There is strong evidence supporting cardiac rehabilitation and heart failure (HF) disease management programs which aim to decrease morbidity and premature death, and to improve quality of life. As many patients with a cardiac condition often have other co-morbidities and complex disease, programs provide a multidisciplinary and comprehensive disease management approach.

Whilst local needs and resources may differ, services should be provided in a manner that best suits the needs of the individual and should include:

• Individualised initial assessment to identify physical, social and psychological factors that influence cardiovascular health
• Education to assist patients to make lifestyle changes to address cardiovascular risk factors
• Education to optimise monitoring of symptoms and self-management
• Education to optimise medication adherence
• Assistance to improve or return to daily functioning (e.g., activities of daily living (ADL), driving, work) or in circumstances where the condition precludes this, to maximise function and provide support [#woodruffe-s-neubeck-l-clark-ra-et-al.-2015]

All patients with cardiovascular disease (CVD) should be referred to a cardiac rehabilitation program. [ #national-heart-foundation-of-australia.-secondary-prevention-of-cardiovascu, #national-heart-foundation-of-australia-and-australian-cardiac-rehabilitatio] Much of the evidence supporting cardiac rehabilitation focuses on patients who have recently been hospitalised following myocardial infarction (MI) or cardiac surgery, however recent evidence suggests that other conditions are also likely to benefit.

Eligibility criteria

Patients recovering from a hospital admission with:

• Acute MI (ST elevation MI (STEMI) and Non ST elevation MI (NSTEMI), +/- post MI revascularisation)
• Revascularisation procedures (coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI))
• Medically managed coronary artery disease (CAD) (e.g., stable angina)
• Valve replacement and repair
• Insertion of pacemaker or implantable cardiac defibrillator (ICD)
• Heart transplant, ventricular assist device
• Stable heart failure

Other patients likely to benefit:

• Atrial fibrillation (AF)
• High risk for CAD
• Familial hypercholesterolaemia

All patients with symptoms of HF, regardless of aetiology, should be considered for enrolment into a heart failure disease management program as outlined in the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand guidelines. [#national-heart-foundation-of-australia-and-australian-cardiac-rehabilitatio] This includes HF with reduced ejection fraction (HFrEF; systolic HF), HF with preserved ejection fraction (HFpEF; diastolic HF), and right HF.

Hospital readmissions are common in these patients and often occur within the first 2-4 weeks post discharge. These admissions are often avoidable with vigorous symptom monitoring and case management by specialist multidisciplinary services. Most HF services consist of a specialist HF nurse who works alone or with allied health professionals. Where designated HF services are not available, patients may be managed by a cardiac rehabilitation team or a more general chronic disease multidisciplinary service.

Multidisciplinary care has been shown to benefit patients:

• Recently hospitalised with HF
• At high risk of readmission (co-morbidities, symptomatic HF)
• Who are elderly, or lack social and economic support
• At high risk of worsening HF

Services can be delivered in a variety of ways in acute and non-acute health facilities, as well as at home.  Modes of delivery are usually a combination of face to face individual or group encounters, telephone calls, video calls, telemonitoring and home visits. [#woodruffe-s-neubeck-l-clark-ra-et-al.-2015, #clark-ra-inglis-sc-mcalister-fa-et-al.-2007, #mcalister-fa-stewart-s-ferrua-s-et-al.-2004, #phillips-co-singa-rm-rubin-hr-et-al.-2005, #van-spall-hgc-rahman-t-mytton-o-et-al]

Inpatient care

During the inpatient phase, multidisciplinary services should focus on:

• Practical support regarding clinical management and the hospital stay
• Support and education around risk modification, self management principles, resumption of activity, driving and return to work, as relevant to the individual
• Early discharge support
• Introduction and referral to post acute management and follow up

Outpatient care

Post hospital discharge patients may be followed up in a range of settings.  Home visits and disease management clinics have been found to be effective in reducing mortality in patients with heart failure. [#van-spall-hgc-rahman-t-mytton-o-et-al]

Centre-based approaches

• Centre based approaches may include a variety of interactions from one on one clinic visits to comprehensive disease management programs.
• Individual consultations are useful for initial review post-discharge, initial assessment for exercise rehabilitation and for patients with complex needs, such as those requiring medication titration or psychological support
• Multidisciplinary rehabilitation programs conducted in hospitals or community settings should, where possible, include both exercise as well as education sessions. These are generally conducted as a group to provide patients with social interaction
• For exercise rehabilitation, the hospital setting is preferable for patients with: severe or unstable disease (including those awaiting heart transplant), complex co-morbidities and supplemental oxygen requirements

Home-based approaches

• Home-based support may be delivered by a variety of approaches including face-to-face home visits, telephone or video coaching, and computer or mobile phone programs and applications
• Home-based support can provide access to services for patients who are working, who experience transport difficulties or have severe deconditioning following an inpatient admission
• Interviewing patients at home helps identify issues such as expired, duplicated or medicines that have previously been stopped, as well as the storage conditions of medicines (e.g., GTN tablets). Over-the-counter complementary medications may also be more readily available for review in the home setting

Apps and other support tools

There are an increasing number of applications and online programs, wearable devices, and structured telephone and remote monitoring support services that can help patients to maintain motivation to make life-style changes and respond to changes in symptoms.  The available technology is changing rapidly and ranges from main stream wearable devices, tailored text messaging services to maintain motivation through to telemonitoring of physiological parameters.