The Role of Cardiac Rehabilitation in Achieving Optimal Treatment

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The clinical practice of European cardiologists is directed by the European Society of Cardiology™s guidelines for several clinical entities, in which ├óÔé¼´åİoptimal medical treatment™ (a specific drug regime and lifestyle measures) for each syndrome is defined. The described pharmacotherapy is composed of several drugs, since the clinical research behind the recommendations is conducted using an ├óÔé¼´åİon top of™ strategy. For example, an asymptomatic patient after an acute coronary syndrome with normal ventricular function and without residual ischaemia has an indication to take at least four types of tablets per day, which is difficult to understand and to follow long term. The cost of the drugs is sometimes beyond the patient™s means, which also contributes to lower compliance. A clinician™s practice is usually very busy, which means it is almost impossible to perform patient education and promote adherence to drug therapy and lifestyle changes. Cardiac rehabilitation, as proved by the Global Secondary Prevention Strategies to Limit Event Recurrence after Myocardial Infarction (GOSPEL) study, may be considered the best available secondary prevention programme, as it educates patients and promotes adherence to the optimal medical treatment to a greater degree than usual care.

Coronary artery disease, optimal medical treatment, cardiac rehabilitation, exercise training, secondary prevention, evidence-based medicine, compliance to medical treatment

Disclosure: The author has no conflicts of interest to declare.
Received: 20 November 2010 Accepted: 14 January 2011 Citation: European Cardiology, 2011;7(1):62├óÔé¼ÔÇ£5
Correspondence: Miguel Mendes, Av. Professor Reynaldo dos Santos, 2794-095 Carnaxide, Portugal. E:



As far as I know, the designation ├óÔé¼´åİoptimal medical treatment™ was first used by the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial1 investigators as a synonym for the state-of-the-art measures encompassing drug regime, diet and physical activity recommended by the US guidelines for stable angina and acute coronary syndrome (ACS). Looking at the most recent European Society of Cardiology (ESC) guidelines on stable angina2 and ACS with3 or without4 ST elevation, a strict recommendation for antiplatelet medication (acetylsalicylic acid [ASA] alone or in combination with clopidogrel), an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), a beta-blocker and a statin (alone or in combination with ezetimibe) can be found for both subsets (see Table 1).

In the stable angina guideline, optional recommendations for nitrate, amlodipine, nicorandil, molsidomine, ivabradine, trimetazidine and ranolazine, alone or in combination, for angina and a fibrate or nicotinic acid for high-density lipoprotein (HDL) and/or triglyceride control can be found.

The 2008 ESC heart failure guidelines5 recommend a combined approach of a device (cardiac resynchronisation therapy [CRT] and/or implantable cardioverter├óÔé¼ÔÇ£defibrillator [ICD], according to clinical criteria, left ventricular ejection fraction [LVEF] and QRS length), if appropriate, and drug therapy, combining ACE inhibitors, ARBs, aldosterone antagonists and beta-blockers for improved prognosis and symptoms, together with diuretics, digoxin or warfarin for control of symptoms or atrial fibrillation.

In addition to the drug regime recommended in the guidelines, many patients follow prescriptions for additional drugs for diabetes, gout, Parkinson™s or Alzheimer™s disease, osteoporosis and osteoarthritis, and may also take other drugs for associated conditions such as tinnitus, vertigo or glaucoma. Owing to the main disease and associated conditions, many patients are supposed to follow an extensive drug regime that frequently entails taking 20 or more tablets per day.


