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Vol. 40. Núm. 11.
Páginas 877-887 (Novembro 2021)
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Vol. 40. Núm. 11.
Páginas 877-887 (Novembro 2021)
Original Article
Open Access
Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey
Reabilitação cardíaca em Portugal: resultados do inquérito nacional 2019
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José Paulo Fontesa,
Autor para correspondência
fontes.jpaulo1@gmail.com

Corresponding author.
, Eduardo M. Vilelab, Anaí Durazzoc, Madalena Teixeirab
a Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Portugal
b Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
c Cardiology Department, Centro Hospitalar de Lisboa Ocidental, Portugal
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Table 1. Cardiac rehabilitation centers in Portugal, 2019.
Table 2. Composition of the teams involved in cardiac rehabilitation programs.
Table 3. Design of exercise training sessions for phases II and III of cardiac rehabilitation programs.
Table 4. Components of cardiac rehabilitation programs.
Table 5. Numbers of participants in cardiac rehabilitation programs in Portugal, 2019.
Table 6. Distribution of participants by diagnosis in phases II and III cardiac rehabilitation programs.
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Abstract
Introduction

Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal.

Objectives

This study reports the results of the 2019 survey on CR.

Methods

In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention.

Results

In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%.

Conclusion

The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

Keywords:
Cardiac rehabilitation
Secondary prevention
Cardiovascular disease prevention
Resumo
Introdução

A reabilitação cardíaca (RC) apresenta um papel central na medicina cardiovascular. Contudo, diversos obstáculos à sua aplicação têm sido descritos. Ao longo dos anos, a Sociedade Portuguesa de Cardiologia tem realizado um inquérito nacional referente ao estado da RC em Portugal.

Objetivos

O presente estudo apresenta os resultados do questionário nacional de 2019.

Métodos

Em dezembro de 2019 um questionário voluntário englobando itens relacionados com esta intervenção foi enviado aos centros que apresentavam programas de RC.

Resultados

Em 2019, vinte e cinco centros apresentavam programas estruturados de RC. Um total de 2 182 indivíduos participou em programas de fase II de RC, representando um acréscimo de 13% face ao último inquérito. Destes, 67,2% foram referenciados por doença cardíaca isquémica e 14,5% por insuficiência cardíaca. As síndromas coronárias agudas (SCA) representaram 49,3% das referenciações, com uma cobertura estimada de 9,3%. Um total de 606 doentes participou em programas de fase III (um decréscimo de 37%). As taxas de desistência variaram entre 0-68%; 91% dos centros apresentaram taxas de desistência < 25%.

Conclusão

O presente inquérito demonstra um aumento no número de centros e de doentes a participarem em programas de fase II de RC, com um aumento da cobertura estimada após SCA. Apesar destes resultados, a representação mantém-se abaixo dos valores ótimos, sendo que os dados demonstram uma redução no número de doentes em programas de fase III. Estes resultados reforçam a importância da otimização da inclusão em programas de RC e compliance, por forma a permitir uma maior implantação desta intervenção.

Palavras-chave:
Reabilitação cardíaca
Prevenção secundária
Prevenção cardiovascular
Texto Completo
Introduction

Cardiovascular disease (CVD) is a significant cause of morbidity and mortality.1,2 Although significant advances have been made in terms of prevention, diagnosis, and overall management, leading to improved outcomes, CVD still represents an important healthcare burden.1–4 As such, optimized prevention measures across the cardiovascular continuum are of pivotal importance.3,4 In this context, cardiac rehabilitation (CR) programs play a central role in contemporary cardiovascular medicine.3,4 Although exercise training (ET) is a critical component of this intervention, over the years CR programs have evolved into a broadly multidisciplinary and multi-layered framework, providing a holistic and integrative approach to the complex cardiovascular patient.4–7 As well as ET, some of the core components of these structured programs presently include the identification and control of cardiovascular (CV) risk factors as well as overall therapeutic optimization and counseling regarding adherence, nutritional assessment, smoking cessation counseling, psychological assessment and intervention, and educational sessions, as well as other ancillary interventions such as socioeconomic support and vocational advice.5,6,8

Several publications have reported extensively on the plethora of beneficial effects associated with structured CR programs in terms of morbidity and mortality, especially in the setting of ischemic heart disease (IHD),9–11 and also on parameters such as control of CV risk factors, functional capacity and quality of life.12–15 Given these data, current guidelines on different CV diseases such as IHD and heart failure (HF) strongly support the use of CR, which is a class I, level A recommendation in these two settings, as a pivotal aspect of optimal patient management.3,4,16–18 While their role across a broad range of CVD is presently consensual, several obstacles to the optimal application of CR programs have also been described. Among these are differences in program design, as well as suboptimal patient representation (particularly among certain subgroups such as the elderly, women, and those living far from healthcare centers) and adherence.4,10,19,20

Over the course of the last two decades, the Working Group on Exercise Physiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology (SPC) has periodically assessed the state of CR in Portugal, by performing a national survey.8,21–23 Initially carried out in 1998 and subsequently updated in 2004, 2007 and 2013-14, this survey has enabled the growth of this intervention in Portugal to be analyzed and tracked, as well as providing an important and pragmatic insight into its most central challenges. This paper presents the results of the 2019 national survey on CR, and compares some of its indicators with previous results, in order to provide an overview of the current state of CR in Portugal.

