TY - JOUR
AU1 - Niebauer, Josef
AU2 - Mayr, Karl
AU3 - Tschentscher, Markus
AU4 - Pokan, Rochus
AU5 - Benzer, Werner
AB - Abstract Over the past decades undisputable evidence has accumulated identifying the panoply of beneficial effects of exercise training, smoking cessation, blood pressure lowering, glycaemic and lipid control, as well as psycho-social interventions on cardiovascular risk factors, the well-being, morbidity and mortality of patients with cardiac diseases with or without acute events. Nevertheless, despite all the evidence, insurance companies are more than hesitant to provide patients with an adequate infrastructure to allow outpatient cardiac rehabilitation in their community. Whereas some countries still favour in-hospital rehabilitation, others are on the verge of introducing cardiac rehabilitation for the first time. Thanks to the efforts of the Working Group of Outpatient Cardiac Rehabilitation of the Austrian Cardiac Society, detailed guidelines for outpatient cardiac rehabilitation have been introduced, which not only include aims, contents and duration of outpatient cardiac rehabilitation, but also requirements for staff, quality of care and infrastructure. As a result cardiac rehabilitation in Austria is currently undergoing a transition process from exclusive in-hospital cardiac rehabilitation to a more open approach of granting patients a choice between in-hospital and outpatient rehabilitation. Experience gained appears relevant to a great number of colleagues in many countries Europe – as well as worldwide. Since these guidelines were and still are the basis for implementing outpatient cardiac rehabilitation, they are presented in great detail, so that they may either be applied as is or simply stimulate discussion. Cardiovascular risk factors, exercise training, diet, quality of life, secondary prevention Introduction Aims and practices of cardiac rehabilitation vary considerably among European countries. 1–6 Whereas some countries do not offer standardized care, others practise according to detailed local guidelines. Therefore, detailed information on existing and well-functioning programmes is of great interest, especially to countries that are currently on the verge of introducing outpatient cardiac rehabilitation. Furthermore, such information can serve as guidance for countries with established programmes that continuously strive to improve them. In Austria, national guidelines exist for outpatient cardiac rehabilitation5 and they have led to a standardized care throughout Austria. In an attempt to harmonize outpatient cardiac rehabilitation throughout Europe, the Austrian model might serve as a template for other countries. Therefore, the Austrian model is presented in great detail, thus providing sufficient depth to allow for comparison with programmes of the respective country or institution. The Austrian guideline aims to ensure the best possible but still affordable outpatient rehabilitation to patients with high risk of or documented cardiac diseases, cardiac events or percutaneous or surgical interventions of the heart (Table 1). The number of hours given in this article may serve as an example on how cardiac rehabilitation can be performed, in order to help patients achieve treatment targets (Table 2). Due to the very different economical and infrastructural resources of the various European countries, the following standard might not be met by some countries right away, whereas services in other countries might even exceed these. Table 1. Indications and contraindications for outpatient cardiac rehabilitation Indications  • Acute coronary syndrome (STEMI and NSTEMI)  • Percutaneous coronary intervention (PCI)  • Stable coronary heart disease  • Aortocoronary bypass surgery  • Other surgeries of the heart and the big vessels  • Heart and lung transplantation  • Chronic heart failure (NYHA-stadium II, III)  • Pulmonary hypertension  • Peripheral artery occlusive disease (claudicatio intermittens)  • Prevention in motivated high risk patients (SCORE: 10-year-risk of cardiovascular death of >5%; PROCAM: coronary event of >20%).  • Electro-physiological intervention  • Implantation of a cardiac pacemaker or a defibrillator  • Haemodynamically stable arrhythmia  • Sustained ventricular tachycardia or cardiac arrest Contraindications  • Unstable angina pectoris  • Acute endomyocarditis or other acute infections  • Recent pulmonary artery embolism or phlebothrombosis  • Haemodynamically relevant arrhythmia  • Critical obstructions of the left ventricular discharge apparatus  • Physical, psychological or mental limitations prohibiting cardiac rehabilitation Indications  • Acute coronary syndrome (STEMI and NSTEMI)  • Percutaneous coronary intervention (PCI)  • Stable coronary heart disease  • Aortocoronary bypass surgery  • Other surgeries of the heart and the big vessels  • Heart and lung transplantation  • Chronic heart failure (NYHA-stadium II, III)  • Pulmonary hypertension  • Peripheral artery occlusive disease (claudicatio intermittens)  • Prevention in motivated high risk patients (SCORE: 10-year-risk of cardiovascular death of >5%; PROCAM: coronary event of >20%).  • Electro-physiological intervention  • Implantation of a cardiac pacemaker or a defibrillator  • Haemodynamically stable arrhythmia  • Sustained ventricular tachycardia or cardiac arrest Contraindications  • Unstable angina pectoris  • Acute endomyocarditis or other acute infections  • Recent pulmonary artery embolism or phlebothrombosis  • Haemodynamically relevant arrhythmia  • Critical obstructions of the left ventricular discharge apparatus  • Physical, psychological or mental limitations prohibiting cardiac rehabilitation Open in new tab Table 1. Indications and contraindications for outpatient cardiac rehabilitation Indications  • Acute coronary syndrome (STEMI and NSTEMI)  • Percutaneous coronary intervention (PCI)  • Stable coronary heart disease  • Aortocoronary bypass surgery  • Other surgeries of the heart and the big vessels  • Heart and lung transplantation  • Chronic heart failure (NYHA-stadium II, III)  • Pulmonary hypertension  • Peripheral artery occlusive disease (claudicatio intermittens)  • Prevention in motivated high risk patients (SCORE: 10-year-risk of cardiovascular death of >5%; PROCAM: coronary event of >20%).  • Electro-physiological intervention  • Implantation of a cardiac pacemaker or a defibrillator  • Haemodynamically stable arrhythmia  • Sustained ventricular tachycardia or cardiac arrest Contraindications  • Unstable angina pectoris  • Acute endomyocarditis or other acute infections  • Recent pulmonary artery embolism or phlebothrombosis  • Haemodynamically relevant arrhythmia  • Critical obstructions of the left ventricular discharge apparatus  • Physical, psychological or mental limitations prohibiting cardiac rehabilitation Indications  • Acute coronary syndrome (STEMI and NSTEMI)  • Percutaneous coronary intervention (PCI)  • Stable coronary heart disease  • Aortocoronary bypass surgery  • Other surgeries of the heart and the big vessels  • Heart and lung transplantation  • Chronic heart failure (NYHA-stadium II, III)  • Pulmonary hypertension  • Peripheral artery occlusive disease (claudicatio intermittens)  • Prevention in motivated high risk patients (SCORE: 10-year-risk of cardiovascular death of >5%; PROCAM: coronary event of >20%).  • Electro-physiological intervention  • Implantation of a cardiac pacemaker or a defibrillator  • Haemodynamically stable arrhythmia  • Sustained ventricular tachycardia or cardiac arrest Contraindications  • Unstable angina pectoris  • Acute endomyocarditis or other acute infections  • Recent pulmonary artery embolism or phlebothrombosis  • Haemodynamically relevant arrhythmia  • Critical obstructions of the left ventricular discharge apparatus  • Physical, psychological or mental limitations prohibiting cardiac rehabilitation Open in new tab Table 2. Targets for all patients with atherosclerotic diseases Physical activity Energy expenditure >2000 kcal/week: a. Everyday 30 min of physical activity (e.g. occupational physical activity, walking, climbing stairs, bicycling instead of driving a car, gardening), approximately 1000 kcal in total. b. 2 h/week structured endurance training (3x40 min), approximately 800 kcal in total with the additional goal to increase the maximum oxygen uptake by >20% and/or the performance on the bicycle ergometer to 100–120% of the age-adjusted index value. c. 1 h resistance training per week (2x30 min), 200 kcal in total to increase muscle mass and muscle force (Table 8). Morphometrics a. Body fat percentage of <20% in men and <25% in women measured with standardized testing methods (body impedance analysis; calliper). b. Waist circumference <102 cm in men and <89 cm in women. c. Normal weight, i.e. BMI <25. Lipid metabolism a. LDL < 100 mg/dl (2.6 mmol/l) or <70 mg/dl (1.8 mmol/l) in high risk coronary patients b. Triglycerides < 150 mg/dl (1.7 mmol/l). Glucose metabolism Fasting blood glucose level < 110 mg (6.1 mmol/l); HbA1C <6.5%. Blood pressure <140/90 mmHg or rather 130/80 mmHg if additional risk factors, especially diabetes mellitus and/or chronic renal failure = GFR <60 ml/min are present. Nutrition Heart healthy diet in keeping with the recommendation of the American Heart Association Science Advisory and Coordinating Committee. Smoking Cessation Psychosocial status and quality of life a. Reduction of anxiety and depressiveness: HADS-Score <8. b. Health-related quality of life: MacNew Global Score increase of >0.5 Pharmaceutical secondary prevention a. Aspirin and/or Clopidogrel as indicated b. Beta blocker c. ACE inhibitors or A-II-receptor blocker d. Statin Physical activity Energy expenditure >2000 kcal/week: a. Everyday 30 min of physical activity (e.g. occupational physical activity, walking, climbing stairs, bicycling instead of driving a car, gardening), approximately 1000 kcal in total. b. 2 h/week structured endurance training (3x40 min), approximately 800 kcal in total with the additional goal to increase the maximum oxygen uptake by >20% and/or the performance on the bicycle ergometer to 100–120% of the age-adjusted index value. c. 1 h resistance training per week (2x30 min), 200 kcal in total to increase muscle mass and muscle force (Table 8). Morphometrics a. Body fat percentage of <20% in men and <25% in women measured with standardized testing methods (body impedance analysis; calliper). b. Waist circumference <102 cm in men and <89 cm in women. c. Normal weight, i.e. BMI <25. Lipid metabolism a. LDL < 100 mg/dl (2.6 mmol/l) or <70 mg/dl (1.8 mmol/l) in high risk coronary patients b. Triglycerides < 150 mg/dl (1.7 mmol/l). Glucose metabolism Fasting blood glucose level < 110 mg (6.1 mmol/l); HbA1C <6.5%. Blood pressure <140/90 mmHg or rather 130/80 mmHg if additional risk factors, especially diabetes mellitus and/or chronic renal failure = GFR <60 ml/min are present. Nutrition Heart healthy diet in keeping with the recommendation of the American Heart Association Science Advisory and Coordinating Committee. Smoking Cessation Psychosocial status and quality of life a. Reduction of anxiety and depressiveness: HADS-Score <8. b. Health-related quality of life: MacNew Global Score increase of >0.5 Pharmaceutical secondary prevention a. Aspirin and/or Clopidogrel as indicated b. Beta blocker c. ACE inhibitors or A-II-receptor blocker d. Statin ACE: angiotensin converting enzyme; GFR: glomerular filtration rate. Open in new tab Table 2. Targets for all patients with atherosclerotic diseases Physical activity Energy expenditure >2000 kcal/week: a. Everyday 30 min of physical activity (e.g. occupational physical activity, walking, climbing stairs, bicycling instead of driving a car, gardening), approximately 1000 kcal in total. b. 2 h/week structured endurance training (3x40 min), approximately 800 kcal in total with the additional goal to increase the maximum oxygen uptake by >20% and/or the performance on the bicycle ergometer to 100–120% of the age-adjusted index value. c. 1 h resistance training per week (2x30 min), 200 kcal in total to increase muscle mass and muscle force (Table 8). Morphometrics a. Body fat percentage of <20% in men and <25% in women measured with standardized testing methods (body impedance analysis; calliper). b. Waist circumference <102 cm in men and <89 cm in women. c. Normal weight, i.e. BMI <25. Lipid metabolism a. LDL < 100 mg/dl (2.6 mmol/l) or <70 mg/dl (1.8 mmol/l) in high risk coronary patients b. Triglycerides < 150 mg/dl (1.7 mmol/l). Glucose metabolism Fasting blood glucose level < 110 mg (6.1 mmol/l); HbA1C <6.5%. Blood pressure <140/90 mmHg or rather 130/80 mmHg if additional risk factors, especially diabetes mellitus and/or chronic renal failure = GFR <60 ml/min are present. Nutrition Heart healthy diet in keeping with the recommendation of the American Heart Association Science Advisory and Coordinating Committee. Smoking Cessation Psychosocial status and quality of life a. Reduction of anxiety and depressiveness: HADS-Score <8. b. Health-related quality of life: MacNew Global Score increase of >0.5 Pharmaceutical secondary prevention a. Aspirin and/or Clopidogrel as indicated b. Beta blocker c. ACE inhibitors or A-II-receptor blocker d. Statin Physical activity Energy expenditure >2000 kcal/week: a. Everyday 30 min of physical activity (e.g. occupational physical activity, walking, climbing stairs, bicycling instead of driving a car, gardening), approximately 1000 kcal in total. b. 2 h/week structured endurance training (3x40 min), approximately 800 kcal in total with the additional goal to increase the maximum oxygen uptake by >20% and/or the performance on the bicycle ergometer to 100–120% of the age-adjusted index value. c. 1 h resistance training per week (2x30 min), 200 kcal in total to increase muscle mass and muscle force (Table 8). Morphometrics a. Body fat percentage of <20% in men and <25% in women measured with standardized testing methods (body impedance analysis; calliper). b. Waist circumference <102 cm in men and <89 cm in women. c. Normal weight, i.e. BMI <25. Lipid metabolism a. LDL < 100 mg/dl (2.6 mmol/l) or <70 mg/dl (1.8 mmol/l) in high risk coronary patients b. Triglycerides < 150 mg/dl (1.7 mmol/l). Glucose metabolism Fasting blood glucose level < 110 mg (6.1 mmol/l); HbA1C <6.5%. Blood pressure <140/90 mmHg or rather 130/80 mmHg if additional risk factors, especially diabetes mellitus and/or chronic renal failure = GFR <60 ml/min are present. Nutrition Heart