Lucan · Conditions

Cardiac rehabilitation

Australian guidance: Heart Foundation Cardiac Rehabilitation Guidelines

1. Definition and epidemiology

Cardiac rehabilitation (CR) is a structured, multidisciplinary, evidence-based program delivered after a cardiovascular event or diagnosis of atherosclerotic cardiovascular disease (ASCVD), aimed at reducing morbidity, mortality, and hospital readmissions while improving quality of life. In Australia, cardiovascular disease remains the leading cause of death, with Aboriginal and Torres Strait Islander Australians experiencing death rates up to two and a half times higher than the rest of the population, making culturally competent CR delivery a priority. Phase II CR programs, which are the focus of Australian Heart Foundation guidance, are delivered in the outpatient setting typically in the weeks following hospital discharge.

2. Pathophysiology

Following a major cardiac event such as ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndrome (NSTEACS), myocardial injury results from ischaemia and necrosis of cardiomyocytes, which are replaced by non-contractile fibrous scar tissue (Robbins Ch 11). The surviving myocardium undergoes adverse remodelling, including ventricular dilatation and hypertrophy, driven by neurohormonal activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. These processes reduce cardiac output and left ventricular ejection fraction (LVEF), increasing the risk of heart failure, arrhythmia, and recurrent ischaemic events. Physical deconditioning begins rapidly after a cardiac event, compounding the haemodynamic burden. CR targets this remodelling trajectory through supervised exercise training, which improves myocardial oxygen efficiency, endothelial function, and autonomic tone, and through risk factor modification that slows progression of the underlying atherosclerotic process.

3. Clinical presentation and diagnostic criteria

CR is indicated for patients diagnosed with ASCVD, including those who have experienced STEMI, NSTEACS, unstable angina, or have established stable coronary artery disease, peripheral artery disease, or have undergone coronary revascularisation. There are no formal diagnostic criteria for CR eligibility in the traditional sense; eligibility is determined by cardiovascular diagnosis and functional capacity. At the initial CR assessment, clinicians document socio-demographic details, clinical history including prior interventions, current medications, exercise capacity (using tools such as the Six-Minute Walk Test or submaximal bicycle ergometer assessment), lifestyle risk factors covering physical activity, diet, smoking, and alcohol use, psychosocial health including screening for depression and anxiety, and baseline anthropometry including waist circumference. Goal-setting is undertaken collaboratively at the initial assessment and reviewed throughout the program.

4. Investigations and AU-specific cutoffs

The initial CR assessment incorporates measurement of modifiable risk factors with the following AU-specific targets:

• Low-density lipoprotein cholesterol (LDL-C): less than 1.8 mmol/L for secondary prevention of cardiovascular disease (ASCVD)
• High-density lipoprotein cholesterol (HDL-C): greater than 1.0 mmol/L
• Triglycerides: less than 2.0 mmol/L
• Blood pressure: less than 140/90 mmHg
• Glycated haemoglobin (HbA1c): less than 7 mmol/mol (or an individualised target based on diabetes duration, CVD burden, and hypoglycaemic risk)
• Waist circumference: less than 94 cm in men, less than 80 cm in women
• Physical activity target: minimum 150 minutes per week of moderate-intensity activity
• Alcohol: less than 2 standard drinks per day

Exercise capacity assessment by symptom-limited testing or the Six-Minute Walk Test informs the tailored exercise prescription. Depression and anxiety screening is undertaken using validated tools such as the PHQ-2 (with PHQ-9 follow-up if positive) or the Hospital Anxiety and Depression Scale (HADS). Quality of life is assessed using tools such as the WHOQOL-BREF or AQoL.

5. Management

Phase II CR in Australia is guided by the Heart Foundation "A Pathway to Cardiac Recovery" framework and the Australian Cardiovascular Health and Rehabilitation Association (ACRA) Core Components document. The program is organised across four domains and ten evidence-based modules.

Foundations: Every participant receives a comprehensive individualised initial assessment followed by collaborative goal-setting. Individualised care plans are shared with the participant, their GP, and cardiologist.

