinides), to
reduce the risk of hypoglycaemic episodes. Self-assessment
of glycaemia allows early identification of hypoglycaemia
and is an effective means of preventing severe hypoglycaemic episodes [193].
The patient’s rehabilitation team and the patient should
know how to counteract the signs of hypoglycaemia and how
to manage these in emergency situations: stop exercise,
combined with consumption of simple and complex sugars.
When blood glucose before exercise is greater than
250 mg/dL (13.9 mmol/L), ketonuria needs to be checked.
If the patient is without ketosis, feeling well and properly
hydrated, then physical activity can be performed with caution, with regular capillary blood testing recommended at
least hourly during the training session.
Therapeutic education of the diabetic patient aims to
ensure that the patient understands the effects of their
medications, particularly those that can cause hypoglycaemia (sulphonamides, gliclazides and insulin), and to help
the patient perform self-monitoring (recorded in a notebook). The psychological benefits of cardiac rehabilitation
[194] favour the active involvement of diabetic patients in
changing their behaviour.
The cardiac rehabilitation period provides the opportunity to obtain specialist advice according to the combined
recommendations of the FSC and the Francophone Society
of Diabetes [195—198]. The opinion of a diabetologist is
useful to guide therapeutic choices, adapt the times for taking medications under particular working conditions (shift
work, night work and meals eaten at the work place or
in the company restaurant) and improve patient education.
320
Elderly patients
The elderly population is defined by the World Health Organization as being aged over 60 years but most studies
consider patients aged over 75 years.
The prescription of and participation in cardiovascular rehabilitation programmes remains rare among elderly
patients, particularly women [199], despite the recommendations of experts and guidelines [200]. There are several
reasons for this: the small differences between the normal aged and pathological heart [199,201]; the frequency
of depressive syndromes and social isolation [199]; and the
frequency of comorbidities.
Rehabilitation should be performed in a centre specialized in cardiovascular pathology when the principal
diagnosis is cardiological without prohibitive comorbidities
or if the patient is able to regain or consolidate autonomy
in their daily life. In other cases, a stay in a geriatric rehabilitation centre should be considered.
The objectives of cardiovascular rehabilitation programmes are essentially to improve autonomy; limitations
of physical capacity are the most cited factor affecting
the quality of life of elderly cardiac patients, notably in
cases of HF [202]. Reconditioning to exercise in this elderly
population gives benefits similar to those in younger subjects in terms of maximal or submaximal exercise capacities
[203].
Some methods seem particularly adapted to elderly subjects —– notably interval training, which is rapidly effective
and well tolerated [204]. Segmental strength training, training using light resistance on machines and aquagym training
[147] improve muscular strength and help these patients to
regain their autonomy.
Dietary measures and lifestyle changes should be promoted, as in younger populations.
Notably, the beneficial effects of stopping smoking and
controlling blood pressure are similar to those in younger
populations [205].
Recommendation 8: organization
Legislation and regulations
These recommendations include recent regulatory developments applicable to the establishment of and the technical
conditions of the service of FCR [1—3,38,39].
The decrees of application and the legal circular for
interpretation establish the general working conditions for
FCR services. The management of cardiovascular pathologies is subject to particular conditions stated in a dedicated
file (File C) attached to the legal circular. The general
role of FCR includes care, re-education and rehabilitation,
prevention, therapeutic education and help with reintegration.
In addition to the measures concerning the internal organization of care (types of pathology and patients managed,
required expertise, continuity of care, material resources),
the decrees lay down that certain arrangements ‘‘based
on the organization of the FCR structures, fulfil the aim
of flexibility in the management of patients’’. These are
the validation of the indication and the evaluation of the
B. Pavy et al.
needs and objectives before all admissions, establishing
coordination, networks or management procedures between
FCR and upstream and downstream organization, the role
of expert advice and registration with the Operational
Resource Repertoire.