healthy diet in keeping with the recommendation of the American Heart Association Science Advisory and Coordinating Committee. Smoking Cessation Psychosocial status and quality of life a. Reduction of anxiety and depressiveness: HADS-Score <8. b. Health-related quality of life: MacNew Global Score increase of >0.5 Pharmaceutical secondary prevention a. Aspirin and/or Clopidogrel as indicated b. Beta blocker c. ACE inhibitors or A-II-receptor blocker d. Statin ACE: angiotensin converting enzyme; GFR: glomerular filtration rate. Open in new tab Definition of cardiac rehabilitation and prevention Cardiac rehabilitation and prevention is a coordinated approach by an interdisciplinary team (Table 3) aiming to provide the best possible physical and psychological outcomes for patients with cardiac diseases or those following an acute event. The approach aims to support patients during an indication-specific (Table 4) and phase-specific (Table 5) rehabilitation programme to resume both work and their familiar place in society with their own fortitude and to limit or reverse the progress of their medical condition through sustained health-related life habits. In the following, we will present the Austrian requirements for staff qualifications, programme contents as well as rooms and equipment (Table 6) in order to be granted accreditation as an outpatient cardiac rehabilitation programme. Table 3. Human resources required for outpatient cardiac rehabilitation phase II and III Responsible medical administration  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient Medical presence in an outpatient cardiac rehabilitation institute  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient  • Specialist in general medicine plus diploma in cardiac rehabilitation or at least 5 years of occupation in an accredited cardiac rehabilitation institution Instructor in an outpatient cardiac rehabilitation institute  • Sports scientist plus diploma in cardiac rehabilitation or  • Physiotherapist plus diploma in cardiac rehabilitation Psycho-cardiac care in an outpatient cardiac rehabilitation institute  • Clinical psychologist plus diploma in cardiac rehabilitation  • Health psychologist plus diploma in cardiac rehabilitation  • Psychotherapist plus diploma in cardiac rehabilitation Responsible medical administration  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient Medical presence in an outpatient cardiac rehabilitation institute  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient  • Specialist in general medicine plus diploma in cardiac rehabilitation or at least 5 years of occupation in an accredited cardiac rehabilitation institution Instructor in an outpatient cardiac rehabilitation institute  • Sports scientist plus diploma in cardiac rehabilitation or  • Physiotherapist plus diploma in cardiac rehabilitation Psycho-cardiac care in an outpatient cardiac rehabilitation institute  • Clinical psychologist plus diploma in cardiac rehabilitation  • Health psychologist plus diploma in cardiac rehabilitation  • Psychotherapist plus diploma in cardiac rehabilitation Open in new tab Table 3. Human resources required for outpatient cardiac rehabilitation phase II and III Responsible medical administration  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient Medical presence in an outpatient cardiac rehabilitation institute  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient  • Specialist in general medicine plus diploma in cardiac rehabilitation or at least 5 years of occupation in an accredited cardiac rehabilitation institution Instructor in an outpatient cardiac rehabilitation institute  • Sports scientist plus diploma in cardiac rehabilitation or  • Physiotherapist plus diploma in cardiac rehabilitation Psycho-cardiac care in an outpatient cardiac rehabilitation institute  • Clinical psychologist plus diploma in cardiac rehabilitation  • Health psychologist plus diploma in cardiac rehabilitation  • Psychotherapist plus diploma in cardiac rehabilitation Responsible medical administration  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient Medical presence in an outpatient cardiac rehabilitation institute  • Specialist in internal medicine and cardiology or  • Specialist in internal medicine plus diploma in cardiac rehabilitation or  • Specialist in internal medicine with at least 2 years of occupation in an accredited cardiac rehabilitation institution, thereof at least 1 year inpatient  • Specialist in general medicine plus diploma in cardiac rehabilitation or at least 5 years of occupation in an accredited cardiac rehabilitation institution Instructor in an outpatient cardiac rehabilitation institute  • Sports scientist plus diploma in cardiac rehabilitation or  • Physiotherapist plus diploma in cardiac rehabilitation Psycho-cardiac care in an outpatient cardiac rehabilitation institute  • Clinical psychologist plus diploma in cardiac rehabilitation  • Health psychologist plus diploma in cardiac rehabilitation  • Psychotherapist plus diploma in cardiac rehabilitation Open in new tab Table 4. Indication-specific recommendation for the appropriate phase of outpatient cardiac rehabilitation Condition after acute coronary syndrome (STEMI) Phase III, IV, in selected cases phase II Condition after bypass surgery Phase III, IV, in selected cases phase II Condition after other heart surgeries Phase III, IV, in selected cases phase II Condition after heart and lung transplantation Phase III, IV Chronic heart failure Phase III, IV, in selected cases phase II Condition after acute coronary syndrome (NSTEMI) Phase II, III, IV Condition after PCI Phase II, III, IV Patients with stable coronary heart disease Phase II, III, IV Pulmonary hypertension Phase II, III, IV Patients with PAOD Phase II, III, IV Prevention on motivated high risk patients Phase II, III, IV Condition after electro-physiological intervention Phase II, III, IV Patients after implantation of a cardiac pacemaker or a defibrillator Phase II, III, IV Patients with haemodynamic stable arrhythmia Phase II, III, IV Condition after acute coronary syndrome (STEMI) Phase III, IV, in selected cases phase II Condition after bypass surgery Phase III, IV, in selected cases phase II Condition after other heart surgeries Phase III, IV, in selected cases phase II Condition after heart and lung transplantation Phase III, IV Chronic heart failure Phase III, IV, in selected cases phase II Condition after acute coronary syndrome (NSTEMI) Phase II, III, IV Condition after PCI Phase II, III, IV Patients with stable coronary heart disease Phase II, III, IV Pulmonary hypertension Phase II, III, IV Patients with PAOD Phase II, III, IV Prevention on motivated high risk patients Phase II, III, IV Condition after electro-physiological intervention Phase II, III, IV Patients after implantation of a cardiac pacemaker or a defibrillator Phase II, III, IV Patients with haemodynamic stable arrhythmia Phase II, III, IV PAOD: peripheral arterial obstructive disease. Open in new tab Table 4. Indication-specific recommendation for the appropriate phase of outpatient cardiac rehabilitation Condition after acute coronary syndrome (STEMI) Phase III, IV, in selected cases phase II Condition after bypass surgery Phase III, IV, in selected cases