Methods

In December 2019 a voluntary questionnaire was sent to all centers offering CR programs, including the following items: general information on the center, including name, location, type (public or private institution), and year of CR program inception, composition of the team and its coordinators, description of the CR phases offered (i.e. phases I, II and III), program components, total number of participants and distribution by diagnosis in 2019, drop-out rate, and associated reasons for lack of adherence. In addition, a description of the main factors concerning patient enrollment and maintenance in the program was also requested.

The responses were analyzed and compared with the results of the previous surveys.

ResultsCardiac rehabilitation centers

According to the present survey, a total of twenty-five centers offered structured CR programs in Portugal in 2019 (Table 1). Of these, 11 were in the North region, one in the Central region, twelve in the Greater Lisbon region and one in the South region. Compared to the previous survey,8 there were six new centers. Of these, five were public – Centro Hospitalar Universitário de Lisboa Norte (Hospital de Santa Maria)/Faculdade de Medicina da Universidade de Lisboa, Centro de Reabilitação Cardiovascular da Universidade de Lisboa, Centro Hospitalar de Lisboa Ocidental (Hospital de Santa Cruz), Centro Hospitalar de Leiria, and Centro Hospitalar de Trás-os-Montes e Alto Douro – and one was private (Instituto CUF). Compared to the previous survey, four centers had discontinued CR programs – one public (Hospital de Vila Franca de Xira) and three private (Clínica Dr. Dídio de Aguiar, Instituto de Cardiologia Preventiva de Almada, and Clínica da Cruz Vermelha – Sabrosa).

Table 1.

Cardiac rehabilitation centers in Portugal, 2019.

Center  Location  Start of activity (year)  Coordinator   
Public centers
Hospital das Forças Armadas, Pólo de Lisboa  Lisbon  1988  Conceição Silveira  Cardiologist 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Hospital de Gaia)  Vila Nova de Gaia  1993  Madalena TeixeiraFátima Miranda  CardiologistPhysiatrist 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Centro de Reabilitação do Norte)  Vila Nova de Gaia  2016  Sofia ViamonteMadalena Teixeira/Eduardo Vilela  PhysiatristCardiologists 
Centro Hospitalar Universitário do Porto (Hospital de Santo António)  Porto  2000  Preza FernandesSandra Magalhães  CardiologistPhysiatrist 
Centro Hospitalar Entre Douro e Vouga (Hospital de São Sebastião)  Santa Maria da Feira  2001  Luís Martins/Fernando PintoCatarina Aguiar Branco  CardiologistsPhysiatrist 
Unidade Local de Saúde de Matosinhos (Hospital de Pedro Hispano)  Matosinhos  2001  Paula Almeida  Physiatrist 
Centro Hospitalar Universitário de Lisboa Central (Hospital de Santa Marta)  Lisbon  2004  Pedro RioJorge DiasVítor Ferreira  CardiologistPhysiatristRehabilitation nurse 
Centro Hospitalar Universitário de São João  Porto  2008  Afonso RochaVítor Araújo/Paula Dias  PhysiatristCardiologists 
Centro Hospitalar Universitário do Algarve (Hospital de Faro)  Faro  2012  Salomé Pereira  Cardiologist 
Hospital Beatriz Ângelo  Loures  2013  Duarte Espregueira Mendes  Cardiologist 
Centro Hospitalar Universitário de Lisboa Norte/Faculdade de Medicina da Universidade de Lisboaa  Lisbon  2014  Ana Abreu  Cardiologist 
Centro de Reabilitação Cardiovascular da Universidade de Lisboa (CRECUL)b  Lisbon  2016  Ana AbreuHelena Santa-Clara  CardiologistExercise physiologist 
Hospital Garcia de Orta  Almada  2014  Luísa BentoSofia Bento  CardiologistPhysiatrist 
Centro Hospitalar de Lisboa Ocidental (Hospital de Santa Cruz)  Lisbon  2016  Miguel Mendes/Anaí DurazzoOlga Galvão/Sofia Santos  CardiologistsPhysiotherapists 
Centro Hospitalar de Leiria  Leiria  2017  Alexandra Antunes  Cardiologist 
Centro Hospitalar de Trás-os-Montes e Alto Douro (Hospital de Vila Real)  Vila Real  2018  José Paulo Fontes  Cardiologist 
Private centers
Instituto do Coração  Lisbon  1988  Miguel MendesAna Adegas  CardiologistPhysiotherapist 
Faculdade de Motricidade Humana (CORLIS)  Lisbon  1991  Miguel MendesHelena Santa-Clara  CardiologistExercise physiologist 
Fisimaia  Maia  1992  José Paulo FontesEunice Vouga  CardiologistPhysiatrist 
Diprofisio  Porto  1993  Madalena TeixeiraAna Ramalhão  CardiologistPhysiotherapist 
SAMS  Lisbon  2004  Ana AbreuCecília Vaz Pinto  CardiologistPhysiatrist 
Clínica Fisiatria MCCB Drª. Maria do Carmo Aguiar Branco  Vila Nova de Gaia  2007  Marlene FonsecaCatarina Aguiar Branco  CardiologistPhysiatrist 
Clínica das Conchas  Lisbon  2007  Jorge Ruivo  Internist 
Hospital da Luz  Lisbon  2010  Daniel FerreiraPaloma Valdívia  CardiologistPhysiatrist 
Instituto CUF  Porto  2019  Afonso Rocha  Physiatrist 
a

Including Hospital de Santa Maria (phase I) and Hospital Pulido Valente (phase II).

b

Phase III.

a,b Since 2020 these two centers have been unified as Centro de Reabilitação Cardiovascular CHULN/FMUL/CRECUL (accreditation process by the European Association of Preventive Cardiology).