Cardiovascular FCR units are, like any other hospital
establishment, subject to Law No. 2009-879 of 21 July 2009
concerning hospital reform and health care for patients in
the various areas of France (called the HPST Law). Similarly,
cardiovascular rehabilitation units must develop (article
L. 6113-2 of the Code de la Santé Publique [CSP]) ‘‘a policy of
evaluating professional practices, methods of organization
of health care and all activities concerning overall management of the patient’’ as part of a policy of continuous
improvement of quality and risk management, as credited
by an external certification process (article L. 6113-3 of the
CSP).
Personnel
Medical expertise
Article D. 6124-177-30 al.2 of the CSP requires the on-site
presence of a cardiologist, who is able to intervene immediately during the rehabilitation phases.
Due to the potential complexity of the cardiovascular pathologies managed, the risk of death and the
required specific expertise, the FSC recommends that
the medical responsibility and coordination of FCR units
specialized in cardiovascular problems is performed by
a qualified physician specialized in cardiology and vascular illnesses or a qualified specialist in cardiovascular
pathology; this physician is also responsible for organizing the continuity of patient care. It is preferable that
the coordinating cardiologist has documented expertise
(university diploma) in the field of cardiac rehabilitation.
The medical team includes one or several collaborating cardiologists as appropriate and, where possible,
other specialists, such a diabetologist or nutritional doctor, psychiatrist, tobaccologist, occupational physician,
physical and rehabilitation medicine physician and pneumologist.
In addition to follow-up and therapeutic adaptation, the
cardiologist: validates the eligibility of the patient; in collaboration with the multidisciplinary team and the patient,
establishes a treatment plan, which should be periodically
re-evaluated; performs the necessary cardiology examinations of patients during their stay and decides on further
examinations as deemed necessary; and plans the programmes and supervises the exercise training programme
and therapeutic education sessions.
Paramedical expertise
The mandatory paramedical personnel include a nurse, a
physiotherapist, a dietician and a social worker. Although
not mandatory, the presence of a psychologist is highly
desirable. The paramedical team may also include other
personnel (e.g. an auxiliary nurse, a physical education
instructor and an occupational therapist). It is imperative
that all the personnel are regularly trained in emergency
procedures and are motivated and trained in therapeutic
education activities.
FSC guidelines for cardiac rehabilitation in adults
321
Facilities
Care security and management of emergencies
Accommodation
Article D. 6124-177-30 of the CSP states that ‘‘the continuation of medical care is ensured by a qualified specialist
physician or a physician competent in cardiology and vascular medicine or a qualified specialist in cardiovascular
pathology. At least one nurse should be present with the
patients in training areas. If there is any need, a qualified
cardiology specialist intervenes immediately’’. The legal
circular DHOS/01 No. 2008-305 of 3rd October 2008 states
that the continuity of care ‘‘is ensured by an on-site or oncall doctor, by the presence of a night nurse and by the
availability of physiotherapy at the weekend and on public
holidays. Emergency medical intervention must be possible at any instant. The possibility of patient transfer to an
intensive care unit at any moment must be organized by
convention’’.
The FSC recommends the presence of a doctor authorized by the coordinator to ensure the continuity of care
and to manage emergencies on site. Failing this, an organization with an on-call cardiologist is recommended ‘‘to
ensure a time to physician intervention that is compatible
with patient safety’’. The procedures for emergency calls
should be known by the professionals and tested regularly.
Emergency procedures should be written, validated and circulated.
During the training phases, the presence of medical
personnel in the training room is not required but the cardiologist should be able to intervene immediately if needed
(article D. 6124-177-30 of the CSP).
Conventional or ambulatory hospitalization must conform to
current regulations. The rooms ‘‘are equipped with a call
device, adapted to the patient’s status. Access to medical
fluids is organized within time scales compatible with safety
requirements’’. ‘‘The spaces necessary for friends and family members to be close to patients’’ are also required.
Professional areas
The layout of all premises must facilitate the first steps of
resuscitation on site and evacuation of the patient. These
premises must include: an ‘‘emergency room’’ equipped
for emergency procedures and cardiac resuscitation before
transfer (one or several beds with an emergency trolley, cardioscopes, defibrillator, intubation equipment and breathing
gas supplies); a technical area allowing non-invasive examinations to be performed for functional evaluation and
surveillance of patients; a training room (each patient must
have a surface of at least 4 m2 of gymnasium space available; a therapeutic pool and access to outdoor tracks can be
included among the resources according to the possibilities
of each centre); a physiotherapy area for managing individual physiotherapy treatments; a relaxation area is desirable;
and an education area reserved for providing information
to and therapeutic education of patients and their families.