  1. Boden WE, O™Rourke RA, Teo KK, et al., Optimal medical therapy with or without PCI for stable coronary disease, N Engl J Med, 2007;356:1503├óÔé¼ÔÇ£16.
  2. Fox K, Garcia MA, Ardissino D, et al., Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology, Eur Heart J, 2006;27:1341├óÔé¼ÔÇ£81.
  3. Van de Werf F, Bax J, Betriu A, et al., Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology, Eur Heart J, 2008;29:2909├óÔé¼ÔÇ£45.
  4. Rapezzi C, Biagini E, Branzi A, Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: the task force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology, Eur Heart J, 2008;29:277├óÔé¼ÔÇ£8.
  5. Dickstein K, Cohen-Solal A, Filippatos G, et al., ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM), Eur J Heart Fail, 2008;10:933├óÔé¼ÔÇ£89.
  6. Daly C, Clemens F, Lopez-Sendon JL, et al., The impact of guideline compliant medical therapy on clinical outcome in patients with stable angina: findings from the Euro Heart Survey of stable angina, Eur Heart J, 2006;27:1298├óÔé¼ÔÇ£1304.
  7. Kotseva K, Wood D, De Backer G, et l., EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries, Eur J Cardiovasc Prev Rehabil, 2009;16:121├óÔé¼ÔÇ£37.
  8. Kotseva K, Wood D, De Backer G, et al., Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries, Lancet, 2009;373:929├óÔé¼ÔÇ£40.
  9. Adams KF, Schatzkin A, Harris TB, et al., Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old, N Engl J Med, 2006;355:763├óÔé¼ÔÇ£78.
  10. Tuomilehto J, Lindstrom J, Eriksson JG, et al., Prevention of type 2 diabetes by changes in lifestyle among subjects with impaired glucose tolerance, N Engl J Med, 2001;344:1343├óÔé¼ÔÇ£50.
  11. Bosch J, Yusuf S, Gerstein HC, et al., Effect of ramipril on the incidence of diabetes, N Engl J Med, 2006;355:1551├óÔé¼ÔÇ£62.
  12. Zhou MS, Schulman IH, Prevention of diabetes in hypertensive patients: results and implications from the VALUE trial, Vasc Health Risk Manag, 2009;5:361├óÔé¼ÔÇ£8.
  13. Ichikawa Y, Comparative effects of telmisartan and valsartan on insulin resistance in hypertensive patients with metabolic syndrome, Intern Med, 2007;46:1331├óÔé¼ÔÇ£6.
  14. Parving HH, Lehnert H, Brochner-Mortensen J, et al., The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes, N Engl J Med, 2001;345:870├óÔé¼ÔÇ£8.
  15. Aronow WS, Ahn C, Incidence of new coronary events in older persons with diabetes and prior myocardial infarction treated with sulfonylureas, insulin, metformin, and diet alone, Am J Cardiol, 2001;88:556├óÔé¼ÔÇ£7.
  16. Knowler WC, Barrett-Connor E, Fowler SE, et al., Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin, N Engl J Med, 2002;346:393├óÔé¼ÔÇ£403.
  17. Freeman DJ, Norrie J, Sattar N, et al., Pravastatin and the development of diabetes: evidence for a protective treatment effect in the West of Scotland Coronary Prevention Study, Circulation, 2001;103:357├óÔé¼ÔÇ£62.
  18. Iestra JA, Kromhout D, van der Schouw YT, et al., Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review, Circulation, 2005;112:924├óÔé¼ÔÇ£34.
  19. Chow CK, Jolly S, Rao-Melacini P, et al., Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes, Circulation, 2010;121:750├óÔé¼ÔÇ£8.
  20. Ades PA, Balady GJ, Berra K, Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative, J Cardiopulm Rehabil, 2001;21:263├óÔé¼ÔÇ£72.
  21. Piepoli MF, Corra U, Benzer W, et al., Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation, Eur J Cardiovasc Prev Rehabil, 2010;17:1├óÔé¼ÔÇ£17.
  22. Corra U, Piepoli MF, Carre F, et al., Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: Key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation, Eur Heart J, 2010;31:1967├óÔé¼ÔÇ£74.
  23. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA, Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials, JAMA, 1988;260:945├óÔé¼ÔÇ£50.
  24. O™Connor GT, Buring JE, Yusuf S, et al., An overview of randomized trials of rehabilitation with exercise after myocardial infarction, Circulation, 1989;80:234├óÔé¼ÔÇ£44.
  25. Jolliffe JA, Taylor RS, Thompson D, et al., Exercise-based rehabilitation for coronary heart disease, Cochrane Database Syst Rev, 2001;(1):CD001800.
  26. Taylor RS, Brown A, Ebrahim S, et al., Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials, Am J Med, 2004;116:682├óÔé¼ÔÇ£92.
  27. Clark AM, Hartling L, Vandermeer B, McAlister FA, Meta-analysis: secondary prevention programs for patients with coronary artery disease, Ann Intern Med, 2005;143:659├óÔé¼ÔÇ£72.
  28. Franklin BA, Kahn JK, Gordon NF, Bonow RO, A cardioprotective ├óÔé¼┼øpolypill├óÔé¼┼Ñ? Independent and additive benefits of lifestyle modification, Am J Cardiol, 2004;94:162├óÔé¼ÔÇ£6.
  29. Gielen S, Schuler G, Adams V, Cardiovascular effects of exercise training: molecular mechanisms, Circulation, 2010;122:1221├óÔé¼ÔÇ£38.
  30. Giannuzzi P, Temporelli PL, Corra U, Tavazzi L, Antiremodeling effect of long-term exercise training in patients with stable chronic heart failure: results of the Exercise in Left Ventricular Dysfunction and Chronic Heart Failure (ELVD-CHF) Trial, Circulation, 2003;108:554├óÔé¼ÔÇ£9.
  31. Haykowsky MJ, Liang Y, Pechter D, et al., A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed, J Am Coll Cardiol, 2007;49:2329├óÔé¼ÔÇ£36.
  32. Pavy B, Iliou MC, Meurin P, et al., Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation, Arch Intern Med, 2006;166:2329├óÔé¼ÔÇ£34.
  33. Van Camp SP, Peterson RA, Cardiovascular complications of outpatient cardiac rehabilitation programs, JAMA, 1986;256:1160├óÔé¼ÔÇ£3.
  34. . Giannuzzi P, Temporelli PL, Marchioli R, et al., Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network, Arch Intern Med, 2008;168:2194├óÔé¼ÔÇ£2204.
  35. Lavie CJ, Milani RV, Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training, Mayo Clin Proc, 2005;80:335├óÔé¼ÔÇ£42.
  36. Lavie CJ, Milani RV, Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training, Am J Cardiol, 2004;93:336├óÔé¼ÔÇ£9.
  37. Dawood N, Vaccarino V, Reid KJ, et al., Predictors of smoking cessation after a myocardial infarction: the role of institutional smoking cessation programs in improving success, Arch Intern Med, 2008;168:1961├óÔé¼ÔÇ£7.