An increase in the number of CR centers was seen compared to previous data, with progressive growth since the first survey8,21–23 (Figure 1). Although asymmetries between regions persisted, unlike in the previous report the Central region now had one CR center (Centro Hospitalar de Leiria) (Table 1).

Figure 1.

Changes in numbers of cardiac rehabilitation centers in Portugal over the last two decades.

(0,13MB).
Team composition and program coordination

As in the previous survey, all centers reported multidisciplinary teams, all of which included a cardiologist (Table 2). In the present survey, physiatrists were involved in 80% of CR programs (an increase of 6% compared to the previous survey) (Table 2).8 A total of 68% of CR programs reported the involvement of other healthcare professionals (among them pulmonologists, endocrinologists, internists, vascular surgeons, and social care workers).

Table 2.

Composition of the teams involved in cardiac rehabilitation programs.

Cardiologist  100% 
Physiatrist  80% 
Psychiatrist/psychologist  76% 
Dietitian/nutritionist  92% 
Physiotherapist  92% 
Nurse  56% 
Exercise physiologist/human kinetics expert  12% 
Other  68% 

Joint coordination by both a cardiologist and a physiatrist was most frequent (40%), followed by coordination by a cardiologist (24%). Other combinations of coordinators are depicted in Table 1.

Program phases and components

According to the present survey, 12 centers (all public) provided phase I programs, and 22 provided phase II programs, as compared to nine and 21, respectively, in 2014.8 Analyzing only centers that provided formal ET sessions as part of their design, a total of 13 centers provided phase III programs (a comparable figure to the previous survey).8 It should be noted that although for the present analysis only programs providing formal ET sessions as part of phase III CR were described, other centers reported providing overall clinical assessment (of varying types) and lifestyle guidance (including exercise) as part of the long-term maintenance phase, similar to the results in the previous survey.8

Program design and duration varied in terms of the number of ET sessions per week and total program duration, although most phase II CR programs included two to three sessions per week, for 24-36 sessions (Table 3). For phase III CR programs (including only those with formal ET sessions), designs ranged from one to three sessions per week, with the option for long-term maintenance in some programs (Table 3).

Table 3.

Design of exercise training sessions for phases II and III of cardiac rehabilitation programs.

Center  Phase II design (number of ET sessions)  Phase III design (number of ET sessions) 
Hospital das Forças Armadas, Pólo de Lisboa  3 times/week; 36 sessions  – 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Hospital de Gaia)  2-3 times/week; 24-36 sessions  – 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Centro de Reabilitação do Norte)  2 times/week; 8-24 sessions  2 times/week; 8-24 sessions 
Centro Hospitalar Universitário do Porto (Hospital de Santo António)  2 times/week; 12-24 sessions  – 
Centro Hospitalar Entre Douro e Vouga (Hospital de São Sebastião)  2-3 times/week; 24-48 sessions  1-2 times/week; 4-24 sessions 
Unidade Local de Saúde de Matosinhos (Hospital de Pedro Hispano)  2 times/week; 12-24 sessions  – 
Centro Hospitalar Universitário de Lisboa Central (Hospital de Santa Marta)  2 times/week; 32 sessions  2 times/week; 48 sessions 
Centro Hospitalar Universitário de São João  2 times/week; 16-24 sessions  – 
Centro Hospitalar Universitário do Algarve(Hospital de Faro)  3 times/week; 24-36 sessions  – 
Hospital Beatriz Ângelo  2-3 times/week; 16-48 sessions  – 
Centro Hospitalar Universitário de Lisboa Norte/Faculdade de Medicina da Universidade de Lisboaa  2-3 times/week; 24-36 sessions  – 
Centro de Reabilitação Cardiovascular da Universidade de Lisboa (CRECUL)  –  3 times/week 
Hospital Garcia de Orta  3 times/week; 32 sessions  NS 
Centro Hospitalar de Lisboa Ocidental (Hospital de Santa Cruz)  2-3 times/week; 20-40 sessions  <1 time/week; 8-10 sessions 
Centro Hospitalar de Leiria  2 times/week; 24 sessions  – 
Centro Hospitalar de Trás-os-Montes e Alto Douro (Hospital de Vila Real)  3 times/week; 24 sessions  – 
Instituto do Coração  3 times/week; 24-36 sessions  ≤3 times/week 
Faculdade de Motricidade Humana – CORLIS  –  3 times/week 
Fisimaia  2 times/week; 24 sessions  2 times/week 
Diprofisio  2-3 times/week; 24-36 sessions  2 times/week 
SAMS  3 times/week; 36 sessions  – 
Clínica Fisiatria MCCB Drª. Maria do Carmo Aguiar Branco  2 times/week; 24-48 sessions  1-2 times/week; 4-24 sessions 
Clínica das Conchas  –  2 times/week; 48 sessions 
Hospital da Luz  3 times/week; 36 sessions  – 
Instituto CUF  2 times/week; 12 sessions  2 times week; 12 sessions 

ET: exercise training; NS: not specified.

a

Phase II (Hospital Pulido Valente).

