Cardiac Rehabilitation in German Speaking Countries of Europe—Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH—Part 1

Abstract

Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on “treatment intensity” including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. Conclusions: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Cardiac Rehabilitation in German Speaking Countries of Europe—Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH—Part 2

“…In the following, the recommendations for most important contents of ebCR and their application in clinical practice, as well as particular needs of special patients groups, including gender issues, and the potential of new forms of ebCR like tele-rehabilitation and home-based ebCR, are discussed. The contents being evaluated can be categorized as follows: The following recommendations are based on most recent and topic-related scientific guidelines and by a semi-structured evaluation of scientific literature (classification: S2k; see Methods in Part 1; [1]).…”

“…Initiation, organization, and methodology of evidence generation, applied in the Cardiac Rehabilitation Guidelines of German speaking countries in Europe (Germany, Austria, Switzerland; D-A-CH), have been described in detail in Part 1 [ 1 ]. The “Grades of recommendation” (see Table 1 ) were based on the scientific evidence as derived from the literature and a formal consensus process of all members of the steering committee in accordance with the “GRADE Evidence-to-Decision framework” and supervised by the AWMF (“Association of the Scientific Medical Societies in Germany”).…”

“…The “degree of consensus” is expressed in percentages of all steering committee members participating in the consensus generating process. The “classification of scientific evidence” followed the definitions of SIGN (Scottish Intercollegiate Guidelines Network) and was only applicated in chapters classified by “S3” (for details, see Part 1; [ 1 ]).…”

“…We cordially thank Ekkehard Grünig, Zentrum für pulmonale Hypertonie, Thorax-Klinik am Universitätsklinikum Heidelberg, Germany) for the highly competent paragraph on ebCR in patients with pulmonary arterial hypertension and Irina Brüggemann (53229 Bonn, Germany) for her support during the elaboration of this guideline. Guidelines initiation, organization and financial support (funding) are outlined in "Methods" of part 1 [1]. Officially nominated delegates of participating scientific societies and health care institutions ("Steering Committee"):…”

“…The condensed version of these guidelines (LLKardReha-D-A-CH) in English language are presented in two parts. Part 1 [ 1 ], describes the methodology of guideline development and the evidence of ebCR for a broad spectrum of clinical indications. Part 2, as presented in this review, concentrates on most important contents of ebCR, such as exercise training, psychological interventions and patient education, with their application in clinical practice.…”