Part 1—Cardiac Rehabilitation After an Acute Myocardial Infarction: Four Phases of the Programme

Authors, Journal, Affiliations, Type, DOI

• Aneta Aleksova, Alessandra Lucia Fluca, Antonio Paolo Beltrami, Elena Dozio, Gianfranco Sinagra, Maria Marketou, Milijana Janjusevic
• Journal of Clinical Medicine 2025, 14, 1117
• Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste; University of Trieste; University of Udine; University of Milan; University of Crete
• Type: Review article (Part 1 of 2)
• DOI: https://doi.org/10.3390/jcm14041117

Overview

This two-part review traces the evolution of cardiac rehabilitation (CR) from mandatory bed rest through "armchair" therapy to evidence-based early mobilisation, then systematically details the four programme phases for post-MI patients. The historical 1988 meta-analysis (10 RCTs, n=4,347) demonstrated a 25% mortality reduction with CR, establishing its role in secondary prevention. Phases I–II are supported by multiple RCTs showing reductions in cardiac remodeling, improved LVEF, fewer MACEs, and better exercise capacity; Phase III/IV data are sparse and one retrospective study found no benefit on hard endpoints. The RESILIENT RCT introduced a critical finding: mobile health-based CR did not improve outcomes in older adults, signalling the need for age-specific delivery adaptations.

Keywords

Cardiac rehabilitation; myocardial infarction; cardiac remodeling; mortality; illness perception

Key Takeaways

Epidemiology and Background

• Ischemic heart disease affected ~126 million people worldwide in 2017; highest prevalence in Central and Eastern Europe
• Acute MI accounts for 13.6% of in-hospital deaths and 10% of deaths within the first year post-discharge
• WHO 2019: ACS was the leading cause of mortality globally (16% of total deaths); deaths from ACS rose from >2 million to 8.9 million between 2000 and 2019
• Low referral and participation rates remain a major challenge; patients frequently revert to prior unhealthy habits after programme completion

Historical Overview

• 1929 (Levine): bedrest 4–6 weeks recommended for coronary thrombosis
• 1952 (Levine & Lown): "armchair" therapy proposed — seated positioning to reduce lung congestion; replaced strict bedrest
• Prolonged bed rest causes elevated inflammation, pressure ulcers, calcium excretion, rapid loss of bone and skeletal muscle mass within hours of admission
• First CR RCTs (1972–1985): mortality reductions were not individually statistically significant
• 1988 meta-analysis (Oldridge et al.): 10 RCTs, n=4,347 patients; 25% reduction in mortality in CR group vs control
• CROS-II meta-analysis: reduced mortality in ACS patients after revascularisation from 1995 onward (biased by inclusion of observational studies)
• 2021 Cochrane review (Dibben et al.): 85 RCTs, n=23,430 CHD patients; CR associated with small reduction in all-cause mortality and large reduction in MI and all-cause hospitalisation at 6–12 months; little or no effect on non-CV mortality and CV hospitalisation up to 12 months

Phase I — In-Hospital Cardiac Rehabilitation

• Initiated while patient is still hospitalised (acute stage)
• Assessment includes: clinical-instrumental parameters, medical procedures, previous clinical history, upper/lower extremity function tests, functional mobility
• Education on benefits of exercise training and control of modifiable/non-modifiable CV risk factors is critical for adherence; lack of understanding of CR was identified as a barrier to recruitment
• Exercise progression: begins with sitting up in bed and basic upper/lower extremity tests → progresses to short walks around the hospital; all actions individually tailored and carefully monitored
• Psychosocial support essential: acute MI causes anxiety and depression that reduce QoL
• Zheng et al. 2008 (RCT, n=60): 6-month supervised exercise (3×/week) started 3–7 days post-PCI → reduced cardiac remodeling, increased LVEF vs pharmacological therapy + standard advice
• Jiang et al. 2021 (RCT, n=98): kinetic energy progressive exercise within 1 week of PCI → elevated LVEF, enhanced QoL vs routine intervention
• Nakamura et al. 2021 (retrospective, n=31,603): early rehabilitation within 3 days → shorter hospital stay; no change in grade of autonomy comparing early vs usual care
• Kanazawa et al. 2020 (retrospective, n=13,697): Phase I within several days of admission → reduced revascularisation risk by 20%, readmissions for cardiac disease by 19% over ~1 year; dose-dependent association (low-frequency rehab also beneficial)
• Early mobilisation in ICU (Zang et al. 2020 meta-analysis, 15 RCTs, n=1,941): effective for preventing ICU-acquired weakness, reducing hospital stay, improving functional mobility