Other program components in addition to ET (present in all CR programs) are reported in Table 4.

Table 4.

Components of cardiac rehabilitation programs.

Component  Percentage of CR programs 
Exercise  100% 
Nutritional counseling  100% 
Specific program  52%; 16% NS 
Appointment with a dietitian/nutritionist  32% all patients; 52% some patients; 12% NS 
CV risk factor management   
Dyslipidemia management  92%; 4% NS 
Hypertension management  96%; 4% NS 
Smoking cessation counseling  88%; 8% NS 
Specific program  36%; 12% NS 
Specific appointment with a specialist  8% all patients; 64% some patients; 24% NS 
Psychosocial assessment  68%; 8% NS 
Specific program  56%; 16% NS 
Appointment with a psychiatrist/psychologist  16% all patients; 52% some patients; 28% NS 
Vocational counseling  48%; 8% NS 
Sexual counseling  48%; 8% NS 

CR: cardiac rehabilitation; CV: cardiovascular; NS: not specified.

Number of participants, distribution by diagnosis and total activity in 2019

In 2019, a total of 2182 patients were included in phase II CR programs (Table 5). The number of patients included increased by 13% compared to the previous survey. Of these, 93% (2031 patients) attended public centers. Assessment of previous surveys8,23 shows that the number of patients participating in phase II CR programs in public centers presented an increasing trend (71% in 2007, 86% in 2013, and 93% in the present survey).

Table 5.

Numbers of participants in cardiac rehabilitation programs in Portugal, 2019.

Center  Phase II: number of patients referred due to ACS/total number of patients  Phase III: total number of patients 
Hospital das Forças Armadas, Pólo de Lisboa  6/8  – 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Hospital de Gaia)  160/252  – 
Centro Hospitalar de Vila Nova de Gaia/Espinho (Centro de Reabilitação do Norte)  16/77 
Centro Hospitalar Universitário do Porto (Hospital de Santo António)  164/282  – 
Centro Hospitalar Entre Douro e Vouga (Hospital de São Sebastião)  130/645  254 
Unidade Local de Saúde de Matosinhos (Hospital de Pedro Hispano)  57/104  – 
Centro Hospitalar Universitário de Lisboa Central (Hospital de Santa Marta)  34/47 
Centro Hospitalar Universitário de São João  121/188  – 
Centro Hospitalar Universitário do Algarve (Hospital de Faro)  28/29  – 
Hospital Beatriz Ângelo  43/66  – 
Centro Hospitalar Universitário de Lisboa Norte/Faculdade de Medicina da Universidade de Lisboaa  58/79  – 
Centro de Reabilitação Cardiovascular da Universidade de Lisboa (CRECUL)b  –  87 
Hospital Garcia de Orta  79/85  NS 
Centro Hospitalar de Lisboa Ocidental (Hospital de Santa Cruz)  46/100  102 
Centro Hospitalar de Leiria  34/36  – 
Centro Hospitalar de Trás-os-Montes e Alto Douro (Hospital de Vila Real)  33/33  – 
Instituto do Coração  7/22  14 
Faculdade de Motricidade Humana – CORLIS  –  25 
Fisimaia  4/10  31 
Diprofisio  4/6  19 
SAMS  19/20  – 
Clínica Fisiatria MCCB Drª. Maria do Carmo Aguiar Branco  20/59  59 
Clínica das Conchas  – 
Hospital da Luz  6/14  – 
Instituto CUF  7/20  – 
Total  1076/2182  606 

ACS: acute coronary syndromes; NS: not specified.

a

Phase II (Hospital Pulido Valente).

a,b Since 2020 these two centers have been unified as Centro de Reabilitação Cardiovascular CHULN/FMUL/CRECUL (accreditation process by the European Association of Preventive Cardiology).

A total of 606 patients were included in phase III CR programs (Table 5). A decrease of 37% in the number of patients undergoing these programs was seen compared to the previous survey.8 Most patients were treated in public centers (75%), similarly to the previous survey (75% in 2013).8

Twenty-three centers reported data on drop-out rates, which ranged from 0% to 68%. Notably, 91% of CR programs presented drop-out rates of less than 25%. Among the motives reported for lack of adherence to the program were difficulties with transportation, distance between the center and the patient's residence, financial constraints, lack of family support, lack of interest or motivation, fear of ET and unawareness of its benefits, comorbidities and work-related issues. Some of the major difficulties reported by the centers concerning CR entry and maintenance were the center's limited capacity to include more patients (especially due to limitations in terms of facilities and/or healthcare professionals) and low referral rates, as well as the motives described above for lack of adherence (with the exception of fear of ET and unawareness of its benefits).

IHD was the most common referral indication for phase II CR programs (Tables 5 and 6). This was responsible for 67.2% of referrals for phase II CR programs when acute coronary syndromes (ACS), elective percutaneous coronary interventions, coronary surgery, and chronic coronary syndromes were pooled (Table 5). Specifically, ACS were responsible for 49.3% of phase II CR referrals, similarly to the previous two surveys, in which myocardial infarction (MI) was reported in 51.8% of patients in 2013, and 50% in 2007.8,23 HF was the second most common referral indication, and the primary reason for referral in 14.5% of cases, thus continuing the increasing trend reported in the previous survey, in which it represented 12.7% of referrals.8,23

Table 6.