phase II Condition after other heart surgeries Phase III, IV, in selected cases phase II Condition after heart and lung transplantation Phase III, IV Chronic heart failure Phase III, IV, in selected cases phase II Condition after acute coronary syndrome (NSTEMI) Phase II, III, IV Condition after PCI Phase II, III, IV Patients with stable coronary heart disease Phase II, III, IV Pulmonary hypertension Phase II, III, IV Patients with PAOD Phase II, III, IV Prevention on motivated high risk patients Phase II, III, IV Condition after electro-physiological intervention Phase II, III, IV Patients after implantation of a cardiac pacemaker or a defibrillator Phase II, III, IV Patients with haemodynamic stable arrhythmia Phase II, III, IV Condition after acute coronary syndrome (STEMI) Phase III, IV, in selected cases phase II Condition after bypass surgery Phase III, IV, in selected cases phase II Condition after other heart surgeries Phase III, IV, in selected cases phase II Condition after heart and lung transplantation Phase III, IV Chronic heart failure Phase III, IV, in selected cases phase II Condition after acute coronary syndrome (NSTEMI) Phase II, III, IV Condition after PCI Phase II, III, IV Patients with stable coronary heart disease Phase II, III, IV Pulmonary hypertension Phase II, III, IV Patients with PAOD Phase II, III, IV Prevention on motivated high risk patients Phase II, III, IV Condition after electro-physiological intervention Phase II, III, IV Patients after implantation of a cardiac pacemaker or a defibrillator Phase II, III, IV Patients with haemodynamic stable arrhythmia Phase II, III, IV PAOD: peripheral arterial obstructive disease. Open in new tab Table 5. Phases of outpatient cardiac rehabilitation and prevention Phase I Early in-hospital mobilization after an acute event Phase II Outpatient cardiac rehabilitation: most often the preferable alternative to inpatient rehabilitation 4-6 weeks Phase III Assure sustainability of the results achieved during phase II 6-12 months Phase IV: Responsibility of every patient: heart groups, sports clubs, home training, etc. Lifelong Phase I Early in-hospital mobilization after an acute event Phase II Outpatient cardiac rehabilitation: most often the preferable alternative to inpatient rehabilitation 4-6 weeks Phase III Assure sustainability of the results achieved during phase II 6-12 months Phase IV: Responsibility of every patient: heart groups, sports clubs, home training, etc. Lifelong Open in new tab Table 5. Phases of outpatient cardiac rehabilitation and prevention Phase I Early in-hospital mobilization after an acute event Phase II Outpatient cardiac rehabilitation: most often the preferable alternative to inpatient rehabilitation 4-6 weeks Phase III Assure sustainability of the results achieved during phase II 6-12 months Phase IV: Responsibility of every patient: heart groups, sports clubs, home training, etc. Lifelong Phase I Early in-hospital mobilization after an acute event Phase II Outpatient cardiac rehabilitation: most often the preferable alternative to inpatient rehabilitation 4-6 weeks Phase III Assure sustainability of the results achieved during phase II 6-12 months Phase IV: Responsibility of every patient: heart groups, sports clubs, home training, etc. Lifelong Open in new tab Table 6. Minimal infrastructure for an outpatient cardiac rehabilitation institution for phase II and III Emergency equipment and procedures  • Telephone  • Emergency and resuscitation equipment   – 1 ECG   – 1 blood pressure device   – 1 cardiac defibrillator   – 1 intubation equipment   – 1 Ambu bag   – 1 first aid kit (first aid drugs and infusions, needles, swabs, infusion set)  • Procedures:   – an agreed and practised CPR protocol   – staff skilled in CPR at each session   – regular resuscitation courses Requirements for adequate rooms and exercise equipment  • 2 locker rooms including showers and sanitary facilities  • Equipment for endurance training:   – endurance equipment (cycle ergometer or treadmill)   – continuous ECG monitoring   – optional: gym big enough for walking/running Emergency equipment and procedures  • Telephone  • Emergency and resuscitation equipment   – 1 ECG   – 1 blood pressure device   – 1 cardiac defibrillator   – 1 intubation equipment   – 1 Ambu bag   – 1 first aid kit (first aid drugs and infusions, needles, swabs, infusion set)  • Procedures:   – an agreed and practised CPR protocol   – staff skilled in CPR at each session   – regular resuscitation courses Requirements for adequate rooms and exercise equipment  • 2 locker rooms including showers and sanitary facilities  • Equipment for endurance training:   – endurance equipment (cycle ergometer or treadmill)   – continuous ECG monitoring   – optional: gym big enough for walking/running Open in new tab Table 6. Minimal infrastructure for an outpatient cardiac rehabilitation institution for phase II and III Emergency equipment and procedures  • Telephone  • Emergency and resuscitation equipment   – 1 ECG   – 1 blood pressure device   – 1 cardiac defibrillator   – 1 intubation equipment   – 1 Ambu bag   – 1 first aid kit (first aid drugs and infusions, needles, swabs, infusion set)  • Procedures:   – an agreed and practised CPR protocol   – staff skilled in CPR at each session   – regular resuscitation courses Requirements for adequate rooms and exercise equipment  • 2 locker rooms including showers and sanitary facilities  • Equipment for endurance training:   – endurance equipment (cycle ergometer or treadmill)   – continuous ECG monitoring   – optional: gym big enough for walking/running Emergency equipment and procedures  • Telephone  • Emergency and resuscitation equipment   – 1 ECG   – 1 blood pressure device   – 1 cardiac defibrillator   – 1 intubation equipment   – 1 Ambu bag   – 1 first aid kit (first aid drugs and infusions, needles, swabs, infusion set)  • Procedures:   – an agreed and practised CPR protocol   – staff skilled in CPR at each session   – regular resuscitation courses Requirements for adequate rooms and exercise equipment  • 2 locker rooms including showers and sanitary facilities  • Equipment for endurance training:   – endurance equipment (cycle ergometer or treadmill)   – continuous ECG monitoring   – optional: gym big enough for walking/running Open in new tab Diploma of cardiac rehabilitation for phase II and phase III Prerequisites for physicians to obtain the diploma of cardiac rehabilitation Specialist in internal medicine. Specialist in general medicine. Contents of the course for the diploma of cardiac rehabilitation for physicians Theoretical training total of 60 h Introduction: Goals of the instruction course. Role of the physician in a cardiac rehabilitation programme (medical, therapeutic, exercise, physiological and pedagogical aspects). Block 1: Conducting and interpreting exercise tests 20 h Exercise tests (quality criteria, special ergometry modes and protocols) 2 h Basics of performance diagnostics 3 h Functional diagnostics of acute and chronic cardiovascular adaptations to exercise 5 h Substrate utilization (muscular energy metabolism) 3 h Functional diagnostics of acute and chronic metabolic adaptations to exercise (lactate performance diagnostics) 2 h Functional diagnostics of acute and