心脏康复：影响与概念（英）

An overview of the evidence for cardiac rehabilitation, including the core components of cardiac rehabilitation, its impact on morbidity and mortality and the need to improve uptake.

The health landscape is continually changing. Financial austerity has reached peak levels and led to demands from health funders and commissioners for much greater accountability in terms of the quality of service delivery and measurable patient outcomes.
Cardiac rehabilitation (CR) is a clinical and cost-effective intervention delivered by a multidisciplinary team (MDT). Despite having extensive evidence of effect, it has failed to attract half of eligible patients.1-3

The stated ambition of NHS England and NICE, through its quality standard (QS99), is to improve uptake from 45% to greater than 65% in the next 5 years.4,5 Cardiologists play a fundamental role in treating heart disease, especially following a heart attack, with GPs orchestrating the longer-term care of these patients.

Cardiologists and GPs are well placed to support and endorse CR by promoting referral, which is known to improve uptake and completion of CR.

What is cardiac rehabilitation?

Cardiac rehabilitation often involves a combination of inpatient and outpatient services. Patients are recruited during an acute cardiac event or planned hospital procedure and supports them through to ba[x]seline assessment, core delivery of CR, and final re-assessment with long-term planning (Figure 1).

Figure 1.

CR services are multi-component, tailored to patient need, and ba[x]sed on an assessment of all core components of CR, which includes lifestyle interventions, education, risk factor management, psychosocial interventions, and long-term management, delivered by a skilled multidisciplinary team (see box 1).6

Box 1: BACPR core components of cardiac rehabilitation6
Lifestyle interventions for:

physical activity and exercise training
diet and weight management
smoking cessation
Education and support for health behaviour change

Medical risk factor management

Psychosocial support, including management of anxiety and depression

A long-term management strategy

Audit, evaluation, and certification of meeting minimum standards

How do we know about the quality of CR delivery?

The National Audit of Cardiac Rehabilitation (NACR), which is funded by the British Heart Foundation, monitors CR delivery against nationally agreed minimum clinical standards.1

The NACR tracks uptake to CR annually and, although there has been a steady improvement year-on-year, the national mean for CR uptake remains at less than half (47%) of the number of eligible patients.1 Repeated NICE guidance, over the last 10 years, has recommended CR attendance for conventional post-heart attack patients, and those with heart failure.3,7

Delivery
A recent review of CR evidence and practice highlights that UK CR has made significant progress but programmes need to be more innovative if they are to attract a higher proportion of eligible patients.8 The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) service standards for CR, and national data from routine clinical practice, suggest that patient outcome is optimal when CR is delivered early.6,9

There is huge variability in the timing of CR across England, Wales, and Northern Ireland, which is of major concern as it means that patients in one part of the country, where CR is timely, are likely to do better than in locations where there i