Mortality from coronary artery disease (CAD) has decreased in recent decades in developed countries, but morbidity associated with CAD has increased. Improvements in diagnostic techniques and treatment in the acute phase of myocardial infarction (MI) have improved survival in these patients,1,2 which makes it particularly important to develop strategies for secondary prevention.

At the same time, cardiac rehabilitation (CR) programs have evolved from being limited to exercise training to comprehensive secondary prevention programs. They now include certain essential components: patient assessment, therapeutic optimization, diet/nutritional counseling, risk factor management, psychosocial management and vocational advice, physical activity counseling and exercise training.3,4 Such comprehensive CR programs aim not only to improve functional capacity but also to foster healthy behaviors and compliance with therapy, with a view to delaying progression of atherosclerotic disease and preventing future cardiac events.

Various studies and meta-analyses have demonstrated the benefits of CR, particularly in CAD patients, in whom they have reduced overall mortality by 20%, cardiac mortality by 26%, and rehospitalization by 25%.5–7 Based on this evidence, CR is a class I recommendation for CAD in both the American Heart Association/American College of Cardiology Foundation and the European Society of Cardiology guidelines.8–12 In recent years, this recommendation has been extended to heart failure (HF) patients.13

Despite the well-documented benefits of CR, it continues to be underused and few programs have been implemented in Portugal. The Portuguese Society of Cardiology's Working Group on Exercise Physiology and Cardiac Rehabilitation has periodically performed national surveys assessing CR in Portugal, first in 1998, and again in 2004 and 2007.14–16 The survey reported here continues this work, assessing the situation regarding CR in Portugal in 2013-14 and analyzing how it has developed by comparing the results with previous surveys.

In November 2014, a questionnaire including the following items was sent to all centers offering CR programs:

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  General information on the center (name, location, public or private, year of beginning CR programs)

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  Composition of team and coordinators

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  Description of CRP phases offered

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  Program components

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  Total number of participants and distribution by diagnosis in 2013

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  Funding bodies.

The responses were analyzed and compared with the results of previous surveys. Based on Directorate-General of Health (DGS) data for hospital morbidity17 and the total number of patients with MI admitted for CR by each center, the percentage of patients admitted for a phase II CR program following discharge after MI in 2013 was calculated.

The present survey identified 23 centers in Portugal offering CR programs in 2014, 12 public and 11 private. This represents a significant increase in the number of public centers over the years, from only two in 1998 (Belém Military Hospital, a pioneering public center that began activity in 1988, and Centro Hospitalar de Vila Nova de Gaia, which began offering CR in 1993) to seven in 2004 and 2007, and 12 in 2014.

There was also a significant rise in the number of patients attending phase II programs, the number tripling between 2007 and 2013, from 683 to 1927. Public centers were largely responsible for this increase, rehabilitating 86% of patients, while private centers rehabilitated only 14%. It was not possible to compare patient numbers for the other CR program phases since these were not quantified in earlier surveys.

MI was the most common diagnosis of participants in CR programs, as in previous surveys. Nevertheless, based on DGS data for hospital morbidity, only 8% of MI patients attended phase II programs in Portugal in 2013. This figure, while clearly better than the 3% identified in the 2007 survey, is still lower than the European average.18 In the European Cardiac Rehabilitation Inventory Survey by Bjarnason-Wehrens et al. in 2009, the mean percentage of eligible patients admitted to CR programs in Europe was 30%, while in the UK, Sweden, Luxemburg and Germany the figure was around 50%. Almost half of the countries included in this survey had legislation regarding phase II CR; for example, in Germany, CR following MI has been guaranteed by law since 1974, and has led to the development of a network of 170 CR centers.18 There are several reasons for the low percentage of patients undergoing CR in Portugal, including an insufficient number of CR centers and their asymmetrical geographical distribution, incompatibility between program timetables and working hours, economic restraints (such as patients’ share of treatment costs and travel expenses), and a lack of awareness of CR on the part of patients and physicians, leading to low rates of referral.

We hope that publishing the results of the latest survey will encourage the establishment of new CR programs, particularly in centers outside of Porto and Lisbon, thus helping to reduce the considerable asymmetry in geographical distribution that currently exists. It is essential to develop a national network of centers offering CR. All hospitals with cardiology departments should have phase I and II programs,19 and be actively involved in phase III, possibly in association with health centers in the community. Most hospitals already have the various health professionals needed to form a multidisciplinary CR team, but these are usually occupied in other duties and few have specific training in this area. As well as training, investment is also needed in facilities and equipment such as ergometers and telemetry monitors, and so the involvement and commitment of health authority decision-making bodies are also essential.

At the same time, it is important that existing CR programs should continue to grow and that more eligible patients with diagnoses other than MI, notably those who have undergone cardiac surgery or elective percutaneous coronary intervention, should be referred, while not neglecting those with HF and those with cardiac resynchronization therapy (CRT) devices or implantable cardioverter-defibrillators (ICDs).

Improved access to CR could in some cases be achieved by implementing home-based programs based on the model widely used in the UK. Such programs, designed for low-risk patients, are structured interventions with regular patient monitoring, including visits by CR team members to the patient's home and contact by telephone or the internet. A recent review demonstrated that home-based programs appear to be equally effective as those offered in hospitals or clinics. There were no significant differences in outcomes up to 12 months of follow-up or in healthcare costs.20 Each center should develop the model most suited to their particular situation.

Another way to improve access and adherence to CR would be to pass specific legislation promoting secondary prevention and CR programs aimed at, for example, reducing or abolishing patients’ share of treatment costs, subsidizing travel expenses and scheduling sessions to fit in with working hours.

Initiatives to raise awareness of and provide training in CR also have an important role, both for the general population and patients and for health professionals, particularly physicians. Including a CR component in the training program of cardiology interns would dispel the skepticism and unfounded concerns that still exist and help to make CR an integral part of the spectrum of cardiovascular disease treatment.

Although much remains to be done, the latest survey identified several positive developments that show that CR in Portugal is consistently evolving in line with international guidelines. The programs have become more comprehensive: besides exercise training, almost all now include risk factor management. Other components such as advice on diet/nutrition and weight control, psychosocial assessment and smoking cessation counseling are available in a large proportion of centers. Patients with conditions that are more recent indications for CR, including those with CRT devices or ICDs, are now being admitted to CR programs and the percentage of patients with HF as the referral diagnosis has risen from 5% to 12.7%. Most phase II programs last 8-12 weeks (two or three sessions a week, making a total of 24-36 sessions), as found in the rest of Europe18 and the US,21 where Medicare has provided coverage for up to three weekly sessions for 12 weeks after MI, coronary bypass surgery or stable coronary disease since 1982, and coverage was later expanded to other indications.21 Shorter programs offer less opportunity for sustained lifestyle changes.

Despite the positive developments in Portugal, challenges remain. Investment in cardiovascular disease prevention is essential and CR plays a crucial role in this. Decision-making bodies should be made more aware of the importance of CR programs, which have been shown to be cost-effective.22,23

The number of centers offering CR programs and the volume of patients rehabilitated increased considerably between 2007 and 2013-14. The percentage of MI patients referred for CR increased from 3% to 8%, and HF patients are increasingly admitted to such programs. The latest survey showed that CR has shown consistent growth and evolved in line with international guidelines. Nevertheless, Portugal remains below the European average in CR, and further improvements are still needed.

The authors have no conflicts of interest to declare.