chronic respiratory adaptations to exercise training (spirometry, ergospirometry, blood gases) 3 h Case studies from performance diagnostics (from physiology to pathology) 2 h Block 2: Training theory, nutrition, cardiology, complications – emergency 20 h Aspects of training theory in cardiac rehabilitation 8 h Nutrition 6 h Epidemiology of cardiovascular disease 1 h Diagnostics and therapy of cardiovascular disease 3 h Complications – emergencies 2 h Block 3: Psychosomatics – psychology – pedagogic/organization and administration 20 h Psychosomatics – psychology – pedagogic Methodology and didactics (basics of negotiation, group management and organization, communication training, practical practice) 8 h Psychosocial part (psychosomatics/psycho-cardiology/-therapy, psycho-cardiac interventions) 5 h Organization and administration The phases of rehabilitation 1 h Requirements for establishment and organization of an outpatient cardiac rehabilitation institute 1 h Documentation and practical practice 3 h Goals and guidelines of outpatient cardiac rehabilitation 2 h Continuing medical education 10 h This block contains 10 h of 45 min each that participants collect by attending national and/or international medical conferences (congresses, seminars, symposia, etc.). Topics of courses need to be related to the anticipated role in a cardiac rehabilitation programme and may include cardiology, internal medicine, sports medicine, exercise physiology, nutrition, emergency medicine and psycho-cardiology. Online courses or online literature study is encouraged but does not qualify. Courses have to be attended after enrolment into the course for the diploma of cardiac rehabilitation. Total amount of credits to be obtained Specialist in general medicine: 60 h – complete training course; 10 h – continuing medical education. Specialist in internal medicine plus diploma in sports medicine: 26 h – nutrition;   – psychosomatics – psychology – pedagogic;   – organization and administration; 10 h – continuing medical education. Specialist in internal medicine: 54 h – conducting and interpreting exercise tests;   – training theory, nutrition;   – psychosomatics – psychology – pedagogic;   – organization and administration; 10 h – continuing medical education. Transfer of credits from other advanced education (on application only) Specialist in general medicine with a diploma in sport medicine: 20 h – conducting and interpreting exercise tests. Specialist in general medicine with a diploma in nutritional medicine: 6 h – nutrition. Specialist in general medicine with a diploma emergency medicine: 2 h – complications – emergencies. Specialist in general medicine with diploma in psychosocial medicine or psychosomatic medicine or psychotherapeutic medicine: 12 h – psychosomatics – psychology – pedagogic. Specialist in internal medicine: 3 h – diagnostic and therapy of cardiovascular disease; 1 h – epidemiology of cardiovascular disease; 2 h – complications – emergencies. Specialist in internal medicine with additive internist sports medicine profession: 3 h – diagnostic and therapy of cardiovascular disease; 1 h – epidemiology of cardiovascular disease; 2 h – complications – emergencies; 8 h – aspects of training theory in cardiac rehabilitation – basics in training methodologies – development of exercise-/training lessons; 20 h – conducting and interpreting exercise tests. Prerequisites for instructors to obtain the diploma of cardiac rehabilitation Sports scientist. Physiotherapist. Contents of the course for the diploma of cardiac rehabilitation for instructors Theoretical training Introduction: Goals of the instruction course. Role of the physician in a cardiac rehabilitation programme (medical, therapeutical, exercise physiological and pedagogical aspects). Block 1 – Basics of movement- and training-pedagogic as well as movement- and sports-didactics 20 h Theories and basic concepts of movement- and training-pedagogic: Education, learning as well as development through body and movement experiences 5 h Training-andragogy and training-geragogy: adult- and elderly education through movement and training 5 h Health, disease and rehabilitation from a sport-pedagogical perspective: Salutogenesis and pathogenesis, health promotion and primary prevention through movement and training 5 h Training didactics 5 h Block 2 – Exercise physiology 1 20 h Subject, status and methods of exercise physiology 5 h Muscular effort, performance – structure and development 5 h Ontogenesis of sport-performance 5 h Development of the main factors of sport performance 5 h Block 3 – Exercise physiology 2 20 h Basics of various modes of training 10 h Training system and training control 10 h Block 4 – Cardiology 20 h Symptoms and underlying pathology of the cardiovascular system 4 h Diagnostic and interventional therapy of cardiovascular disease 5 h Conservative therapy of cardiovascular disease 3 h Cardiovascular risk factors 3 h Complications – emergencies (part 1: symptoms of the cardiac patient, cardiac events, cardiopulmonary resuscitation, simulation of emergencies) 5 h Block 5 – Conducting and interpreting exercise tests 20 h Exercise tests (quality criteria, special ergometries and protocols) 2 h Basics of performance diagnostics 3 h Function diagnostics of acute and chronic cardiovascular adaptations to exercise 5 h Substrate utilization (muscular energy metabolism) 3 h Function diagnostics of acute and chronic metabolic adaptations to exercise (lactate performance diagnostics) 2 h Function diagnostics of acute and chronic respiratory adaptations to exercise (spirometry, ergospirometry, blood gases) 3 h Case studies from performance diagnostics (from physiology to pathology) 2 h Block 6 – Training theory, nutrition, cardiology, complications – emergency 20 h Aspects of training theory in cardiac rehabilitation 8 h Nutrition 6 h Epidemiology of cardiovascular disease 1 h Complications – emergencies (part 2: symptoms of the cardiac patient, cardiac events, cardiopulmonary resuscitation, simulation of emergencies) 3 h Complications – emergencies 2 h Block 7 – Psychosomatics – psychology – pedagogic / organization and administration 20 h Psychosomatics – psychology – pedagogic Methodology and didactics (basics of negotiation, group management and organization, communication training) 8 h Psychosocial part (psychosomatics/psycho-cardiology/-therapy, psycho-cardiac interventions) 5 h Organization and administration The phases of rehabilitation 1 h Requirements for establishment and organization of an outpatient cardiac rehabilitation institute 1 h Documentation 3 h Goals and guidelines of outpatient cardiac rehabilitation 2 h Continuing medical education 10 h Total amount of credits to be obtained Sports scientists  Theory: 80 h – blocks 4, 5, 6 and 7;  Continuing medical education: 10 h;  Internship: 60 h. Physiotherapist  Theory: 140 h – blocks 1, 2, 3, 4, 5, 6 and 7;  Continuing medical education: 10 h;  Internship: none. Internship A total of 60 h of internship at an approved in- and/or outpatient cardiac rehabilitation institution. Written proof of completion of the internship has to be signed by the medical supervisor of the institution. Final exam Instructors have to pass an oral or written exam on the contents of the