Cardiac Rehabilitation

Topic Overview

What is cardiac rehabilitation?

Cardiac rehabilitation (rehab) teaches you how to be more active and make lifestyle changes that can lead to a stronger heart and better health. Cardiac rehab can help you feel better and reduce your risk of future heart problems.

In cardiac rehab, you work with a team of health professionals. Often the team includes a doctor, a nurse specialist, a dietitian, an exercise therapist, and a physical therapist. The team designs a program just for you, based on your health and goals. Then they give you support to help you succeed.

If you have had a heart attack, you may be afraid to exercise. Or if you have never exercised, you may not know how to get started. Your cardiac rehab team will help you start slowly and work up to a level that is good for your heart.

Many hospitals and rehab centers offer cardiac rehab programs. You may be part of a cardiac rehab group, but each person will follow his or her own plan.

Who should take part in cardiac rehab?

Doctors often prescribe cardiac rehab for people who have had a heart attackor bypass surgery. But people with many types of heart or blood vessel disease can benefit from cardiac rehab. Rehab might help you if you have:

• Heart failure.
• Peripheral artery disease (PAD).
• Had or plan to have a heart transplant.
• Had angioplasty to open a coronary artery.
• Had another type of heart surgery, such as valve replacement.

Often people are not given the chance to try cardiac rehab. Or they may start a program but drop out. This is especially true of women and older adults. And that’s not good news, because they can get the same benefits as younger people. If your doctor suggests cardiac rehab, stay with it so you can get the best results.

Medicare will pay for cardiac rehab for people with certain heart problems. Many insurance companies also provide coverage. Check with your insurance company or your hospital to see if you will be covered.

What happens in cardiac rehab?

In cardiac rehab, you will learn how to:

• Manage your heart disease and problems such as high blood pressure and high cholesterol.
• Exercise safely.
• Eat a heart-healthy diet.
• Break bad habits, like smoking.
• Reduce stress and depression.
• Get back to work sooner and safely.

Exercise is a big part of cardiac rehab. So before you get started, you will have a full checkup, which may include tests such as an electrocardiogram (EKG or ECG) and a “stress test” (exercise electrocardiogram). These tests show how well your heart is working. They will help your team design an exercise program that is safe for you.

At first your rehab team will keep a close watch on how exercise affects your heart. As you get stronger, you will learn how to check your own heart rate when you exercise. By the end of rehab, you will be ready to continue an exercise program on your own.

What are the benefits of cardiac rehab?

Starting cardiac rehab after a heart attack can lower your chance of dying from a heart attack and can help you stay out of the hospital. It may reduce your need for medicine.

Cardiac rehab may also help you to:

• Have better overall health.
• Lose weight or keep weight off.
• Feel less depressed and more hopeful.
• Have more energy and feel better about yourself.

Changing old habits is hard. But in cardiac rehab, you get the support of experts who can help you make new healthy habits. And meeting other people who are in cardiac rehab can help you know that you're not alone.

Health Tools 

Health Tools help you make wise health decisions or take action to improve your health.

	Actionsets are designed to help people take an active role in managing a health condition.
	Heart disease: Eating a heart-healthy diet
	Heart disease: Walking for a healthy heart
	Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
	Interactive Tool: What Is Your Target Heart Rate?

Frequently Asked Questions

Phases of Cardiac Rehab

Cardiac rehab is a program designed specifically for you and your medical needs. It includes exercise, lifestyle changes, education, and emotional support. It can help improve your health and enable you to live a more active life after you have had a heart attack or heart surgery or if you have a long-term heart problem such as heart failure. Cardiac rehab can also help you return to work safely and in a timely manner.

You may start a cardiac rehab program while you are still in the hospital after having treatment for a heart attack or other heart problem, soon after leaving the hospital, or at any other time to help prevent future heart problems, improve the quality of your life, and make you healthier. Your doctor will give you an exercise prescription that gives you and your cardiac rehab team guidelines for the frequency, duration, and intensity of exercise. The prescription will be based on your medical condition and your fitness level.

