275.1 🎓 醫孞生版

275.1.0.1 📌 䞀頁重點

275.1.0.1.1 Definition
275.1.0.1.1.1 Cardiac Rehabilitation (CR)
  • Comprehensive, multidisciplinary program for patients with cardiovascular disease
  • Combines structured exercise training, education, behavioral modification, and clinical support
  • Goal: ↓ mortality, ↓ MACE, ↓ readmission, ↑ QOL, ↑ functional capacity
275.1.0.1.1.2 Eligible Conditions (2024 AHA/ACC/ACCF Class I)
  • Recent ACS (UA, NSTEMI, STEMI) within 12 months
  • Post-PCI
  • Post-CABG
  • Chronic stable angina (CCS)
  • Heart failure (HFrEF or HFpEF) — Class I after HF-ACTION (2009)
  • Valve repair/replacement (surgical or TAVR)
  • Heart transplant
  • LVAD recipients
  • PAD (intermittent claudication)
  • HCM
275.1.0.1.2 Phases of Cardiac Rehab
275.1.0.1.2.1 Phase I (Inpatient)
  • Begins 24-48h after acute event
  • Early mobilization (sit, stand, walk in room/hallway)
  • Education start: risk factors, medications, signs of recurrence
  • Discharge planning, CR referral
275.1.0.1.2.2 Phase II (Outpatient, Supervised)
  • 36 sessions over 12 weeks (3x/week, 30-60 min each)
  • ECG/HR/BP monitoring
  • Tailored exercise prescription
  • Risk factor modification
  • Counseling: diet, smoking, stress
275.1.0.1.2.3 Phase III (Maintenance, Community)
  • After Phase II
  • Self-directed exercise, periodic re-evaluation
  • Lifelong commitment
275.1.0.1.3 Five Core Components
275.1.0.1.3.1 1. Exercise Training
  • Aerobic (most important):
    • Walking, cycling, treadmill, swimming
    • Intensity: 60-80% of HRmax or VO₂ peak; Borg RPE 12-14
    • Frequency: 3-5x/week
    • Duration: 30-60 min per session
    • 150 min/week moderate OR 75 min/week vigorous
  • Resistance training: 2-3x/week, 10-15 reps × 1-3 sets
  • Flexibility: stretching, yoga
  • Modern approach: HIIT (high-intensity interval training) safe + effective (SAINTEX-CAD trial)
275.1.0.1.3.2 2. Risk Factor Modification
  • BP: < 130/80 (ACC/AHA), < 140/90 (ESC)
  • LDL: < 55 mg/dL post-ACS (very high risk)
  • HbA1c: < 7% (individualized)
  • BMI: < 25 (or ↓ 5-10% weight loss)
  • Waist circumference: < 102 cm ♂, < 88 cm ♀
  • Smoking cessation: NRT, varenicline, bupropion, counseling
275.1.0.1.3.3 3. Nutrition
  • Mediterranean diet (PREDIMED, CORDIOPREV) — Class I
  • Limit saturated fat < 7% of calories
  • ↑ omega-3, fiber, fruits/veg
  • DASH diet for HTN
  • Limit Na < 2.3 g/day
  • Limit alcohol ≀ 2 drinks/day ♂, ≀ 1 ♀
275.1.0.1.3.4 4. Behavioral / Psychological Support
  • Depression screening (PHQ-9) — Class I
  • Anxiety screening
  • Cognitive behavioral therapy (CBT)
  • Stress management (mindfulness, yoga)
  • Social support
275.1.0.1.3.5 5. Medical Therapy Optimization
  • Ensure guideline-directed medical therapy (GDMT)
  • Adherence checks
  • Adjust based on response
  • Vaccinations (flu, pneumococcal, COVID-19)
275.1.0.1.4 Outcomes (Evidence-Based)
275.1.0.1.4.1 Mortality + MACE
  • Cochrane 2021 meta-analysis (n > 23,000):
    • All-cause mortality: RR 0.83 (↓ 17%)
    • Cardiovascular mortality: RR 0.78 (↓ 22%)
    • Hospital readmission: RR 0.74 (↓ 26%)
  • Even more benefit in HFrEF (HF-ACTION 2009)
275.1.0.1.4.2 Functional Outcomes
  • ↑ VO₂ peak by ~ 15-25%
  • ↑ 6-minute walk distance
  • ↓ angina symptoms
  • ↑ QOL (SF-36, KCCQ)
275.1.0.1.4.3 Healthcare Cost
  • Cost-effective: ~ $1,000-3,000 per QALY (well below threshold)
  • ↓ readmissions save $5,000-10,000 per patient
275.1.0.1.5 Barriers to CR Participation
275.1.0.1.5.1 Patient-Level
  • Lack of awareness
  • Transportation
  • Cost / co-pay
  • Comorbidities, frailty
  • Cultural / language barriers
  • Work schedules
275.1.0.1.5.2 System-Level
  • Low referral rates (~ 30% nationally, ~ 50% post-MI)
  • Limited center availability
  • Reimbursement issues
  • Insurance pre-authorization
275.1.0.1.5.3 Mitigation Strategies
  • Automatic referral (default in EHR)
  • Hybrid / home-based CR with telemedicine
  • Wearable monitoring (HR, SpO2, ECG)
  • Mobile apps + tele-rehab
  • Community-based programs
275.1.0.1.6 Special Populations
275.1.0.1.6.1 Elderly
  • Lower intensity initially, slower progression
  • Resistance training to combat sarcopenia
  • Fall prevention
  • Cognitive screening
  • NEAT (non-exercise activity thermogenesis) still beneficial
275.1.0.1.6.2 Women
  • Lower referral / participation rates
  • More depression, anxiety
  • Different exercise preferences (group classes, dance)
  • Recognize INOCA / SCAD / postpartum cardiomyopathy
275.1.0.1.6.3 HFrEF (HF-ACTION 2009)
  • Supervised exercise reduced HF hospitalization + death by 11%
  • Improves NYHA class, QOL, VO₂
  • Class I in stable HFrEF
275.1.0.1.6.4 HFpEF (REHAB-HFpEF, OPTIMEX-CLIN)
  • Improves functional capacity
  • Less data on mortality
  • 2024 ACC: Class IIa, growing evidence
275.1.0.1.6.5 PAD (Claudication)
  • Supervised exercise training improves walking distance more than meds
  • Class I per AHA/ACC
275.1.0.1.6.6 Heart Transplant
  • Improves exercise capacity, QOL
  • Cardiac autonomic denervation → blunted HR response
  • HR-independent intensity prescription

275.1.0.2 🩺 床邊速查

  • CR Class I post-ACS, post-PCI/CABG, HF, valve, transplant, LVAD, PAD, HCM
  • Phase II = 36 sessions / 12 weeks, 3x/week
  • 150 min/wk moderate OR 75 min/wk vigorous aerobic
  • Cochrane 2021: CR ↓ mortality 17%, readmission 26%
  • Major barrier: < 30% referred, < 10% complete — push for automatic referral and home-based CR