theoretical education. Continuing medical education This block contains 10 h of 45 min each that participants collect by attending medical conferences. Topics of courses need to be related to the anticipated role in a cardiac rehabilitation programme and may include cardiology, internal medicine, sports medicine, exercise physiology, nutrition, emergency medicine and psycho-cardiology. Onlinecourses or online literature study is encouraged but does not qualify. Courses have to be attended after enrolment into the course for the diploma of cardiac rehabilitation. Prerequisites for clinical/health psychologist and psychotherapists to obtain the diploma of cardiac rehabilitation (Table 2) Clinical psychologist. Health psychologist. Psychotherapist. Contents of the course for the diploma of cardiac rehabilitation for clinical/health psychologist and psychotherapists Theoretical training Block 4 – Cardiology 20 h Symptoms and underlying pathology of the cardiovascular system 4 h Diagnostic and interventional therapy of cardiovascular disease 5 h Conservative therapy of cardiovascular disease 3 h Cardiovascular risk factors 3 h Complications – emergencies (part 1: symptoms of the cardiac patient, events, cardiopulmonary resuscitation, simulation of emergencies) 5 h Continuing medical education 10 h Internship Twelve hours of internship at an approved in- and/or outpatient cardiac rehabilitation institution under the professional supervision of a health psychologist. Written proof of completion of the internship has to be signed by the medical supervisor of the institution. Final exam Instructors have to pass an oral or written exam on the contents of the theoretical education. Continuing medical education This block contains of 10 h of 45 min each that participants collect by attending national and/or international medical conferences (congresses, seminars, symposia, etc.). Topics of courses need to be related to the anticipated role in a cardiac rehabilitation programme and may include cardiology, internal medicine, sports medicine, exercise physiology, nutrition, emergency medicine and psycho-cardiology. Online courses or online literature study is encouraged but does not qualify. Courses have to be attended after enrolment into the course for the diploma of cardiac rehabilitation. Initial, intermediate and final medical examination in an outpatient cardiac rehabilitation institution for phase II and phase III Initial medical examination Medical history. Physical exam. Classifying and recording present diagnostic findings (if necessary, send for further consultation). Classifying and recording the risk factor profile (if necessary, request additional laboratory tests). Psycho-social status. Resting electrocardiogram (ECG). Ergometry (exception: existing ergometry < 4 weeks old). Confirming presence of indication for cardiac rehabilitation. Ruling out contraindications against cardiac rehabilitation. Defining the individual rehabilitation goals with patients and developing a rehabilitation plan. Recent test results (<4 weeks) before the start of a cardiac rehabilitation programme that should at least comprise the following: Resting ECG. Resting blood pressure. Ergometry. Echocardiography. Total cholesterol. High density lipoprotein cholesterol. Low density lipoprotein cholesterol. Triglycerides. Serum creatinine. Fasting blood glucose. HbA1C. Body weight and body mass index. Abdominal girth. Psycho-social status plus assessment of health-related quality of life using validated measuring instruments. Intermediate medical examination (i.e. end of phase II or beginning of phase III) Physical exam. Classifying and recording present diagnostic findings (if necessary, send for further consultation). Resting ECG. Ergometry. Classifying and recording the risk factor profile (if necessary, request additional laboratory tests). Psycho-social status. Final medical examination Physical exam. Classifying and recording present diagnostic findings (if necessary, send for further consultation). Resting ECG. Ergometry. Classifying and recording the risk factor profile (if necessary, request additional laboratory tests). Psycho-social status. General recommendations for psycho-somatic, psychological and psychotherapeutic support in outpatient cardiac rehabilitation A cardiac rehabilitation programme has to be designed with the understanding that aetiology, pathogenesis, diagnostics and therapy of acute as well as chronic diseases and their consequences cannot be dealt with adequately without psychological and social concept. Training requirements for psychologists and psychotherapists are listed in Table 7. Table 7. Training requirements for psychologists and psychotherapists Special discipline . Theory . Continuing medical education . Internship . Clinical psychologist Block 4 (20 h) 10 h 12 h Health-psychologist Block 4 (20 h) 10 h 12 h Psychotherapist Block 4 (20 h) 10 h 12 h Clinical/health-psychologist and psychotherapists with at least 1 year occupation at an accepted rehabilitation institution Block 4 (20 h) 10 h none Special discipline . Theory . Continuing medical education . Internship . Clinical psychologist Block 4 (20 h) 10 h 12 h Health-psychologist Block 4 (20 h) 10 h 12 h Psychotherapist Block 4 (20 h) 10 h 12 h Clinical/health-psychologist and psychotherapists with at least 1 year occupation at an accepted rehabilitation institution Block 4 (20 h) 10 h none Open in new tab Table 7. Training requirements for psychologists and psychotherapists Special discipline . Theory . Continuing medical education . Internship . Clinical psychologist Block 4 (20 h) 10 h 12 h Health-psychologist Block 4 (20 h) 10 h 12 h Psychotherapist Block 4 (20 h) 10 h 12 h Clinical/health-psychologist and psychotherapists with at least 1 year occupation at an accepted rehabilitation institution Block 4 (20 h) 10 h none Special discipline . Theory . Continuing medical education . Internship . Clinical psychologist Block 4 (20 h) 10 h 12 h Health-psychologist Block 4 (20 h) 10 h 12 h Psychotherapist Block 4 (20 h) 10 h 12 h Clinical/health-psychologist and psychotherapists with at least 1 year occupation at an accepted rehabilitation institution Block 4 (20 h) 10 h none Open in new tab Psychosomatics Psychosomatics include psychosocial history taking and psychometric tests (Hospital Anxiety and Depression Scale, MacNew) to: elicit the pertinence of psychosocial problems; recognize newly emerging problems (e.g. depressive adjustment disorders, post-traumatic symptoms, secondary cardiac anxieties, etc.) as well as its spontaneous improvement. Clinical-psychological, health-psychological and psychotherapeutic measures and treatment Number of hours: 24 h of a total of 160 h Allocation:  60% in phase II, 40% in phase III At least 2 h as entrance interview, 1 h after each 3–4 weeks and before discharge, e.g. within the first 6 weeks: 12 h; within the following 6 months: 12 h Psycho-cardiac conversation group: with inclusion of health-psychological interventions and psychotherapeutic tenor for all patients. Group sessions with 2 h each. For patients with specific clinical- and health-psychological or psychotherapeutic diagnoses, access should be permitted to applicable methods. Thus, an entrance interview with a clinical