Table 1

Intervention recommendations for delivery of the core components of CR in low-resource settings, with level of evidence

Core componentRecommendationLevel of evidence*
1. Exercise1a. Programmes of exercise should, wherever feasible, be offered to all subjects recovering from major CHD events.w1–w11LMICs—low quality of evidence
1b. The frequency goal should be to conduct exercise training on at least 3 days but preferably on most days of the week.Consensus based
1c. 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 has been possible then the presence of chest pain induced by exercise and relieved by rest or nitroglycerin warrants evaluation prior to initiating exercise at intensities at or above this intensity. Without an exercise ECG, the recommended exercise training intensity should be in the light and moderate ranges.Consensus based
1d. The duration of aerobic exercise training would depend on the patient's initial functional capacity and progression in the programme and 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% in duration per week. Warm-up and cool-down activities would precede and follow the aerobic exercise bout.Consensus based
1e. Patients at lower risk or who have completed a period of supervised rehabilitation can be promoted to exercise safely in a home-based or community setting. Supervised exercise setting is for high-risk patients.w12 w13LMICs—low quality of evidence
1f. Walking is the preferred mode of exercise, as it is no-cost. However, non-weight-bearing exercise is recommended for patients with musculoskeletal pain or limitations. This should be augmented with resistance training where possible.Consensus based
2. Diet2a. Fruits and vegetables
Consumed in abundance as affordable, particularly locally grown fruits and vegetables. At least 400 g/day (ie, five portions), but ideally double this. There should be a greater intake of vegetables than fruit.w14 w15
Having a variety of different coloured fruit and/or vegetables daily will aid a diverse micronutrient intake. A maximum of one glass (150 mL) of fruit juice each day.
HIC—high quality of evidence
Consensus based
2b. Whole grains and fibre
Should be incorporated into the diet in the least refined and highest fibre form.w16
Refined starches and sugars along with sugar-sweetened beverages should be limited.w17
HICs—moderate quality of evidence
HICs—moderate quality of evidencew17
2c. Dietary fat
The primary source of fat should be an unsaturated fat (olive oil, sunflower oil, canola/rapeseed oil) replacing saturated fat (lard, butter) where possible.w18 w19 Trans fatty acids (partially hydrogenated fat) should be avoided.
HICs—high quality of evidence
2d. Salt
Less than 5 g salt/2000 mg sodium per day.w20 Reduction of processed, smoked, cured, bread and cereal products will aid achievement.
HICs—high quality of evidence
2e. Protein
Use fish, poultry, nuts and legumes as an alternative to fatty red or processed meats. For those living in coastal areas, eating fish caught locally may be more affordable.
Consensus based
2f. Dairy products
These are non-essential although can be useful sources of protein or calcium for some; there is no benefit from a high intake.
Consensus based
2g. Vitamin and mineral supplements
Not required if a balanced diet is consumed, unless indicated by other conditions.
Consensus based
2h. Patients with raised LDL cholesterol
The incorporation of stanol and sterol ester products can be encouraged in the correct dose.w21
HICs—moderate quality of evidence
3. TobaccoPsychological interventions
3a. For all patients: brief advice from trained health professional or physician
Brief opportunistic advice consists of up to 30 min of discussion with patients aimed at prompting a quit attempt and in some cases enhancing chances of the success of that quit attempt. It can be provided by a physician, nurse or trained health personnel at the CR facility. It may include advice to stop, providing information about the health consequences of smoking, how the different components of cigarette smoke cause harm, the benefits of quitting, advice on methods of quitting and in some cases offer of further support.w22
LMICs—high quality of evidence
Pharmacological interventions where available: non-physician based
3b. NRT
NRT products are recommended for all smokers and smokeless tobacco users with stable cardiovascular disease and those who have suffered an acute event on hospital discharge.w23 w24 Those with unstable disease should be assessed by a cardiologist prior to NRT use.
