Core Components of Cardiac Rehabilitation Programs: 2024 Update

Authors, Journal, Affiliations, Type, DOI

• Todd M. Brown, Quinn R. Pack, Ellen Aberegg, LaPrincess C. Brewer, Yvonne R. Ford, Daniel E. Forman, Emily C. Gathright, Sherrie Khadanga, Cemal Ozemek, Randal J. Thomas; on behalf of AHA/AACVPR
• Circulation, 2024;150:e328–e347
• Multi-institutional: University of Alabama Birmingham, Baystate Medical Center, Mayo Clinic, University of Vermont, UIC, Brown University, and others
• Type: AHA Scientific Statement; endorsed by American College of Cardiology
• DOI: 10.1161/CIR.0000000000001289

Overview

First update to AHA/AACVPR core components of cardiac rehabilitation (CR) since 2007. CR is a medically supervised, multidisciplinary secondary prevention program proven to reduce mortality and improve quality of life in CVD, yet enrollment remains ~20% of eligible patients nationally. Nine core components are defined: patient assessment, nutritional counseling, weight management and body composition, CVD risk factor management (HTN/dyslipidemia/DM/tobacco), psychosocial management, aerobic exercise training, strength training, physical activity counseling, and program quality. Two components are newly delineated: strength training (separated as a standalone component) and program quality (a new component targeting the enrollment gap and health equity). Virtual, remote, and hybrid CR delivery models are formally incorporated as equivalent to in-person CR for low–moderate risk patients.

Keywords

cardiac rehabilitation, secondary prevention, cardiovascular diseases, aerobic exercise training, strength training, program quality, health disparities

Key Takeaways

Program Structure and Qualifying Diagnoses

• CR requires: physician medical director + physician/nonphysician practitioner supervision at all times; individualized treatment plan (ITP) signed by physician, updated every 30 days; outcomes assessment at completion
• Medicare-qualifying diagnoses: acute MI (past 12 months), CABG, coronary angioplasty/stenting, heart valve repair/replacement, heart or heart–lung transplantation, stable angina, stable chronic HF (LVEF ≤35%, NYHA II–IV, on optimal HF therapy ≥6 weeks)
• Alternative delivery models lacking physician director, day-to-day supervision, and all core components are not CR and are not an acceptable substitute
• Delivery modes: in-person (traditional), virtual/synchronous (real-time audiovisual), remote/asynchronous (no real-time interaction), hybrid — all valid; hybrid likely the key strategy to reach the Million Hearts 70% enrollment target from the current ~20%

Patient Assessment

• Comprehensive initial evaluation: cardiac/vascular diagnoses, CVD function, ASCVD risk factors, comorbidities (DM, HTN, PAD, CKD, OSA, PH, CHD), all medications, vaccination status
• Social history: medication affordability, physical activity patterns, sleep, substance use, social support, health literacy, socioeconomic status, goals of care
• Physical examination: vital signs, cardiac/pulmonary auscultation, cognitive and mental status, frailty, fall risk, 12-lead ECG + baseline telemetry
• Functional assessment tools: 5-Times Sit-to-Stand, Short Physical Performance Battery, Activities of Daily Living, Instrumental ADLs — important for frail or deconditioned patients
• Home environment assessment: broadband internet access, technology comfort, access to exercise space and healthful foods — determines remote/virtual CR feasibility

Nutritional Counseling

• Dietary assessment using validated food frequency questionnaires at program entry and completion; related to clinical outcomes (HbA1c, weight)
• Dietary patterns: DASH, Mediterranean, USDA, vegetarian/plant-based — emphasise positive food behaviors, limit saturated fat, sodium, added sugars
• SMART goal setting; individualized goals documented in ITP; progress reviewed weekly; dietitian referral indicated for DM, HF, malnutrition, or inadequate response to general guidance (more effective after ≥3 encounters)

Weight Management and Body Composition

• Body composition (fat-to-lean ratio) more closely associated with CVD risk than BMI alone; normal-weight obesity is a high-risk phenotype
• Sarcopenia highly prevalent in CVD — contributes to frailty and CVD risk; must be addressed alongside body fat
• Waist circumference: most feasible; DEXA/MRI most accurate but impractical remotely; new digital tools emerging
• HIIT may improve body composition more than moderate-intensity continuous training; weight loss medications and bariatric surgery reduce fat but may also reduce lean mass even with exercise

CVD and Risk Factor Management

• Hypertension: Target SBP <130 mmHg and DBP <80 mmHg; lifestyle modifications + pharmacotherapy in concert with primary clinician; measure in both arms at entry; physician-approved medication algorithms supported for staff-limited programs
• Dyslipidemia: LDL-C <70 mg/dL for ASCVD; <55 mg/dL if at very high risk; fasting lipid profile at entry; medication adherence assessed each session
• Diabetes: HbA1c <7% for most patients; diet recommendations (Mediterranean, low carbohydrate, plant-based, nut-enriched); pharmacotherapy coordination
• Tobacco cessation: All current/recent smokers receive cessation intervention; exhaled CO measurement as motivating tool; pharmacotherapy per ATS guideline; referral to dedicated cessation programs

Psychosocial Management

• Validated screening for depression, perceived stress, and anxiety at entry and completion
• Other domains: sexual dysfunction, anger, hostility, loneliness, social isolation, substance misuse patterns that interfere with CR
• Interventions: cognitive behavioral therapy, stress management, relaxation training, individual or group counseling, supportive CR environment and community resources
• Persisting depression at CR completion independently predicts increased post-CR mortality, particularly with concurrent anxiety and hostility
• Remote/virtual delivery: technology access and psychiatric safety protocols must be established