How fast you recover depends on your age, your health, and whether you have other health conditions that may slow your recovery. A younger person without other health problems may improve more quickly than an older person who is in poor health. Depending on your condition and how you respond to rehab, you may stay in a particular phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase.

If any of the following symptoms last for more than a few minutes before, during, or after your exercise session, stop exercising and seek medical help:

• Any unusual discomfort, such as chest pain or angina
• Nausea
• Extremely heavy breathing
• Severe fatigue
• Extreme sweating
• Abnormal changes in heart rate, including either of the following:
  • Unexplained low heart rate, or
  • Dramatically higher heart rate than your target heart rate
• Abnormal blood pressure, including any of the following:
  • Drop in systolic blood pressure
  • Failure of systolic blood pressure to rise
  • Excessive blood pressure (over 240/100 millimeters of mercury, or mm Hg)
• Blood sugar below 80 milligrams per deciliter (mg/dL) or above 250 mg/dL

Cardiac rehab has four phases. Your doctor will determine which phase is best for you to start your program.

Phase I: Inpatient program

Phase I takes place in the hospital after you have experienced a heart attack or other major heart problem. Phase I of cardiac rehab usually includes:

• Determining how well you can care for yourself (bathing, dressing, and grooming) after your heart attack or surgery.
• Measuring your ability to exercise. Your doctor will probably want you to have an exercise test before you begin your cardiac rehab exercise program. This test will show what types of exercise are safe for you and how soon you can begin to exercise.
• Identifying which daily activities, such as lifting, you can safely do.
• Providing patient and family education about the lifestyle changes you need to make, such as eating healthy foods and stopping cigarette smoking. Changes in your diet may be difficult to make, but even small changes can help lower cholesterol levels and improve your health. For ideas that can help you get started, see:

  Heart disease: Eating a heart-healthy diet.

• Doing light exercise, such as walking short distances several times a day and possibly beginning a weight-training program.

Home program, phase II, and phase III: Outpatient programs

The remaining three phases of your cardiac rehab take place outside the hospital. At first, your rehab team will keep a close watch on how exercise affects your heart and how you are progressing, before gradually releasing you from supervision to continue cardiac rehab on your own. The healthier lifestyle you've learned—including eating a balanced diet, exercising regularly, and not smoking—can then become a way of life for you.

During this time you may also see your doctor regularly to treat other medical conditions, including high cholesterol and high blood pressure.

Cardiac rehab during home program, phase II, and phase III usually includes:

• Close monitoring and supervision during the early part of your exercise program.
• Preparing you to return to work and the recreational activities you enjoyed before your heart problems. Your work or leisure activities may need to be modified.
• Providing education and counseling for you and your family to help you maintain a lifestyle of healthy habits that will lower your risk of having further heart problems. Depression is common in people with heart problems. Counseling and medicines for depression, if necessary, may be another important part of cardiac rehab.
• Making a plan to help you start a safe home exercise program and participate in other unsupervised activities. For tips on walking as exercise, see:

  Heart disease: Walking for a healthy heart.

Why It Is Done

Cardiac rehab can help you recover from a heart attack or other major heart problem or help improve your quality of life if you have long-term heart disease, such as chronic angina or heart failure. Cardiac rehab can also help you prevent future heart problems if you are at high risk for heart disease or heart attack. Studies have shown that people of any age can benefit from a rehab program, but this is especially true for older adults, women, and people who are at higher risk for developing heart failure. Cardiac rehab can also help you return to work safely and in a timely manner.

You might benefit from cardiac rehab if you:

• Are medically stable after having had a heart attack or heart surgery, including a heart transplant.
• Have heart failure. The exercises you do in cardiac rehab may not improve your heart's ability to pump, but they will strengthen the other muscles in your body, help you do activities more easily, and improve the quality of your life.
• Have angina (chest pain). Cardiac rehab may prevent future heart problems and teach you ways to manage symptoms of the disease.
• Have a pacemaker or another device to keep your heartbeat regular. Cardiac rehab programs can teach you safe ways to exercise if you have a pacemaker.

