Objective Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.
Methods A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.
Results Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.
Conclusions Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.
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The epidemic of coronary heart disease (CHD) in low/middle-income countries (LMICs) is staggering.1 Resultant premature mortality has significant negative economic impact. To lessen the impact of CHD on individuals and societies, a comprehensive approach is needed. Cardiac rehabilitation (CR) provides such an approach, through delivery of risk reduction therapies and promotion of heart-healthy behaviours such as physical activity, nutrition and tobacco cessation. CR, delivered to patients with stable angina through to myocardial infarction, and its' sequelae, as well as those who have undergone an interventional procedure to ameliorate these conditions, reduces cardiovascular mortality by 26% and rehospitalisation by 18%.2
There has been considerable implementation of expensive acute coronary care units and revascularisation centres in many MICs, yet research suggests that proven, low-cost secondary prevention strategies such as CR are not implemented.3 To our knowledge, CR is only available in approximately one-quarter of MICs and one-tenth of Low-income countries (LICs).4 The reasons are complex, and include healthcare budgetary issues (particularly for LICs), inadequate legislation, lack of trained healthcare providers, the dearth of randomised controlled trials on effects of CR in LMICs such as are available in high-income countries (HICs)2 and most centrally lack of clinical practice guidelines on how CR can be implemented in low-resource settings.5 ,6
In 1993, the World Health Organization (WHO) published a seminal report entitled ‘Rehabilitation after Cardiovascular Diseases, With Special Emphasis on Developing Countries’, which outlined recommendations on how CR could be delivered in low-resource settings.6 Despite considerable advances in our knowledge about CR and in information and communication technologies in the last two decades, this WHO report has not been updated. More recently, all of the components of an integrated CR service can be found within the targets set by WHO in their 25×25 initiative. In the WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases (2013–2020), it is recommended that all patients ‘should have access… to nationally determined sets of the needed … rehabilitative health services’ (p. 13), with CR specifically listed in the menu of policy options (p. 69).1
Accordingly, an expert panel was convened to develop a testable CR model for low-resource settings (primarily MICs and under-resourced areas in HICs), which is forwarded herein. The development process applied is described in online supplementary file 1, and was informed by previous methods.7 The search strategy for the literature review to inform recommendation development is shown in online supplementary file 1. Consideration of costs and affordability preface the model recommendations.
Supplementary file 1
CR cost and affordability
For CR to be implemented in low-resource settings, financial resources must be considered. With data largely from HICs, CR has been demonstrated to be both effective and cost-effective.8 ,9 But what about other resource settings? In 2013, health expenditures accounted for 11.9% of gross domestic product in HICs but only 5.8% in MICs and 6.4% in LICs; in the same year, per capita health expenditures in low-income countries were US$37 (hence these countries are not a focus for the recommendations herein) and US$256 in MICs.
A recent publication has examined the costs and cost-effectiveness of CR in MICs suggesting that, as of 2015, there have been three publications with CR cost data, all from seven Latin American MICs, with another two publications from Latin American upper-MICs on the cost-effectiveness of CR.10 With CR programmes based on the typical supervised CR model in the USA (three times per week with telemetry; please note CR models delivered in other HICs, however, cost less), the mean 3-month CR programme cost data for the seven Latin American MICs was approximately US$360 to the public healthcare system. The cost-effectiveness of CR was estimated to be US$18 050 per life-year gained and US$22 560 per quality-adjusted life-year in Brazil and US$3156 per life-year gained and US$998 per quality-adjusted life-year in Colombia. According to the WHO,11 CR in Brazil can be considered cost-effective at between one and three times the gross domestic product (US$11 200 in 2013) and highly cost-effective in Colombia at less than gross domestic product (US$7830 in 2013).
While CR may be considered cost-effective in the two Latin American upper-MICs, the mean cost for a 3-month USA-model CR programme to the public healthcare system in the seven MICs of approximately US$360 is 61% of the 2013 mean healthcare expenditure of US$590 in the same seven countries.10 ,12 For this reason, it is imperative that a lower-cost approach to CR be developed, implemented and tested, as is outlined below.
Low-resource CR model
The core components of CR have been established by the major CR associations from HICs, namely the American,13 Australian,14 British,15 Canadian16 and European associations.17 These core components have also been agreed-upon in the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) charter, which has also been endorsed by CR associations in LMICs.18 Herein each of the following common core components has been adapted for the MIC setting: (1) assessment, (2) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (3) medical risk factor management (eg, lipid control, blood pressure (BP) control), (4) education for self-management and (5) return to work.