Aerobic Exercise Training

• Frequency: 3–5 days/week (3 supervised CR sessions; supplement home exercise on non-CR days aiming for ≥5 days/week)
• Intensity — Moderate: 40–59% heart rate reserve (HRR) or RPE 12–13 on Borg 6–20 scale
• Intensity — Vigorous: 60–89% HRR or RPE 14–17; do NOT use resting HR + 20–30 bpm or age-predicted max HR — wide inaccuracy
• Safety ceiling: 10 bpm below HR associated with angina, SBP >240 mmHg, ST depression >1 mm, AF, SVT, complex ventricular ectopy, or other signs of exertional intolerance
• Duration: 20–60 min per session; increase duration by 1–5 min/session until goal achieved, then increase intensity; 5–10% intensity increments well tolerated
• Modes: treadmill, cycling, elliptical, rowing, stair climbing, arm/leg ergometry; HIIT is safe in CR and superior to MICT for cardiorespiratory fitness improvement
• Goals: ≥15% increase in peak VO2; ≥40% increase in estimated peak MET from 3rd to last session; ≥10% increase in 6-min walk distance
• Graded exercise testing preferred for individual prescription; Talk Test or 6-min walk test when formal testing unavailable (may underestimate capacity)

Strength Training (new standalone component in 2024)

• Separated from aerobic exercise as its own core component to reflect the growing evidence base for resistance training since 2007
• Frequency: 2–3 non-consecutive days/week
• Intensity: 40–60% of 1-repetition maximum; RPE 11–13; increase load by ~5% when upper rep limit achieved comfortably; progress from 1 to 3 sets
• Volume: 1–3 sets × 8–10 exercises targeting major muscle groups × 10–15 repetitions/set
• Equipment: weight machines, free weights, elastic bands, body weight — all valid; breathing technique critical (exhale on contraction) for remote delivery safety
• Goal: Prevent/treat frailty, reduce fall risk — particularly important in older adults with deconditioning or sarcopenia; also improves lean mass and cardiorespiratory fitness in low-functioning individuals
• Frailty/fall assessment tools: Timed Up and Go (≥12 s = at risk); 30-Second Chair Stand (age/sex-referenced norms); 4-Stage Balance Test; Berg Balance Scale (41–56 independent; 21–40 walking assistance; 0–20 wheelchair-bound)

Physical Activity Counseling

• Goal: ≥150 min/week moderate-intensity or ≥75 min vigorous-intensity activity; most CR patients do not achieve this during the program
• Sedentary time independently associated with CVD risk; initial emphasis on "move more, sit less"
• Step count evidence: 8,000 vs 4,000 steps/day → HR 0.49 for all-cause mortality (n=4,840); each 1,000-step increment → 15% lower mortality (n=226,889)
• Pedometers + remote communication platforms improve cardiorespiratory fitness and activity levels; considerable variability warrants continued refinement

Program Quality (new core component in 2024)

• Added to reflect national initiatives since 2007 (Million Hearts, AACVPR, ACC, AHA) to increase enrollment and reduce underutilisation and health disparities
• Mandatory annual quality assessment at three levels: system (hospital referral), program (enrollment/adherence/completion), patient (fitness, risk factors)
• Million Hearts CR Collaborative target: enroll 70% of eligible patients (current rate: ~20%)
• AACVPR patient-level performance measures: improvement in functional capacity, depression, BP control, tobacco intervention — submitted as part of triennial program certification
• Quality improvement must actively address underserved populations at systematic risk for CR exclusion: women, racial/ethnic minorities, rural patients, frail, elderly, non-English speakers, those with socioeconomic barriers
• Final outcomes report forwarded to referring clinician documenting all assessments, interventions, progress, and goals

Limitations of the Document

• Scientific statement, not a clinical practice guideline with formal COR/LOE grading — evidence strength varies substantially across components
• Aerobic and strength training recommendations extrapolated largely from non-CR trial settings
• Psychosocial intervention evidence limited; remote psychosocial care unvalidated in diverse populations
• Body composition assessment methods (waist circumference, BIA) not validated across racial/ethnic subgroups
• Long-term efficacy of virtual/remote CR in underserved communities with environmental, financial, or technologic barriers has not been established

Key Concepts Mentioned

• concepts/Cardiac-Rehabilitation — primary topic; full framework for CR delivery
• concepts/Dyslipidemia-Management — LDL-C targets (<70 / <55 mg/dL) identical to CR risk factor management goals
• concepts/Exercise-in-HCM — CR FITT framework provides structured aerobic and strength training principles
• concepts/Heart-Healthy-Dietary-Patterns — dietary pattern goals align with CR nutritional counseling component

Key Entities Mentioned

• entities/Heart-Failure — stable HF (LVEF ≤35%, NYHA II–IV, ≥6 weeks optimal therapy) is a Medicare-qualifying CR indication
• entities/Atrial-Fibrillation — listed among arrhythmia criteria for adjusting aerobic exercise intensity ceiling

Wiki Pages Updated

• Created: wiki/sources/cardiac-rehab-aha-2024.md
• Created: wiki/concepts/Cardiac-Rehabilitation.md
• Updated: wiki/entities/Heart-Failure.md (added Cardiac Rehabilitation section)
• Updated: wiki/concepts/Exercise-in-HCM.md (added CR framework context)
• Updated: wiki/wikiindex.md
• Updated: wiki/sourceindex.md