or health psychologist or a psychotherapist with appropriate training should be performed for therapy planning. Recreation: Muscle relaxation according to E. Jacobson is recommended, possibly in two forms: Recreational exercises that are integrated into the exercise training programme and are implemented by the instructor (sports scientist, physiotherapist), after an introduction by a clinical/health psychologist or psychotherapist respectively. Recreation groups: 5–8 h. Instructors with basic knowledge of muscle relaxation according to Jacobson within their professional training should implement the recreational training in the integrated form within the exercise training program after a refresher course. Recreation groups according to E. Jacobson (5–8 h for approximately 8–10 patients) should be carried out by specially trained clinical/healthpsychologist only. Additional psychological and psychotherapeutic measures and psycho-educative methods if necessary: Deepening recreational methods. Smoking cessation. Psychotherapy if indicated (e.g. secondary neurotic processing, adjustment disorders, posttraumatic disorders). Stress management. Every patient should be able to get the above mentioned interventions within his/her psychosocial rehabilitation if adequate. Cardiac rehabilitation clinical team The interdisciplinary or multi-disciplinary rehabilitation team is put together according to the indication-specific requirements of the programme and the needs of the patients (Table 2). Routinely, this involves physicians, physiotherapists, sports scientists, social workers, clinical psychologists, nutritionists, nurses or further specialties as required. Regular team meetings have to be held and should include internal and possibly external case supervision. Structure of outpatient cardiac rehabilitation programmes phase II and III Duration Phase II: 4–6 weeks. Phase III 6–12 months (longer if medically indicated). Amount Phase II: 40–60 h. Phase III: 100 h. Hours must be flexibly adjusted according to the underlying disease, the degree of morbidity, the risk factor profile as well as the occupational and social needs of the patients. If required, patients ought to be referred or transferred to further specialist facilities that cooperate with the particular rehabilitation institution to ensure success of the rehabilitation programme. Contents Exercise therapy Individually adjusted endurance training controlled by ECG monitoring. Individually adjusted resistance training. Intensity and amount is prescribed according to patient fitness level, underlying disease and individual risk profile. Activities of daily life. Flexibility. Coordination. Psycho-cardiology Group size of 8–10 patients. 24 h altogether, approximately 60% in phase II and 40% in phase III. Nutritional education (if possible by a nutritionist) Behaviour modifying approach. 24 hours altogether, approximately 60% in phase II and 40% in phase III. Recreational training/breathing exercise Autogenic training. Progressive muscle relaxation (Jacobson). Educational seminar (for relatives as well) Cardiac diseases, especially coronary heart disease. Cardiac drugs. Examination methods. Cardiovascular risk factors and their treatment. Nutrition, obesity, lipids. Smoking. Hypertension. Stress, stress management. Sedentary versus physically active lifestyle. Coping with the disease, living with the disease. What to do in case of medical emergencies. Smoking cessation Seminar-type or group therapy. Individual counselling. Chronological schedule of outpatient cardiac rehabilitation Phase II Week 1 Medical initial interview: ○ classification of findings and possible amendment; ○ investigation of acute physical performance; ○ tour of the institute; ○ ‘meet and greet’ of relevant staff; ○ nutrition protocol and analysis. 2 h of endurance training: ○ familiarization with the equipment (ECG monitor, ergometer); ○ easy, regenerative and coordinative training after maximal ergometry. clinical-psychological interview with the therapist of the psycho-cardiac therapy group: ○ psychosocial status including determination of health-related quality of life using validated measuring instruments. Week 2 3 h of endurance training: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate;determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 10–30 min/h; training time per week: 30–90 min according to performance level; additional hypertrophy strength training (recommendation see Table 8). Initial interview with nutritionist. Psycho-cardiac therapy group. Educational seminar. Table 8. Recommendations for muscle hypertrophy training Design . Goals . Mode . Intensity . Repetitions . Frequency . Step I Learning and practicing correct exercises; improvement of inter-muscular coordination Dynamic <50% RM 8-15 2 units/wk; 6–8 muscle groups; 1–2 sets/muscle group Preliminary training (3-4 weeks) Step II muscle hypertrophy; improvement of intra-muscular coordination Dynamic 60–80% RM 8-15 2 units/wk; 6–8 muscle groups; 2 sets/muscle group Hypertrophy strength Training Design . Goals . Mode . Intensity . Repetitions . Frequency . Step I Learning and practicing correct exercises; improvement of inter-muscular coordination Dynamic <50% RM 8-15 2 units/wk; 6–8 muscle groups; 1–2 sets/muscle group Preliminary training (3-4 weeks) Step II muscle hypertrophy; improvement of intra-muscular coordination Dynamic 60–80% RM 8-15 2 units/wk; 6–8 muscle groups; 2 sets/muscle group Hypertrophy strength Training RM: repetition maximum = load (kg) / (1 repetition x 0.025) Intensity has to be chosen so that chosen number of repetitions can be performed. Open in new tab Table 8. Recommendations for muscle hypertrophy training Design . Goals . Mode . Intensity . Repetitions . Frequency . Step I Learning and practicing correct exercises; improvement of inter-muscular coordination Dynamic <50% RM 8-15 2 units/wk; 6–8 muscle groups; 1–2 sets/muscle group Preliminary training (3-4 weeks) Step II muscle hypertrophy; improvement of intra-muscular coordination Dynamic 60–80% RM 8-15 2 units/wk; 6–8 muscle groups; 2 sets/muscle group Hypertrophy strength Training Design . Goals . Mode . Intensity . Repetitions . Frequency . Step I Learning and practicing correct exercises; improvement of inter-muscular coordination Dynamic <50% RM 8-15 2 units/wk; 6–8 muscle groups; 1–2 sets/muscle group Preliminary training (3-4 weeks) Step II muscle hypertrophy; improvement of intra-muscular coordination Dynamic 60–80% RM 8-15 2 units/wk; 6–8 muscle groups; 2 sets/muscle group Hypertrophy strength Training RM: repetition maximum = load (kg) / (1 repetition x 0.025) Intensity has to be chosen so that chosen number of repetitions can be performed. Open in new tab Week 3 3 h of endurance training: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate; determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 10–30 min/h; training time per week: 30–90 min according to performance level ○ additional hypertrophy strength training (recommendation see Table 8). Psycho-cardiac therapy group. Nutrition. Educational seminar. Week 4 3 h of endurance training: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate; determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 10–30 min/h; training time