It must be conceded that delivery of CR in high-resource settings does not always include all of the recommended components, and access remains low. Moreover, despite evidence of the efficacy of CR delivered in non-hospital settings, it is most-often delivered in these expensive settings.19 Herein we provide realistic guidance on minimum standards for CR delivery in low-resource settings. These recommendations are forwarded in the spirit that CR champions start small with resources, financial and otherwise, at hand. We should strive to establish programmes where possible, and then build in additional CR components as possible. These programmes must be sensitive to the health literacy, gender, religious and cultural context in which they are embedded.
The CR programme should commence with a comprehensive assessment. It is recommended that the style of the assessment be consistent with motivational interviewing.20 Specifically, the assessment should be patient-centred and goal-oriented. Each of the following elements should be considered in the intake assessment: physical activity, diet, tobacco consumption, overweight/obesity, CHD knowledge, depression, return to work, lipids, BP, medications and diabetes. At the completion of the comprehensive formal assessment, documentation should be made of the findings. The client and the CR provider should discuss a plan of treatment accordingly.
Recommendations for delivering each of the core components are shown in table 1. While each core component is addressed separately, it is conceived that the lifestyle and behaviour elements weave consistently across all the recommendations, and should be applied in a patient-centred manner. Secondary prevention including BP and cholesterol management, and prescription of cardioprotective medication where available, also forms an integral part of the model. Given the centrality of exercise to CR, more detail regarding delivering this component in low-resource settings is outlined below.
Supplementary file 2
The benefits of regular exercise in patients with CHD have been well established in both well-resourced and low-resource settings.2 ,21 There is a strong positive effect of physical exercise training on the pathogenesis of CHD, symptoms specific to the pathology, physical fitness and strength and quality of life. Accordingly, programmes of exercise should, wherever feasible, be offered to all subjects recovering from major CHD events.22
Stratification of patient risk for an adverse event during exercise
There are few contraindications to participation in some form of regular physical exercise. It is important to appreciate that patients at both ends of the functional spectrum will present for CR. Some will be able to perform exercise without adverse consequences (low-risk patients) and others will have very limited exercise capacity, active ischaemia, acute heart failure, significant arrhythmia or ventricular dysfunction (high-risk). Thus, the process of risk stratification is important.13 The application of a process of risk stratification can guide the exercise intensity and duration, and the appropriate facility type and nature of health professional to supervise the exercise. The intensity of activity at which a cardiac event is likely to occur should be appropriately explained to the patient.
There is evidence that low-risk individuals can safely exercise without medical supervision and safely and promptly return to preillness activities including work. Medical supervision is suggested for high-risk patients (eg, those with exercise-induced myocardial ischaemia with possible ST segment depression and/or angina pectoris and those with left ventricular ejection fraction <30% or ventricular arrhythmia).13 Wherever possible, high-risk cardiac patients should be supervised during moderate exercise by a healthcare provider skilled in management of emergency cardiac events and principles of exercise prescription and patient monitoring in disease states. However, this is not possible in all settings.
The practicalities and realities of providing comprehensive CR including exercise in low-resource settings can be challenging, and require clever usage of existing resources, which can be modified. Equipment for exercise provision and monitoring may be minimal in low-resource settings providing further challenge. Exercise equipment can be costly and also requires maintenance. Furthermore, training of necessary personnel is required to prescribe exercise to patients with the use of advanced equipment. Therefore, in low-resource settings, non-equipment based exercise programmes (eg, walking or cycling if the patient has their own bicycle) provides the most practical option. However, low-cost options to facilitate all forms of exercise training and monitoring of physical activity are available (eg, resistance bands, ‘home-made’ weights, gym/yoga mats and low-cost pedometers).
Basic exercise facility
To optimise affordability, unsupervised exercise is recommended where possible. However, the CR centre will likely be based in a basic facility, to enable initial assessment and training of new or high-risk patients. This facility can be located in a village or community (eg, local meeting place, hall, place of worship, school or field) and could be staffed by a trained community health worker or preferably a healthcare professional. Minimal equipment is needed, with a sphygmomanometer with stethoscope, a watch to measure heart rate, charts and simple recording equipment suggested. Weather conditions, altitude, pollution and general safety of the area are important considerations. Walking programmes and callisthenics, stretching, core stability and other light exercise (eg, resistance bands) can easily be undertaken at a basic exercise facility. Personnel should have at least basic life saving training, and it is strongly recommended that an automated external defibrillator is present, where possible.