Distribution of participants by diagnosis in phases II and III cardiac rehabilitation programs.

Main indication for referral  Phase II  Phase III 
ACS  49.3%  28.5% 
Elective PCI  2.9%  0.8% 
CABG  10.2%  11.7% 
Chronic coronary syndrome  4.8%  14.4% 
Heart valve surgery/percutaneous valvular intervention  5.6%  4.6% 
Heart failure  14.5%  19.8% 
Heart transplantation  0.1%  0.5% 
CV factor management  2.8%  6.9% 
PAD/peripheral intervention (surgical/percutaneous)  5.0%  6.4% 
ICD/CRT  4.2%  5.3% 
Other indications  0.6%  1.0% 

ACS: acute coronary syndrome; CABG: coronary artery bypass grafting; CRT: cardiac resynchronization therapy; CV: cardiovascular; ICD; implantable cardioverter-defibrillator; PAD: peripheral artery disease; PCI: percutaneous coronary intervention.

IHD was also the most common referral indication for phase III CR programs, representing (when different definitions were pooled, as above) 55.4% of referrals (Table 6). HF was also the second most common reason for referral for phase II, accounting for 19.8% of patients participating in phase III CR programs.

To our knowledge, data on the total number of patients suffering and surviving an ACS in 2019 were still not available at the time of data collection and analysis. Based on the last published data by the Directorate-General for Health (DGS), reporting a total of 11510 admissions (episodes) for MI in 2016,24 the CR coverage was estimated to be 9.3%.

Discussion

The present study reports on a pragmatic and contemporary survey on the state of CR in Portugal. Overall, 25 centers provided structured CR programs in 2019. Of these, 12 provided phase I, 22 phase II and 13 phase III interventions. A total of 2182 patients were included in phase II CR programs (1076 in the setting of ACS), while 606 were included in phase III programs.

This study provides important data on the current state of CR in Portugal. Compared to the 2014 data, there was an increase of 33% in the number of centers providing phase I and of 5% in the number of centers providing phase II programs.8 For phase II programs, there was an increase of 13% in the total number of patients included, which translates to an estimated 9.3% coverage of ACS survivors.24 These results are in agreement with the previously reported progressive increase in CR uptake, a finding which is supported by the rise in the number of centers providing these structured interventions and the improvements in terms of the geographical area covered (Table 1).8,21–23 In addition, the Portuguese Registry on ACS (ProACS) showed an increase in the referral rate for phase II programs (scheduled or planned at discharge), which may also be related to this increase (although published data only cover the period up to 2016).25 Nevertheless, overall coverage was still not at an ideal level. Moreover, both the variation in the number of centers (compared to the estimated number expected to provide a broad coverage for the Portuguese population)6 and the reduction in phase III participation should be stressed. Indeed, for structured phase III programs, there was a 37% decrease in the number of patients represented compared to the previous survey.8 These findings should be acknowledged and explored, in order to help develop strategies to promote increases in CR uptake in this setting. Of note, some centers, while not offering structured phase III programs (those including formal ET sessions), nonetheless focused on counseling, especially relating to CV risk factors, thus reinforcing the importance of long-term follow-up and optimization in this patient population.3

Worldwide, the availability and characteristics of CR programs present significant differences.19,26–28 Data from a seminal study by Bjarnason-Wehrens et al., based on the European Cardiac Rehabilitation Inventory Survey, illustrate these variations in different European countries.28 In this study, the proportion of eligible patients included in phase II interventions ranged from <3% to 90%, but was ≤30% in 54% of countries.28 Recent data from the EUROASPIRE V registry further stressed this notion, reporting on 46% of patients advised to undergo CR.29 In the US, studies report participation rates of 20-30%, also with differences among regions and subgroups.30,31 The present survey confirms the sustained increase in the number of centers and patients treated (from 638 in 2007 to 1927 in 2013, and to 2182 in 2019) for phase II programs (Figure 1), which translates into an increased (estimated – see below) coverage after ACS.8,23 Although this improvement should be acknowledged, the 9.3% estimated coverage is still below the optimal value for this intervention.5,6,8,25,28 Several factors have been reported as influencing suboptimal patient representation.6,8,19,20,28,32,33 These include lack of specific facilities and limited capacity to accommodate the number of patients, distance to CR centers, lack of knowledge concerning the intervention (on the part of both healthcare professionals – thus affecting referral rates – and patients), financial constraints, and differences in legislation.6,8,19,20,28,32,33 As expected, several of these were reported by the centers responding to this survey as being associated with lower adherence, as well as affecting patient entry in CR programs (see Results). The present survey thus reinforces the need to address these diverse issues, related to different factors, as tackling some of these challenges could assist in optimizing the uptake of this pivotal intervention. Notably, although drop-out rates ranged from 0 to 68%, most centers (91%) had rates under 25%, which is a proposed quality indicator in a recent statement by the European Association of Preventive Cardiology (EAPC).5 In this context, as the number of CR centers continues to rise (although it is still insufficient given the overall needs, as clearly indicated in previous reports),6,19,34 other parameters should also be recognized as potential obstacles to optimal patient enrollment and adherence.

