May 2024: Cardiac Rehabilitation — Challenges and Advances
The issue
Cardiac‑rehabilitation programs are lifesaving, but wide gaps in how exercise is prescribed and progressed mean many older adults miss out on the full benefit.
What do I need to know?
Experts now urge programs to adopt progressive, concurrent exercise plans and computerized decision tools such as the EXPERT algorithm so each patient’s workout is truly individualized. Starting high‑load resistance work (≥ 70 % of one‑rep max) early is especially important for frail or sarcopenic seniors—and it is safe. Long‑term success also hinges on follow‑up support that combines multimodal exercise, nutrition coaching, behavioral counseling, and periodic digital “nudges” to keep activity levels up after discharge. Intensive Cardiac Rehabilitation (ICR) doubles session time (72 vs 36) to include diet, stress‑management, weight‑control, and smoking‑cessation teaching; observational studies show lower blood pressure, weight, depression, heart‑failure events, and even 12 % lower mortality than standard rehab. Yet ICR is rare—fewer than 2 % of U.S. programs, serving < 1 % of patients. Home‑based and hybrid models are catching up to center‑based rehab in outcomes and participation.
Potential risk of sub‑optimal rehabilitation
The patient has heart disease but has not been referred to any rehab or feels current exercise advice is generic.
Recommended Actions
Ask the cardiologist for a referral and confirm that the program tailors exercise intensity and progression.
Discuss baseline strength testing and inclusion of resistance work from day one.
Explore home‑based or digital‑tool–guided options if travel is a barrier.
Imminent risk of inadequate rehabilitation
The patient is enrolled but has multiple comorbidities, frailty, or plateaus in fitness gains.
Recommended Actions
Request reassessment with a progressive concurrent exercise protocol and consider early introduction of high‑load resistance.
Add nutrition counseling and behavior‑change support; set measurable strength and endurance targets.
Review whether upgrading to ICR is feasible, especially if weight, lipids, or mood need attention.
Confirmed rehabilitation gap
Post‑myocardial‑infarction or heart‑failure patient shows poor functional recovery or recurrent hospitalizations despite standard rehab.
Recommended Actions
Transition to ICR or a specialized program such as REHAB‑HF / MACRO that offers multifaceted, geriatric‑tailored care.
Ensure ongoing digital or phone follow‑ups after program completion to sustain gains.
Coordinate with primary care and physical therapy to manage frailty, sarcopenia, and comorbidities.
What can I do?
Bring these questions to your rehab team: “Is my plan truly individualized? Could high‑load resistance or ICR improve my outcomes? What follow‑up will keep me active after the program ends?” Keep an exercise and symptom log, and note any plateaus to discuss at reassessments. If travel, cost, or session limits pose problems, ask about home‑based or hybrid models and digital decision tools that can guide safe progression while you exercise locally or at home.