per week: 30–90 min according to performance level; ○ additional hypertrophy strength training (recommendation see Table 8). Psycho-cardiac therapy group. Nutrition. Educational seminar. Weeks 5–6 3 h of endurance training: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate; determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 10–30 min/h; training time per week: 30–90 min according to performance level ○ additional hypertrophy strength training (recommendation see Table 8). Psycho-cardiac therapy group. Nutrition. Educational seminar. Health-related quality of life questionnaires. Exercise testing. Optional: progressive muscle relaxation, smoking cessation. Final assessment at the end of phase II: ○ resting ECG; ○ maximal ergometry including exercise ECG; ○ current cardiovascular risk profile; ○ psychosocial status including determination of health-related quality of life using validated measuring instruments; ○ discharge letter, which includes recommendation for exercise training both at home and during phase III rehabilitation; ○ counselling by nutritionist with detailed recommendations. Phase III Weeks 1–24 2 h of endurance training: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 20–40 min/h; ○ additional hypertrophy strength training (recommendation see Table 8). 1 h of home training as minimum requirement for at home: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: initially 20–40 min/h; ○ training time per week: 80–160 min according to performance level. Optional hours according to risk profile and preceding phase-II-rehabilitation: ○ continued smoking cessation; ○ psycho-cardiac therapy group and nutrition training; ○ recreational training. Week 1 and week 24 Assessment of current exercise capacity. Psychosocial status including determination of health-related quality of life using validated measuring instruments. Weeks 25–52 1–2 h of endurance training inside the institute: ○ endurance training: intensity: 50–70% of the maximal or rather symptom limited heart rate determined during maximal ergometry under stable medication or 80–90% of the heart rate at the individual anaerobic threshold respectively; duration: 30–50 min/h; additional hypertrophy training (recommendation see Table 3). 3 h of home training as minimum requirement for at home: training time per week: 150–300 min according to performance level. Final assessment at the end of phase III: ○ resting ECG; ○ maximal ergometry including exercise ECG; ○ current cardiovascular risk profile; ○ psychosocial status including determination of health-related quality of life using validated measuring instruments; ○ discharge letter, which includes recommendation for exercise training both at home and during phase IV rehabilitation; ○ counselling by nutritionist with detailed recommendations. Quality control Quality control is essential to guarantee successful rehabilitation for the patients and should include electronic documentation and data evaluation according to national policies and practice. Data entry into National and European Cardiac Rehabilitation Data Base and Registry – an initiative of the Nucleus on Cardiac Rehabilitation of the European Association of Cardiovascular Prevention and Rehabilitation, European Society of Cardiology. Discussion and conclusion Cardiac rehabilitation has been shown to be beneficial for patients with cardiac diseases, regardless whether it is provided on an in- or outpatient basis.1,3,6 Most recent data are actually in favour of outpatient cardiac rehabilitation, a reason why, in Austria, outpatient rehabilitation is on the rise.7 In order to provide standardized, evidence- and thus guideline-based care to our patients, all Austrian institutions together with the health and retirement insurances agreed on one single model. The model has been presented above in great detail and is meant to serve as a cookbook for those who are on the verge of starting a programme or looking for ways to improve theirs. The Austrian model has amalgamated recommendations from the major national and international professional societies, as well as the invaluable experience of our esteemed colleagues in inpatient cardiac rehabilitation. It also provides a carefully tailored programme, which includes specific recommendations for the consistence of the interdisciplinary team, their qualifications, requirements for space and equipment, programme contents and duration as well as medical tests to be performed during rehabilitation.1–6 We trust that our model is of relevance to a great number of colleagues and will foster a European-wide cluster of outpatient cardiac rehabilitation programmes. It has to be pointed out, however, that cardiac rehabilitation does not end with phase III, but that lifelong secondary prevention is required by every patient. While during phase II patients are being familiarized with the necessary lifestyle changes, phase III serves to induce sustainability. However, in order to help patients successfully make lifetime changes, home-based training programmes have to be tailored together with them and they have to be encouraged to join sports clubs, gyms and any other kind of activities that will help them not only to increase their daily physical activity but also to get them involved in sports. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest None declared. References 1 Bjarnason-Wehrens B , McGee H, Zwisler A Det al. . Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey . Eur J Cardiovasc Prev Rehabil 2010 ; 17 : 410 – 418 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Zwisler AD, Bjarnason-Wehrens B, McGee H, et al. Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey. Eur J Prev Cardiolog. 2012; 19: 143–150 . 3 Corrà U , Piepoli M F, Carré Fet al. . Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: Key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation . Eur Heart J 2010 ; 31 : 1967 – 1974 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Piepoli M F , Corrà U, Benzer Wet al. . Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation . Eur J Cardiovasc Prev Rehabil 2010 ; 17 : 1 – 17 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Benzer W et al. . Guidelines für die ambulante kardiologische Rehabilitation und Prävention in Österreich – Update 2008 . J Kardiol 2008 ; 15 : 298 – 309 . Google Scholar OpenURL Placeholder Text WorldCat 6 Smith S C et al. . AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update . Circulation 2011 ; 124 : 2458 – 2473 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Mittag O et al. . Medium-term effects of cardiac rehabilitation in Germany: systematic review and meta-analysis of results from national and international trials . Eur J Cardiovasc Prev Rehabil 2011 ; 18 : 587 – 693 . Google Scholar Crossref Search ADS PubMed WorldCat © The European Society of Cardiology 2013 This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The European Society of Cardiology 2013
TI - Outpatient cardiac rehabilitation: the Austrian model
JF - European Journal of Preventive Cardiology
DO - 10.1177/2047487312446137
DA - 2013-06-01
UR - https://www.deepdyve.com/lp/oxford-university-press/outpatient-cardiac-rehabilitation-the-austrian-model-8eBZ2dNsmV
SP - 468
EP - 479
VL - 20
IS - 3
DP - DeepDyve
ER -