As in the previous survey, HF presented the second most frequent indication for both phase II (with an increase of 1.8%) and phase III CR programs.8 This is in line with current epidemiological data demonstrating the healthcare burden associated with HF.17,35 Interestingly, referrals after implantation of cardiac resynchronization therapy devices and/or implantable cardioverter-defibrillators also increased (by 3.1%). While the improvement in the number of patients undergoing CR in the setting of HF, albeit small, is encouraging, given the estimated prevalence of this entity efforts should be undertaken to improve referrals.17,35,36 Importantly, different studies have highlighted the cost-effectiveness of this intervention in different patient populations.10,37–39 Given the figures for phase III programs, with fewer patients (Table 5), this is also relevant in this setting.28,40 Of note, the European Cardiac Rehabilitation Inventory Survey has also reported on the broad range of enrollment for these programs, and some of the factors that can hamper their optimization.28

All centers reported having multidisciplinary teams, although frameworks varied (Tables 2 and 4). In this regard, all programs included nutritional counseling, while most offered CV risk factor management, and a large proportion included smoking cessation counseling and psychosocial assessments. Furthermore, access to consultations with different healthcare professionals was also reported for most programs. Although improvements should be made in order to increase the number of programs including these components, the present results reinforce the current notion of CR as a comprehensive and cohesive intervention.5,6 Importantly, recent guidance from both the SPC and EAPC on the components comprising structured CR programs provide a benchmark for the design and tailoring of this intervention.5,6 In this regard, the present results highlight some of the areas where improvement is most needed, as well as presenting some of the potential barriers to their application. Also, the possibility of a national CR registry (as proposed in the current guidelines from the SPC) could further build on the legacy of the present survey, to improve benchmarking concerning various domains of CR.6

As discussed above, the central role of CR programs in CVD has been extensively discussed, and is presently consensual.3–5,9,11,41,42 Although questions concerning the optimal design of such programs, in terms of both efficacy and cost-effectiveness, have still not been fully addressed,4,5,37,43–46 their overall beneficial effects are well established, as supported by the current guidelines.3/4/16-18 The present results are in line with these concepts, with most patients undergoing CR due to IHD and HF, two of the classical indications for these programs.3,17 Although, as previously discussed, efforts should be made to increase the number of patients undergoing CR in the setting of these two entities, as well as improving and streamlining the operative framework (design and scope) of these interventions, future prospects should also be the focus of further research. In this context, the potential role of home-based CR programs should be assessed, particularly given some of the challenges associated with patient adherence and enrollment.5,6,45,47,48 Furthermore, careful consideration should be given to the optimal framework of these programs in the setting of other indications, such as patients with cancer (encompassing the frontier field of cardio-oncology rehabilitation) or left ventricular assist devices.49,50

Limitations

Several limitations of the present study should be acknowledged. Firstly, this was a voluntary survey conducted with a pragmatic design. Several variables which could have been of interest, such as patient age and gender, time between discharge and program initiation (for phase II programs), medication adherence and control of CV risk factors (including specific values for the different CV risk factors, in accordance with the current guidelines), and differences in functional capacity, were not available for the present analysis.3–6,41,42 Secondly, an important limitation is the fact that specific data on the total number of ACS in 2019 were, to the best of our knowledge, not available at the time of data assessment. An estimate was accordingly provided based on the latest available data.24 Moreover, the questionnaire sent to centers in the present survey specified as an indication “acute myocardial infarction/ACS (with or without percutaneous coronary intervention)” (in order to provide a description that reflected the guidelines).3,51,52 Hence, when 2019 data were compared to those of the previous survey (reporting on MI) and to the DGS data (also on MI), it is possible that some cases of unstable angina were categorized in this section. Finally, some of the data (as specified in the above tables) were not available for all centers. Although these caveats should be borne in mind when assessing the present results, they should not hinder the overall interpretation of the data, which provide a comprehensive report on the state of CR in Portugal in 2019.

Conclusion

The present survey shows an overall increase in the number of CR centers and of patients participating in phase II CR programs, with an estimated coverage of 9.3% after an ACS. Although these results are significant, they still highlight an important unmet need in terms of CR enrollment and overall patient participation. Furthermore, the reduction in the number of patients enrolled in phase III CR programs should also prompt reflection, in order to improve patient referral and uptake.

As personalized medicine evolves against the background of increasingly sophisticated diagnostic and therapeutic interventions, bringing about major advances while also leading to new challenges, the pivotal and time-tested role of CR as a holistic framework able to provide major improvements in overall health status across different stages of the cardiovascular continuum should be seen as an integral component of the optimal contemporary standard of care.

Conflicts of interest

The author has no conflicts of interest to declare.

Acknowledgments

The authors would like to express their special thanks to the coordinators of the CR programs for their crucial cooperation in providing the data for the current survey, without which this study would not have been possible, and for their commitment to improving CR in Portugal.