Exams and Tests

Before starting a cardiac rehab program, a thorough risk assessment will be done to determine your heart health and the types of exercises you can safely do. Testing may be done before and during cardiac rehab to help your doctor decide whether you can safely take part in a program and to monitor your progress.

Tests to determine your ability to exercise that may be done before you start cardiac rehab include:

• Resting electrocardiogram (EKG or ECG), a test that measures the electrical signals that control the rhythm of your heartbeat. The graph that shows the results is called an electrocardiogram. A resting ECG will sometimes show if more extensive testing is needed before you start an exercise program.
• Exercise electrocardiogram (ECG), a test that records the electrical activity of the heart. An exercise electrocardiogram (sometimes called a stress or treadmill test) is done during exercise to evaluate how the heart responds to exercise. Your doctor can use the test results to prescribe a safe amount of exercise for you.
• Echocardiogram (echo), a type of ultrasound test that uses high-pitched sound waves to produce an image of the heart. The sound waves are sent through a device called a transducer and are reflected off the various structures of the heart. This test shows how well your heart is pumping blood and how well your heart valves are working. Sometimes it is combined with an exercise stress test.
• Thallium scanning, a test to estimate the amount of blood reaching the heart muscle during rest and exercise. It is typically done to find out the cause of unexplained chest pain or to find out the location and amount of injured heart muscle after a heart attack.
• Ambulatory electrocardiogram (Holter monitoring test), which monitors the electrical activity of your heart while you go about your usual daily activities. Many heart problems occur only during certain activities, such as exercise, eating, sex, emotional stress, bowel movements, or even sleeping. A continuous 24-hour recording is much more likely to detect any abnormal heartbeats that occur during these activities.

Other testing can help monitor your progress during cardiac rehab. Additional monitoring may include blood pressure, cholesterol, weight, blood sugar levels, and exercise ECGs.

You will be monitored closely when you first begin your cardiac rehab program. But after your exercise program is well established, you probably won't need continuous supervision. But if your doctor determines that you have special needs, he or she may want you to wear a monitoring device at home.

Risks

After having a heart attack or surgery or discovering you have heart disease, you may be afraid to exercise or be active. You may worry that exercise will cause another heart attack or that you aren't strong enough for a cardiac rehab program. It may ease your fears to know that as you begin your rehab, your doctor will monitor your activity closely and health professionals will be on hand to deal with any problems you may have. Your rehab team will tailor all of your exercises specifically for you, based on your medical condition and overall health. All cardiac rehab begins slowly at a comfortable pace and may be as gentle as walking on a treadmill.

If you are worried or afraid to be active again, talk to your doctor. Exercise and activity can greatly improve the quality of your life.

But exercise may not be safe for some people. You may not be able to participate in the exercise portion of cardiac rehab if you have:

• Unstable angina.
• Uncontrolled high blood pressure or low blood pressure.
• Heart rhythm problems or heart failure that is not under control.
• Uncontrolled diabetes.
• Experienced problems during exercise in your cardiac rehab program, such as chest pain (angina). Exercise causes the heart to work harder. As the heart works harder, the heart muscle needs more oxygen. If the narrowed heart vessels cannot provide enough blood (and oxygen) to the heart, you will have chest pain.

Even if you can't exercise or be active, you will benefit from other parts of a cardiac rehab program. For example, you can get help with quitting smoking and reducing stress, and you can get advice on how to eat a heart-healthy diet. This type of education can lower the risk of heart-related death.

Medicines may also affect your ability to participate in cardiac rehab. Some prescribed medicines can change your heart rate, blood pressure, and overall ability to exercise. For example, antidepressants may increase your heart rate and decrease your blood pressure at rest and during exercise. Tell your doctor and other health professionals on your rehab team about all of the medicines you are taking, especially if they cause any side effects during exercise.

