Cardiovascular diseases are the leading cause of death globally and in India. Cardiac rehabilitation is essential to support patients' physical, social, and emotional recovery after a cardiac event through a multidisciplinary approach involving medical treatment optimization, lifestyle changes, exercise training, and long-term management. Cardiac rehabilitation traditionally involves 4 phases, starting with in-hospital mobilization in phase 1, followed by home-based recovery in phase 2, and progressing to a supervised outpatient program in phase 3 and independent activity in phase 4, in order to facilitate recovery and prevent future cardiac events.

1. Understanding the need for Cardiac Rehabilitation
Non-communicable diseases (NCDs), also known as chronic diseases are the
result of a combination of genetic, physiological, environmental and behavioral
factors. They are responsible for almost 71% of the total deaths globally today,
with Cardiovascular Diseases (CVDs) accounting for the most NCD deaths
followed by cancer, respiratory diseases and diabetes (WHO 2018). Any cardiac
event caused due to a CVD is life changing and making heathy changes to one’s
life can be difficult. It is therefore essential that support is extended beyond
patients’ hospital admission to ensure optimization of physical, social and
emotional recovery and Cardiac Rehabilitation is the important key to this.
Cardiac Rehabilitation dates back to the early 1900’s, where the concept
evolved from observing simple bed rest for 6 weeks after acute coronary events
to becoming a multidisciplinary approach (1950 by Hellerstein), to help cardiac
patients recover faster and return to their optimal fitness level over a period of
time. Today, it involves pre-operative education and counselling, post-operative
patient care, optimization of medical treatment, lifestyle risk factor modification,
nutritional counselling, smoking cessation, behavioral change and education,
stress management, management of blood pressure, diabetes or dyslipidemia,

2. individually tailored exercises protocol, cardio-protective therapies and long-term
management with timely audit and evaluation.
Cardiovascular diseases (CVDs) have become the leading cause of mortality in
India and a quarter of all mortality is attributable to CVD, with ischemic heart
disease and stroke accounting for more than 80% of CVD deaths. These
statistics point to the fact that Cardiac Rehabilitation is the need of the hour, to
help survivors lead an optimally fit life. The aim is to reduce the risk of a future
cardiac event by stabilizing, slowing, or even reversing the progression of
cardiovascular disease or cardiac insult.
 Patients with cardiovascular disease events such as myocardial infarction,
percutaneous coronary intervention (PCI), bypass surgery (CABG, Coronary
Artery Bypass Graft), stable angina, heart transplant, heart valve surgery and
heart failures (with exceptions) are the ones requiring Cardiac Rehabilitation.
Occasionally, contraindications to this program only concern the exercise aspect
while all other components can be pursued.
Traditionally Cardiac Rehabilitation is divided into 3 phases (some programmes
may have 4 phases with phase 2 being considered as a subacute phase with
light activity at home before beginning a formal supervised outpatient program)
which aims to facilitate recovery and prevent future events.

3. Phase 1 or the in-patient phase is initiated right in the hospital after a Myocardial
Infarction, cardiac event or surgery and extends as long as the patient stays in
the hospitals. It involves the physiotherapist helping patient with monitored early
progressive mobilization including bedside exercises to make self-care possible
by discharge, with brief counselling about the nature of illness, treatment, risk
factor management and follow up planning.
Phase 2 or the subacute phase starts immediately post discharge and usually
extends for 2-4 weeks after percutaneous coronary intervention or Myocardial
Infarction and 4 to 6 weeks after cardiac surgery. It focuses on health education
and resumption of physical activity (light activity) at home and vary in format from
center to center. Contact with the individual either through telephone follow up,
home visits or individual /group education sessions are maintained facilitating
ongoing education and exchange of information.

4. Phase 3 or the supervised outpatient program consists of a supervised program
usually 2-4 weeks after percutaneous coronary intervention or Myocardial
Infarction and 4 to 6 weeks after cardiac surgery in an outpatient setup and
extends for 12 to 36 weeks. It aims to help patients return back to work or
hobbies and lifestyle. During this period, the patient visits the outpatient clinic 2-3
times a week and exercises for 15 to 60 minutes depending on his condition
under the supervision of the therapist. This exercise regime usually includes
aerobic training, stretching/flexibility exercises and an introduction to strength
training. At this stage, the physiotherapist works with the individual to monitor his/
her response to exercise with parameters such as the heart rate, blood pressure,
oxygen saturation, breathing rate, rate of perceived exertion and his ECG and
also trains the individual to monitor his own heart rate and activity level. Certain
outcome measures such as simple walk tests may be used pre and post phase 3
to evaluate the progress in the exercise capacity of the individual.
Phase 4, aims to move the individual towards more intense independent physical
activity and lifetime maintenance with prime focus on physical fitness and
additional risk factor reduction. Here, the physiotherapist expects the individual to
monitor his own response to exercise including heart rate and perceived exertion.
Home or gymnasium exercise program are encouraged with the aim of
continuing risk factor modification and exercise program learned during phase 3.
Cardiac Rehabilitation has numerous benefits such as mortality and morbidity
reduction from exercise-based program, improvement in life quality by improving
symptoms such as lessening of chest pain, dyspnea, fatigue, stress and
enhancement of overall sense of psycho-social well-being. It is not only clinically
effective but also cost effective when compared to lipid lowering medications,
thrombolytic and bypass surgery.