Phase II — Post-Discharge Cardiac Rehabilitation

• Duration: 6–12 weeks in Europe (some programs 2–24 weeks); 6–36 visits over 2–18 weeks in the US (contingent on insurance)
• If Phase I not initiated in hospital, Phase II begins with psychophysical assessment at 1–4 weeks post-discharge
• Assessment includes: residual cardiovascular risk, comorbidities, medication adherence, physical performance via non-invasive exercise tolerance testing
• Exercise types prescribed:
  • Aerobic: large muscle groups in rhythmic manner (cycling, hiking, jogging) — improves hypertension, insulin resistance, obesity
  • Strength training: single muscle group against external resistance (weightlifting) — improves glucose metabolism, body composition, basal metabolic rate, muscle strength
• Exercise prescription principles (FITT-VP): Frequency, Intensity, Time, Volume, Progression
• Illness perception (key Phase II concept): how patients describe their condition, perceive causes and duration, degree of perceived control, emotional consequences
  • Patients who understand their condition express higher motivation for long-term control
  • Darsin Singh et al. 2023 (longitudinal, n=450): BIPQ administered at baseline, 4 sessions, 8 sessions; overall improvement in illness perception baseline→first timepoint, then decline at second timepoint; paradox explained by growing awareness of disease chronicity raising concerns that negatively affect emotional state; patients with more severe symptoms or who had surgery were more likely to engage in CR
• Xiao et al. 2021 (RCT, n=164): 3-month post-discharge exercise programme followed by 9-month community-based self-managed programme → lower MACE risk, better LVEF and 6-minute walk distance vs conventional medical therapy

Phase III — Outpatient Long-Term Cardiac Rehabilitation

• Objective: facilitate long-term adherence to tailored exercise programme and positive lifestyle changes from Phase II; mitigate CV risk factors
• Less rigorous supervision than Phase II; overseen by healthcare professionals
• Brawner et al. 2017 (retrospective, n=230): 8-week Phase III programme (regular and irregular participants); no beneficial effect on non-fatal MI or HF hospitalisation over 5.6-year follow-up
• Giannuzzi et al. 2008 / GOSPEL study (RCT, n=3,241): 3-year multifactorial educational and behavioural programme → reduced incidence of cardiac events vs control

Phase IV — Maintenance

• "Maintenance phase" — final stage of CR
• Intended for patients who completed earlier phases; focus on maintaining progress and preventing future cardiac events through long-term commitment to a heart-healthy lifestyle
• Paucity of literature on Phase III and IV benefits

Emerging Trials

• MCNAIR study: comparative effectiveness of in-person vs telehealth CR delivery (ongoing; NCT05933083)
• RESILIENT RCT: mobile health-based CR (mHealth-CR) vs standard care in older adults with ischemic heart disease — mHealth-CR did NOT improve 6-minute walk distance, health status, or daily activities; underscores need for age-specific adaptations in mHealth CR strategies

Limitations of the Document

• Review article (Part 1 of 2); no original primary data
• Part 2 (not ingested) covers optimal timing, barriers to participation, and gender-based disparities in adherence — the section of highest clinical practical relevance
• Phase III/IV section relies on very few studies with inconsistent results; evidence base characterised by the authors as having a "paucity of literature"
• CROS-II meta-analysis may be biased by inclusion of observational studies
• Heterogeneity in CR programme structures across included studies limits cross-study comparison

Key Concepts Mentioned

• concepts/Cardiac-Rehabilitation — central subject; four-phase structure detailed
• concepts/Illness-Perception-in-CR — illness perception as a modifiable Phase II adherence determinant

Key Entities Mentioned

• entities/Acute-Coronary-Syndrome — primary indication for CR; ACS epidemiology framed as context

Wiki Pages Updated

• wiki/sources/crp-jcm-2025.md — created (this file)
• wiki/concepts/Cardiac-Rehabilitation.md — four-phase structure section added; RESILIENT trial contradiction added
• wiki/sourceindex.md — new source entry added
• wiki/wikiindex.md — Cardiac-Rehabilitation entry updated