How Well It Works

Clinical research has confirmed many benefits of cardiac rehab, including:¹

• A reduced risk of major heart problems and death after a heart attack for those who participate in a cardiac rehab program that includes exercise.
• Decreased severity of angina and decreased need for medicines to control angina.
• Reduced need for hospital stays because of heart problems. Costs for doctor visits and hospital stays are reduced for those who participate in cardiac rehab. Visits to the emergency room are also reduced.
• Decreased blood pressure.
• Reduced shortness of breath and less fatigue in people with heart failure.
• Ability to exercise longer.
• Lower cholesterol and triglyceride levels.
• Reduced emotional stress, depression, and anxiety.

Cardiac rehab can increase the quality of your life by improving your health overall; helping you lose weight, if necessary; reducing depression, stress, and anxiety; and helping to increase your self-esteem.

What to Expect

The goal of cardiac rehab is to help you re-establish and maintain a healthy, active lifestyle after a major heart problem, such as a heart attack or heart surgery, or if you have a long-term heart condition. Most likely, as you progress through cardiac rehab, you'll be concerned about returning to work, resuming recreational and other activities, and resuming a normal sex life.

To maintain the benefits of cardiac rehab, you will have to continue to exercise and follow the healthy lifestyle changes you've learned. Research shows that many people who start a rehab program stop after only a few months, often after the end of phase II, when the close monitoring ends.

Exercise and lifestyle changes. Although exercise, especially weight training, is a significant part of cardiac rehab, lifestyle changes combined with exercise may be more important than exercise alone in keeping your heart healthy. Staying with your program can give you the support you need to make these changes a permanent part of your life and may help reduce the risk of further serious heart problems.

Getting back to work. After you have a heart problem, you may worry about going back to work. Most people can return to work. How quickly you can return to work depends on how bad your heart problem is and how much physical activity your job requires. Some people go back to work part-time in 2 to 3 weeks. Others may require a longer recovery.

If you have a very serious heart problem or your job involves heavy lifting or a great deal of stress, you may want to see a job or vocational counselor. A job counselor can help you return to your current job or help you find training to start a new job.

Resuming a sex life. You or your partner may be worried that you will have symptoms such as chest pain or will not have enough energy for sex. Sharing your concerns and fears about having sex is important for both partners. Both partners need to feel ready to restart an active sex life. Discuss your concerns with a health professional from your rehab program, who can help you and your partner decide if your concerns are warranted and give you suggestions for resuming your sex life. In general, it is safe to resume your sex life about 6 weeks after an uncomplicated heart attack.

Managing stress. Stress management may lower the risk of serious heart problems, such as heart attacks. People who do not deal well with anger and frustration may have a higher risk of coronary artery disease. Learning to manage stress is often part of programs to help you make positive changes in your lifestyle.

Seeking treatment for depression.Depression is often overlooked, especially in older adults, but commonly occurs after a serious heart problem. Depression can make it difficult for you to have the energy to perform some of the cardiac rehab programs. If you feel you suffer from symptoms of depression, make sure you seek help.

Other Places To Get Help

Organizations

Related Information

• Coronary Artery Disease
• Depression
• Heart Attack and Unstable Angina
• Heart Failure
• High Blood Pressure (Hypertension)
• High Cholesterol
• Quitting Smoking
• Weight Management

References

Citations

1. Gami A (2005). Secondary prevention of ischaemic cardiac events, search date February 2006. Online version of Clinical Evidence (14): 1–33.

Other Works Consulted

• American College of Sports Medicine (2006). Exercise prescription modifications for cardiac patients. In PJ Darcy et al., eds., ACSM's Guidelines for Exercise Testing and Prescription, 7th ed., pp. 174–204. Philadelphia: Lippincott Williams and Wilkins.
• Balady GJ, et al. (2007). Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation, 115(20): 2675–2682.
• Graham I (2008). Rehabilitation of the patient with coronary heart disease. In V Fuster et al., eds., Hurst's The Heart, 12th ed., pp. 1529–1548. New York: McGraw-Hill Medical.
• Williams MA, et al. (2007). Resistance exercise in individuals with and without cardiovascular disease: 2007 update: A scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation, 116(5): 572–584.

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