Principles of exercise training
The principles of exercise training in low-resource settings are similar to those in well-resourced settings. However, as it is recognised that in many MICs patients use the exercise mode of walking in their daily work or as their main means of transport, further aerobic training might not be warranted in these cases and the exercise prescription could, therefore, be adjusted to include other components of physical activity. Exercise rehabilitation should be patient-centred, based on patients' clinical status as determined during the pre-exercise assessment, personal preferences, with particular regard to baseline functional capacity. It is also important that the practitioner advises the appropriate exercise prescription for the appropriate stage of the disease and disability. The objective of exercise training in this setting is to limit the physiological and psychological effects of cardiovascular disease, control cardiac symptoms, decrease physiological limitations and improve physical capacity through specific exercise therapy.
Frequency of exercise
The frequency goal should be to conduct exercise training at least 3, but preferably most days of the week. Once safety has been established, patients should be encouraged to exercise at home or outside the programme, to optimise economic efficiency.
Intensity of exercise
Exercise intensity should particularly be patient-centred and it is important that besides expected breathlessness of exercise, the patient remains asymptomatic during and after the exercise session. Many patients can be taught to monitor their own heart rate during exercise. If an exercise ECG has been conducted prior to exercise, the heart rate during exercise should be kept below the symptomatic threshold. If no exercise ECG is possible, then the presence of chest pain induced by exercise and relieved by rest or nitroglycerin is sufficient for the diagnosis of myocardial ischaemia, and this intensity of exercise should be avoided. A useful measure of exercise intensity, particularly in low-resourced settings, is a rating of perceived exertion which can be measured using the 20-point Borg scale.23 Exercise should be performed at an intensity of 11–16 on this scale.
Type of exercise
The type of exercise conducted would depend on the functional capacity of the patient (eg, weight bearing vs non-weight bearing exercise), and the equipment available at the exercise facility, home or community setting. However, the components of exercise training should include: aerobic exercise training (ie, rhythmic, large muscle exercise of both upper and lower limbs that increases heart rate), resistance training, flexibility training, balance or proprioceptive training and core stability training. Walking programmes provide the most basic, inexpensive and effective form of exercise training. Dance and controlled games such as soccer are low-cost, and have been successfully used in CR in low-resource settings.24 CR providers should consider culturally appropriate exercises in their region.
Resistance training is an important component of exercise in patients with CHD, to facilitate necessary muscle strength to perform activities of everyday living (eg, carrying wood, water or groceries), and prevent and manage type 2 diabetes and osteoporosis.25 Briefly, resistance training can be performed with elastic bands, small weights or other objects, or using the patients' own body weight. More than one muscle group, as well as agonist and antagonist muscle groups should be targeted. The initial load or resistance should be able to be lifted, pulled or pushed without difficulty, and allow 10–15 repetitions of the exercise without the patient straining. Eight to 10 exercises of the major muscle groups should be performed on 2–3 days of the week with at least 48 h separating training sessions for the same muscle group. Detailed resistance training guidelines for patients with CHD and heart failure (HF) are available.25
Duration of exercise
The duration of aerobic exercise training would depend on the patient's initial functional capacity and progression in the programme. It might start with a 10 min bout of aerobic exercise, and gradually progress to 60 min per session at a rate of about 10%–20% per week. Warm-up and cool-down activities would precede and follow the aerobic exercise bout.13
Monitoring of exercise training
Besides monitoring of patient's exercise intensity, programme staff should closely monitor the patient's signs and symptoms prior to and during exercise to determine if exercise should be discontinued. These symptoms or signs include: patient feeling ill or febrile prior to exercise, musculoskeletal pain, excessive fatigue or any symptoms of exercise intolerance, failure of heart rate and BP increase during exercise, symptomatic arrhythmia or ischaemia. Furthermore, any change of the patient's medication (where available) should be documented.
The minimum equipment for monitoring would include a watch/stopwatch, sphygmomanometer, charts for patient's to rate dyspnoea or rating of perceived exertion, as well as a log book to chart exercise attendance, duration of exercise and heart rate.
Reassessment and evaluation
Reassessment, audit and evaluation are also considered core components of CR. The goal is to test whether patients are meeting treatment targets at programme completion and have made significant changes through their participation.
Given that many recommendations for CR delivery herein are based on evidence stemming from HICs or consensus, the writing panel particularly encourages evaluation wherever these recommendations are applied. Indeed, the ICCPR plans to undertake field and feasibility tests of this model in future, using low-cost assessment tools, to inform future iterations of this consensus statement. If feasible, incorporation of a control or comparison group, and randomisation of participants to the consensus model versus a comparison group should be built into the evaluation design. It is hoped that in future all recommendations will be based on evidence from the MIC setting.
Adaptation of CR model for greater reach and affordability
Herein a comprehensive model for CR delivery in low-resource settings has been initially proposed. Similar to the ‘Secondary Prevention for All in Need’ model previously forwarded,26 the model is conceived as menu-based and flexible to be applicable in a variety of lower-income contexts and regions.