References
[1]
A. Timmis, N. Townsend, C.P. Gale, et al.
European Society of Cardiology: cardiovascular disease statistics 2019.
Eur Heart J, 41 (2020), pp. 12-85
[2]
G.R. Dagenais, D.P. Leong, S. Rangarajan, et al.
Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study.
[3]
M.F. Piepoli, A.W. Hoes, S. Agewall, et al.
2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).
Eur Heart J, 37 (2016), pp. 2315-2381
[4]
M. Ambrosetti, A. Abreu, U. Corrà, et al.
Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.
Eur J Prev Cardiol, (2020),
[5]
A. Abreu, I. Frederix, P. Dendale, et al.
Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: the avenue towards EAPC accreditation programme: a position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC).
Eur J Prev Cardiol, (2020),
[6]
A. Abreu, M. Mendes, H. Dores, et al.
Mandatory criteria for cardiac rehabilitation programs: 2018 guidelines from the Portuguese Society of Cardiology.
Rev Port Cardiol, 37 (2018), pp. 363-373
[7]
M.F. Piepoli, U. Corrà, S. Adamopoulos, et al.
Secondary prevention in the clinical management of patients with cardiovascular diseases Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology.
Eur J Prev Cardiol, 21 (2014), pp. 664-681
[8]
C. Silveira, A. Abreu.
Cardiac rehabilitation in Portugal: results from the 2013-14 national survey.
Rev Port Cardiol, 35 (2016), pp. 659-668
[9]
A. Salzwedel, K. Jensen, B. Rauch, et al.
Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: update of the Cardiac Rehabilitation Outcome Study (CROS-II).
Eur J Prev Cardiol, 27 (2020), pp. 1756-1774
[10]
L. Anderson, N. Oldridge, D.R. Thompson, et al.
Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis.
J Am Coll Cardiol, 67 (2016), pp. 1-12
[11]
T.M.H. Eijsvogels, M.F.H. Maessen, E.A. Bakker, et al.
Association of cardiac rehabilitation with all-cause mortality among patients with cardiovascular disease in the Netherlands.
JAMA Netw Open, 3 (2020), pp. e2011686
[12]
I. Sjölin, M. Bäck, L. Nilsson, et al.
Association between attending exercise-based cardiac rehabilitation and cardiovascular risk factors at one-year post myocardial infarction.
PLOS ONE, 15 (2020), pp. e0232772
[13]
L. Long, I.R. Mordi, C. Bridges, et al.
Exercise-based cardiac rehabilitation for adults with heart failure.
Cochrane Database Syst Rev, 1 (2019),
[14]
R.S. Taylor, S. Walker, N.A. Smart, et al.
Impact of exercise rehabilitation on exercise capacity and quality-of-life in heart failure: individual participant meta-analysis.
J Am Coll Cardiol, 73 (2019), pp. 1430-1443
[15]
Y.M. Zhang, Y. Lu, Y. Tang, et al.
The effects of different initiation time of exercise training on left ventricular remodeling and cardiopulmonary rehabilitation in patients with left ventricular dysfunction after myocardial infarction.
Disabil Rehabil, 38 (2016), pp. 268-276
[16]
J. Knuuti, W. Wijns, A. Saraste, et al.
2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes.
Eur Heart J, 41 (2020), pp. 407-477
[17]
P. Ponikowski, A.A. Voors, S.D. Anker, et al.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
Eur Heart J, 37 (2016), pp. 2129-2200
[18]
S.D. Fihn, J.M. Gardin, J. Abrams, et al.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery. Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
J Am Coll Cardiol, 60 (2012), pp. e44-e164
[19]
K. Turk-Adawi, M. Supervia, F. Lopez-Jimenez, et al.
Cardiac rehabilitation availability and density around the globe.
EClinicalMedicine, 13 (2019), pp. 31-45
[20]
M. Viana, A. Borges, C. Araújo, et al.
Inequalities in access to cardiac rehabilitation after an acute coronary syndrome: the EPiHeart cohort.
[21]
M. Mendes.
National survey of cardiac rehabilitation programs in Portugal – situation in 1999.
Rev Port Cardiol, 20 (2001), pp. 7-19
[22]
M. Teixeira, F. Sampaio, L. Brízida, et al.
Cardiac rehabilitation in Portugal – developments between 1998 and 2004.
Rev Port Cardiol, 26 (2007), pp. 815-825
[23]
A. Abreu, N. Bettencourt, P. Fontes.
Overview of cardiac rehabilitation in Portugal 2007–2009.
Rev Port Cardiol, 29 (2010), pp. 545-558
[24]
R. Ferreira, M. Macedo, F. Pinto, et al.
Programa Nacional para as Doenças Cérebro-Cardiovasculares 2017.
Direção-Geral da Saúde, (2017),
[25]
A.T. Timóteo, J. Mimoso.
em nome dos investigadores do Registo Nacional de Síndromes Coronárias Agudas. Portuguese Registry of Acute Coronary Syndromes (ProACS): 15 years of a continuous and prospective registry.
Rev Port Cardiol, 37 (2018), pp. 563-573
[26]
G. Chaves, K. Turk-Adawi, M. Supervia, et al.
Cardiac rehabilitation dose around the world: variation and correlates.
Circ Cardiovasc Qual Outcomes, 13 (2020),
[27]
A. Abreu, E. Pesah, M. Supervia, et al.
Cardiac rehabilitation availability and delivery in Europe: how does it differ by region and compare with other high-income countries? Endorsed by the European Association of Preventive Cardiology.
Eur J Prev Cardiol, 26 (2019), pp. 1131-1146
[28]