HICs—high quality of evidence
Pharmacological interventions options for physicians: based on availability, affordability and individual patient profile
3c. Where a physician and the medications are available and affordable, patients should be offered bupropion, cytisine or varenicline.w25–w28
HICs—moderate quality of evidence
4. Body weight/composition4a. All patients with established CHD should have serial (eg, every 6 months) monitoring of BMI and waist circumference.Consensus based
4b. In individuals who are overweight (BMI>25) or obese (BMI>30), a combination of weight loss, dietary changes and physical activity is recommended.w7 w29LMICs—moderate quality of evidence
5. Education5a. Patient education should be personalised, led by trained staff, with regular contact between staff and patients. It should be delivered in individual and/or group settings and if possible, include family members and caregivers. Patient's specific health goals should be discussed.Consensus based
5b. The aim of education should be to influence health beliefs, to elicit positive emotions, to increase optimism about the possibility of change and to heighten the salience of personal experience or other evidence supporting self-efficacy.Consensus based
5c. In addition to education on physical activity, risk factor control, smoking cessation and drug treatment (where feasible), dietary education should be given in terms of food not nutrients, at an appropriate level, in order to facilitate informed healthy choices. Advice should be adapted to meet the specific needs of the patient in the context of his/her family, taking into account factors such as age, culture and lifestyle. For maximum benefit, any targets should be realistic for the longer-term to ensure life-long maintenance.Consensus based
6. Mental health6a. Where CR programmes have access to healthcare professionals capable of: (1) undertaking diagnostic interviews for depression and (2) providing collaborative, stepped depression treatment for those with a positive diagnosis, patients should be screened for depression.Consensus based
6b. Patients who receive a positive depression diagnosis should be encouraged to adhere to CR to achieve the mental health benefits.w30–w32LMICs—moderate quality of evidence
6c. Depression treatment, with antidepressants and/or pharmacotherapy should be based on patient preference and availability. Response to therapy should be monitored, and stepped where inadequate symptom reduction is achieved.w33
Treatment should be communicated with the CR team.
HIC—moderate quality of evidence
Consensus based
6d. CR programmes should offer stress management, where a trained healthcare provider is available.w34HICs—moderate quality of evidence
7. Return to work7a. All CR patients should undergo assessment of occupational type, employment status and desired occupational status.Consensus based
7b. Patients with physically demanding occupations or jobs involving public safety should undergo risk evaluation prior to return to work. Where available, treadmill testing is recommended as the modality of choice for exercise assessment, to ascertain ischaemic threshold, and electrical instability. The 6 min walk test is a viable alternative where resources do not permit treadmill testing.Consensus based
7c. Low-risk individuals are those with no angina symptoms and with good functional status (able to perform >7 METS of work). These patients can return to work within 2 weeks of their event, preferably with some initial CR programming and a plan for ongoing contact and support.w35HICs—moderate quality of evidence
8. Lipids8a. All patients with established CHD should have baseline and subsequent (eg, every 3–6 months) on treatment lipid profile assessments where available.Consensus based
8b. A combination of lifestyle modifications (including dietary changes and physical activity) and pharmacotherapy (where available and affordable) is recommended for all patients.w29 w36LMICs—moderate quality of evidence
8c. Statin therapy, unless contraindicated (in patients with known allergic reactions to statins, active liver disease, as well as in pregnant and lactating women), is warranted for all patients with established CHD, regardless of capacity to test for baseline lipid levels. Absence of blood draw should not be a barrier to prescription of statins. Type and dose of statin is dependent on region/country-specific cost-effectiveness analysis, availability and affordability. Ideally, this should be titrated to achieve a target LDL-C of <70 mg/dL,w37 or to achieve ≥50% reduction in baseline LDL-C.w38HICs—high quality of evidence