Heart health knowledge: Participants receive structured education on heart anatomy and physiology, return to daily activities, modifiable and non-modifiable risk factors, chest pain action plans, and (where applicable) heart failure management plans. Self-management strategies are a central focus, as they increase engagement and reduce hospital readmissions. Exercise training is tailored, progressive, and supervised; the program also educates participants on strategies to reduce sedentary behaviour and increase incidental physical activity. Dietary counselling focuses on healthy dietary patterns (such as DASH or Mediterranean), with individualised sessions from an Accredited Practising Dietitian (APD) for those with complex dietary needs or obesity.

Psychosocial health: Depression and anxiety screening is repeated at program completion. Where distress is identified, referral pathways to specialist psychological services are activated.

Life beyond CR: Return to work, driving, and sexual activity are discussed. Vocational guidance and cardiopulmonary resuscitation (CPR) training are offered. A discharge or summary letter is sent to the GP and cardiologist on program completion.

CR programs are deliverable face-to-face, via telehealth, or through mobile health modalities, enabling access for rural and remote Australians. Programs must be culturally responsive, with specific resources for Aboriginal and Torres Strait Islander participants.

According to the eTG Cardiovascular guidelines, CR programs demonstrably improve morbidity, mortality, and quality of life following a cardiovascular event or ASCVD diagnosis, and referral should be prioritised for all eligible patients.

6. Pharmacology and AU PBS notes

Medication education is an essential CR module; a pharmacist embedded in or affiliated with the program should review cardio-protective medications for all participants. The standard secondary prevention medication regimen encompasses the following classes:

• Antiplatelet therapy: Aspirin 100 to 150 mg orally daily. If aspirin intolerant, clopidogrel 75 mg orally daily. Following ACS, dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is continued for 12 months. Low-intensity rivaroxaban 2.5 mg twice daily may be added to aspirin 100 mg daily in selected patients with stable coronary artery disease or peripheral artery disease with high thrombotic risk; PBS criteria apply and specialist consultation is required before initiating this regimen.
• Statin therapy (high-intensity): Indicated in all patients with ASCVD irrespective of baseline lipid levels to achieve LDL-C less than 1.8 mmol/L. AU PBS streamlined authority codes apply to high-intensity statins for secondary prevention.
• Angiotensin converting enzyme inhibitor (ACEI): Titrated to maximum tolerated dose. Angiotensin II receptor blockers (ARBs) are substituted if ACEI is not tolerated.
• Beta blockers: Continued long term only in patients with LVEF 40% or less, or ongoing ischaemia or angina. Agents with HFrEF evidence include bisoprolol, carvedilol, metoprolol succinate, and nebivolol. Routine long-term beta blockade beyond 12 months is not recommended in patients who are fully revascularised with preserved LVEF.
• Colchicine: Low-dose colchicine is considered in selected patients with recent MI or chronic coronary artery disease under specialist guidance, based on evidence from the COLCOT and LoDoCo2 trials.
• Antihyperglycaemic agents: In patients with diabetes and ASCVD, SGLT2 inhibitors (e.g. empagliflozin, dapagliflozin) or GLP-1 receptor agonists with demonstrated cardiovascular benefit are preferred; this effect is independent of glycaemic control. Annual influenza vaccination is recommended for all patients with ASCVD.

CR medication education sessions cover drug indications, duration of therapy, adherence strategies, and the importance of not stopping medications without consulting a GP or cardiologist.

7. Complications and monitoring

Following completion of Phase II CR, ongoing monitoring targets the same risk factor cutoffs documented at initial assessment. Surveillance includes:

• Repeat exercise capacity assessment at program completion
• Reassessment of lifestyle risk factors (physical activity, diet, smoking, alcohol)
• Repeat psychosocial health screening (depression, anxiety)
• Review of medication adherence and optimisation
• Ongoing BP, lipid, and glycaemic monitoring as per secondary prevention targets

Key complications to monitor in the post-event period include recurrent myocardial infarction, sudden cardiac death (especially in patients with reduced LVEF), heart failure progression, clinically significant arrhythmia, and depression or anxiety, which affect up to one in three post-MI patients and independently worsen cardiovascular outcomes. Participants who are unable to return to work, driving, or activities of daily living by program end should be referred to occupational therapy or cardiac specialist services. Long-term GP follow-up is required to sustain the gains from CR.

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.