B. Bjarnason-Wehrens, H. McGee, A.D. Zwisler, et al.
Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey.
Eur J Cardiovasc Prev Rehabil, 17 (2010), pp. 410-418
[29]
K. Kotseva, G. De Backer, D. De Bacquer, et al.
Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry.
Eur J Prev Cardiol, 26 (2019), pp. 824-835
[30]
P.A. Ades, S.J. Keteyian, J.S. Wright, et al.
Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the million hearts cardiac rehabilitation collaborative.
Mayo Clin Proc, 92 (2017), pp. 234-242
[31]
M.D. Ritchey, S. Maresh, J. McNeely, et al.
Tracking cardiac rehabilitation participation and completion among medicare beneficiaries to inform the efforts of a national initiative.
Circ Cardiovasc Qual Outcomes, 13 (2020),
[32]
A. Cohen-Solal.
Ambulatory cardiac rehabilitation facilities should be present in every cardiology department.
Eur J Prev Cardiol, 25 (2018), pp. 1704-1706
[33]
Q.R. Pack, R.W. Squires, F. Lopez-Jimenez, et al.
The current and potential capacity for cardiac rehabilitation utilization in the United States.
J Cardiopulm Rehabil Prev, 34 (2014), pp. 318-326
[34]
K. Turk-Adawi, N. Sarrafzadegan, S.L. Grace.
Global availability of cardiac rehabilitation.
Nat Rev Cardiol, 11 (2014), pp. 586-596
[35]
C. Fonseca, D. Brás, I. Araújo, et al.
Heart failure in numbers: estimates for the 21st century in Portugal.
Rev Port Cardiol, 37 (2018), pp. 97-104
[36]
M.F. Piepoli, S. Binno, U. Corrà, et al.
ExtraHF survey: the first European survey on implementation of exercise training in heart failure patients.
Eur J Heart Fail, 17 (2015), pp. 631-638
[37]
G.E. Shields, A. Wells, P. Doherty, et al.
Cost-effectiveness of cardiac rehabilitation: a systematic review.
Heart, 104 (2018), pp. 1403-1410
[38]
S. Hinde, L. Bojke, A. Harrison, et al.
Improving cardiac rehabilitation uptake: potential health gains by socioeconomic status.
Eur J Prev Cardiol, 26 (2019), pp. 1816-1823
[39]
I. Frederix, D. Vandijck, N. Hens, et al.
Economic and social impact of increased cardiac rehabilitation uptake and cardiac telerehabilitation in Belgium – a cost-benefit analysis.
Acta Cardiol, 73 (2018), pp. 222-229
[40]
R. Belardinelli, D. Georgiou, G. Cianci, et al.
10-year exercise training in chronic heart failure: a randomized controlled trial.
J Am Coll Cardiol, 60 (2012), pp. 1521-1528
[41]
R. Ross, S.N. Blair, R. Arena, et al.
Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.
Circulation, 134 (2016), pp. e653-e699
[42]
A. De Schutter, S. Kachur, C.J. Lavie, et al.
Cardiac rehabilitation fitness changes and subsequent survival.
Eur Heart J Qual Care Clin Outcomes, 4 (2018), pp. 173-179
[43]
A.B. Gevaert, V. Adams, M. Bahls, et al.
Towards a personalised approach in exercise-based cardiovascular rehabilitation: how can translational research help? A ‘call to action’ from the Section on Secondary Prevention and Cardiac Rehabilitation of the European Association of Preventive Cardiology.
Eur J Prev Cardiol, 27 (2020), pp. 1369-1385
[44]
I. Witvrouwen, E.M. Van Craenenbroeck, A. Abreu, et al.
Exercise training in women with cardiovascular disease: differential response and barriers – review and perspective.
Eur J Prev Cardiol, (2019),
[45]
M. Scherrenberg, M. Wilhelm, D. Hansen, et al.
The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology.
Eur J Prev Cardiol, (2020),
[46]
B. Bjarnason-Wehrens, R. Nebel, K. Jensen, et al.
Exercise-based cardiac rehabilitation in patients with reduced left ventricular ejection fraction: the Cardiac Rehabilitation Outcome Study in Heart Failure (CROS-HF): a systematic review and meta-analysis.
Eur J Prev Cardiol, 27 (2020), pp. 929-952
[47]
R.J. Thomas, A.L. Beatty, T.M. Beckie, et al.
Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.
J Am Coll Cardiol, 74 (2019), pp. 133-153
[48]
R.S. Taylor, S. Sadler, H.M. Dalal, et al.
The cost effectiveness of REACH-HF and home-based cardiac rehabilitation compared with the usual medical care for heart failure with reduced ejection fraction: a decision model-based analysis.
Eur J Prev Cardiol, 26 (2019), pp. 1252-1261
[49]
S.C. Gilchrist, A. Barac, P.A. Ades, et al.
Cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors: a scientific statement from the American Heart Association.
Circulation, 139 (2019), pp. e997-e1012
[50]
S. Adamopoulos, U. Corrà, I.D. Laoutaris, et al.
Exercise training in patients with ventricular assist devices: a review of the evidence and practical advice. A position paper from the Committee on Exercise Physiology and Training and the Committee of Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology.
Eur J Heart Fail, 21 (2019), pp. 3-13
[51]
M. Roffi, C. Patrono, J.P. Collet, et al.
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
Eur Heart J, 37 (2016), pp. 267-315
[52]
B. Ibanez, S. James, S. Agewall, et al.
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
Eur Heart J, 39 (2018), pp. 119-177
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