9. Hypertension control9a. All people who have CHD and heart failure are recommended to have BP assessed at initial CR sessions. Where feasible, multiple BP readings including out of office BP readings (readings in community settings, pharmacies, home) should be used to supplement readings performed in CR sessions. People with high readings assessed in a quiet, comfortable environment (ie, ≥140/90 mm Hg) at two or more visits can be diagnosed with hypertension, while hypertensive urgencies and emergencies are diagnosed immediately. People on treatment for hypertension with BP readings <140/90 mm Hg are also considered to have hypertension.w39HICs—moderate quality of evidence
9b. Lifestyle behaviour advice for people with hypertension as outlined previously in this document is a core aspect of hypertension management.w29 w36LMICs—moderate quality of evidence
9c. Where available, antihypertensive medications, outlined in the cardioprotective point below should be used in specific clinical circumstances (eg, ACE inhibitors in heart failure).See point 10
9d. Achieving the target BP (<140/90 mm Hg) should be the primary clinical focus.w40–w43 Diuretic is often the most affordable and accessible antihypertensive medication. BP control generally requires more than one drug and when three or more drugs are required, barring contraindication, one should be a diuretic.w40–w42 w44–w46HICs—moderate quality of evidence
9e. In people with heart failure, an aldosterone antagonist is indicated where available and affordable.w40–w42 w44 w46HICs—moderate quality of evidence
9f. In people with heart failure, a non-dihydropyridine calcium channel blockers should not be used.w40–w42 w44 w46HICs—moderate quality of evidence
9g. In people with CHD, hypotension and reducing diastolic pressure below 60 mm Hg should be avoided. Therefore, short-acting potent oral agents like nifedipine capsules should not be used.w40 w43 w46–w48HICs—moderate quality of evidence
10. Cardioprotective therapiesAccess to cardioprotective therapies can be limited in LMICs. The recommendations below are only pertinent to regions where these medications are available, affordable and accessible. Unless there is a specific contraindication, history of allergy or definite history of intolerance, the following cardioprotective medications should be prescribed universally in specific scenarios as described below:
10a. Antiplatelet therapy
10.a1 Low-dose aspirin in doses from 75 to 150 mg a day is recommended for all patients with a history of CHD, including those who have been revascularised.w49
10.a2 Higher doses of aspirin have not demonstrated greater clinical benefit, and they increase the risk for gastrointestinal bleeding or ulcers. For patients intolerant or allergic to aspirin, clopidogrel at a dose of 75 mg a day can be used.w49
10.a3 Dual antiplatelet therapy (aspirin plus clopidogrel or equivalent) is indicated in patients undergoing percutaneous coronary revascularisation with stents and is recommended for 1 year if they received a drug-eluting stent or for at least 3 months if they received a bare metal stent.w50
10.a4 Dual antiplatelet therapy is also recommended in patients with a history of recurrent coronary events despite appropriate medical therapy including aspirin.
10.a1 HICs—moderate level of evidence
10.a2 HICs—moderate level of evidence
10.a3 HICs—moderate quality of evidence
10.a4 Consensus based
10b. ACE inhibitors
10b.1 ACE inhibitors are recommended in all patients with type 1 or type 2 diabetes mellitus, in patients with a left ventricular ejection fraction of <40% even in the absence of coronary or atherosclerotic vascular disease, and in patients with a recent anterior myocardial infarctionw51
10b.2 Angiotensin receptor blockers should also be considered.w52
10b.1 HICs—moderate level of evidence
10b.2 HICs—moderate level of evidence
10c. β-Blockers
β-Blockers are indicated in all patients after an ST elevation or non-ST elevation myocardial infarction, in patients with documented ischaemia or clinical angina, and in patients with a left ventricular ejection fraction below 40%, even in the absence of coronary disease.w51
HICs—high level of evidence
10d. Statins
Statins are recommended in every patient with CHD regardless of pre-CR lipid values. Further details on the use of lipid-lowering therapy are provided in section 8.
10e. Patient education and counselling shall be provided to optimise patient medication adherence.w53
HICs—high level of evidence
  • *References found in online supplementary file 2.

  • BMI, body mass index; BP, blood pressure; CHD, coronary heart disease; CR, cardiac rehabilitation; HICs, high-income countries; LDL, low-density lipoprotein; LMICs, low/middle-income countries; METS, metabolic equivalents; NRT, nicotine replacement therapy.