Given there are large variations in the levels of healthcare resources available in low-resource settings, the recommendations should be implemented as possible. Implementation will depend upon the health system structure of each country, as well as availability and type of trained healthcare providers.27
There is now ample evidence that CR is equivalently effective in HICs whether it is delivered in a formal facility or through a home-based model.19 Clearly, CR delivery without requirement for a facility and the associated costs would be most feasible in low-resource settings. CR could be adapted to be more feasibly delivered through community, the home, the internet/mobile technology and within primary care settings.19 ,28
CR remains insufficiently implemented in current clinical practice, whether in high or MICs.4 According to the WHO report on CR in LMICs, all patients with CHD in all countries should have access to CR, and healthcare providers and patients and their families should be aware of CR. CR programmes, of a scope consistent with the available resources in each country, need to be part of every healthcare system.1 ,6
Political commitment and accountability are needed to achieve broad delivery of CR services in MICs. There are too few examples where CR is a sustained health priority on the national health agenda of an MIC.29 Well-planned and organised advocacy programmes, including meetings and dissemination of targeted reports that highlight the importance of CR from an economic, social, developmental and health standpoint, may convince policy-makers to consider CR programmes among their priorities. Strong collaboration is needed between academic groups working in CR with their counterparts in Ministries of Health as well as Finance, the private sector and other-related parts of the healthcare system.
Identification of where CR programmes exist, and supporting these programmes to secure further resources and expand is tantamount. Then, developing national CR recommendations, based on the statement herein but tailored to the local situation, will greatly facilitate implementation.
What is already known on this subject?
Cardiac rehabilitation (CR), a comprehensive outpatient chronic disease management programme, has been established as cost-effective in high-resource settings.
CR delivery in unsupervised settings such as the home and community has been shown to be as effective in mitigating mortality and morbidity as traditional supervised delivery.
What might this study add?
Each of the core components of cardiac rehabilitation (CR), namely assessment, lifestyle and medical risk factor management, patient education and return to work, can be delivered in more affordable and practical ways.
In low-resource settings, CR may be more feasibly delivered by non-physician health workers, in non-clinical settings.
How might this impact on clinical practice?
Delivery of cardiac rehabilitation using the approaches proffered herein could result in greater reach while maintaining benefit, and hence mitigate the epidemic of cardiovascular diseases in lower-resource settings.
We gratefully thank the following Advisory Panel for their thorough review of the manuscript: John Buckley, PhD, Chair of Consensus Statement Advisory Panel, Chair of ICCPR; Professor, Department of Clinical Sciences, University of Chester, UK; Ana Mola, PhD, Director of Care Transitions and Population Health Management. NYU Medical Langone Medical Center; Lis Neubeck, PhD, Senior Lecturer, Sydney Nursing School, Charles Perkins Centre, University of Sydney; Nana Pogosova, MD, Professor of Cardiology, Head of the Federal Health Center and Department of Non-communicable Diseases Prevention. National Research Center for Preventive Medicine/Russia; Rod Taylor, PhD, Professor and Chair of Health Services Research, University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter, UK; Rajesh Vedanthan, MD MPH, Assistant Professor, Zena and Michael A. Wiener Cardiovascular Institute, Department of Medicine, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA. We also extend our sincere thanks to Maureen Pakosh, MISt for undertaking the literature search supporting this statement and Raquel Marinho, MSc for undertaking the literature review and appraisal. We also thank Marcelo Orias, MD and Daniel Lemogoun MD for their review and comment on the hypertension sections.
Endorsed by: International Council of Cardiovascular Prevention and Rehabilitation, World Hypertension League, British Association of Cardiovascular Prevention and Rehabilitation, Singapore Heart Foundation, Grupo Interamericano de Prevención y Rehabilitación Cardiovascular, the Groupe Exercise Réadaptation Sport of the French Society of Cardiology, Group of Cardiopulmonary and Metabolic Rehabilitation of the Brazilian Society of Cardiology, the Russian National Society of Preventive Cardiology, the African Heart Network, Canadian Association of Cardiovascular Prevention and Rehabilitation and the Australian Cardiovascular Health and Rehabilitation Association.
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Contributors SLG and NS cochaired the writing panel, including developing the statement outline and selecting section authors. They serve as guarantors of the work. SM provided oversight and knowledge translation expertise. All other authors considered the identified literature in their areas, and drafted a corresponding section of the recommendations. KIT-A also formatted the manuscript and references. SLG revised the draft for important intellectual content. All authors approve the final version of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.