Equipment
The functional evaluation of the patient and the prescription of types of training require medicotechnical equipment,
including a standard electrocardiograph, equipment for
telemetric monitoring, equipment for exercise tests and cardiac and vascular Doppler echography.
Desirable equipment includes a device for a cardiopulmonary exercise test, a continuous ambulatory
electrocardiograph system with recording of events, a pulse
oximeter, a device to measure ambulatory arterial pressure
and heart rate monitors.
Equipment for exercise training programmes and patient
education includes gym equipment (weights, barbells,
benches, mats), exercise machines (and, if possible, various
different machines, such as a bicycle ergometer, treadmill,
rowing machine, weights bench and crank), educational
audiovisual equipment and educational tools.
All of the training rooms should have call facilities (telephone or other) for use in emergencies. Emergency trolleys
should be sufficient in number and located to be available for any emergency arising in the unit. In particular,
an emergency trolley should be placed in the exercise test
room during examinations and in immediate proximity to
the training rooms. It should contain: first aid treatments
with medications and equipment for injection and perfusion; a homologated defibrillator; intubation and ventilation
equipment; medical fluids; and aspiration equipment.
The validation and proper functioning of the equipment
must be regularly checked. The trolley next to the training rooms must also include a sphygmomanometer and an
electrocardiograph.
Strategy for cardiac rehabilitation
The objectives and types of programmes should be personalized according to age, lifestyle, cardiac pathology and
proximity to the patient’s home. The initial consultation
is fundamental and evaluates the medical state and psychological profile of the patient, the risk factors and the
professional context; it allows the patient to be referred for
rehabilitation involving complete, weekday hospitalization
or ambulatory care. The programme, the types of surveillance, the follow-up and the evaluation are all similar for
all types of organization.
Although the possibility of home-based cardiac rehabilitation is included in the new official rules, this type of care
is not currently used in France for cardiovascular rehabilitation. However, a meta-analysis study has demonstrated
the effectiveness of this type of management for low-risk
patients [206]. The organization of telemedicine could facilitate and ensure the safety of this type of rehabilitation.
Medicoeconomic aspects of cardiovascular
rehabilitation
Cardiac rehabilitation has a favourable cost-benefit ratio for
all types of cardiac disease (ischaemic heart disease or HF)
and for patients of any socioeconomic status; it reduces
the costs of long-term management. Diverse studies show
that after a myocardial infarction, exercise training has
good cost-efficacy ratio, which is better than treatment
322
strategies such as lipid-lowering, thrombolysis and coronary
artery bypass grafting but lower than interventions to stop
smoking [207—211].
In France, offering more equal access and tailored rehabilitation programmes should result in a reduction of health
care costs.
Conclusions and perspectives
The management of patients with chronic pathologies such
as cardiovascular diseases is a national priority for public
health. The constraints are becoming stronger, as a consequence of a growing demand for health care linked to the
high and growing prevalence of cardiovascular problems and
the reductions in the allocation of both financial and medical
resources.
Faced with this challenge, cardiovascular rehabilitation,
placing the patient at the centre of the health care plan, is
particularly appropriate: the exercise training programme,
therapeutic education and psychological support and assistance are also factors for increasing patient autonomy and
responsibility in the management of their health care.
The various hospital legislations since the year 2000 have
formalized this new type of patient management and the
development of telemedicine covered by article 78 of the
HPST Law (Law No. 2009-879 of 21 July 2009) is a pertinent response to the problem of follow-up and motivational
support of patients in their home and to the reduction in
medical resources in several areas of France.
These factors, associated with the required information
and promotion of cardiovascular rehabilitation within the
cardiology medical community through organized teaching
of this specialty (both university training and continuing
education), will make this a central approach in the management of patients with cardiovascular disease.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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