Commentary

Recent data indicate that over 13 million people in the US have CHD, and over 5 million people have a diagnosis of congestive heart failure (CHF).¹ With this burden of disease, CHF is the most common discharge diagnosis for hospitalised Medicare patients. One of the cornerstones of therapy for these patients is regular exercise. Paul Dudley White, MD, one of the founders of the American Heart Association, spent his career touting the benefits of exercise. In his autobiography he comments, “It doesn’t much matter what exercise you take, provided it…suits you in age, strength, aptitude, and experience.”² The early work of Dr. White and others has led to the evolution of modern cardiovascular care to involve formal cardiac rehabilitation programmes. Since their development, the safety of these programmes has been well established and significant adverse events are extremely rare.³

In their review, Smart and Marwick address exercise training in patients with CHF, while Taylor and colleagues review exercise rehabilitation for patients with CHD. Both are comprehensive reviews of the literature and incorporate many pertinent contemporary studies. Benefits of exercise training in these patient populations include improved peak rate of oxygen consumption (VO₂) and cardiac output, efficiencies in oxygen consumption, and decreased rate pressure product.⁴ Accordingly, exercise capacity improves and the threshold for development of cardiac symptoms increases. Along with improvements in these exercise and haemodynamic variables, several neurohormonal markers have been shown to improve in patients with CHF. Decreased levels of aldosterone, angiotensin, natriuretic peptides, and vasopressin are seen.⁵ With the widespread use of cardiac rehabilitation in the CHD and CHF patient populations, other anticipated benefits would include improved quality of life and decreased rates of subsequent hospital admissions. On this basis, it is the rare patient with CHD or CHF who should not be considered a candidate for cardiac rehabilitation.

In this era of cost containment, payment for the services offered by rehabilitation programmes becomes an issue. A large percentage of patients with CHD or CHF are covered by Medicare. The current Medicare policy covers supervised rehabilitation for patients who have a documented diagnosis of acute myocardial infarction within the preceding 12 months, coronary bypass surgery, or stable angina pectoris. Thus, many patients with CHD have coverage for a rehabilitation programme. At present, however, formal rehabilitation programmes for patients with CHF do not receive reimbursement through Medicare. This policy is being reassessed. It is hoped that systematic reviews of the literature as presented here will facilitate policy changes so that the benefits of exercise rehabilitation for more patients with CHD and CHF can be realised.