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Summary for secondary care

Secondary Care Risk Factor Management for Cardiac Rehabilitation

This specialist Guidelines summary provides recommendations on the rehabilitation of patients with heart disease. It provides recommendations on assessment, health behaviour-change techniques, lifestyle risk factor management, psychosocial health, vocational rehabilitation and medical risk management. This summary is intended for use in a secondary care setting by cardiologists.

For the complete set of recommendations, refer to the full guideline.

Recommendations are marked [R] and good-practice points are marked [✓]

Referral, Engagement, and Partner/Carer Involvement


[R] Interventions to improve self efficacy should be considered for inclusion in a cardiac rehabilitation programme.

Partner/Carer Involvement

[✓] Cardiac rehabilitation programmes should consider the contributions family members and carers can make to a patient’s cardiac rehabilitation.

[✓] Specific carer support groups could be considered to focus on the issues partners or carers may encounter in coping with their family member’s cardiac condition.

[✓] Cardiac rehabilitation programmes should be tailored to consider equality and diversity issues.

Assessment and Care Planning

[✓] Comorbidities should be taken into consideration in the assessment of patients attending cardiac rehabilitation to ensure a treatment plan which addresses all the long-term conditions that may be impacting on the patient’s wellbeing.

Individual Assessment and Case Management

[✓] All patients referred to cardiac rehabilitation should undergo an individualised assessment leading to a care plan and interventions specific to their needs.

Lifestyle Risk Factor Management

[✓] Cardiac rehabilitation programmes should place equal emphasis on each of the lifestyle risk factors when supporting patients to make lifestyle changes.

Smoking Cessation

[R] Patients in cardiac rehabilitation who smoke should be offered smoking cessation interventions which include contact for more than 4 weeks.

[R] Smoking cessation interventions should include a combination of telephone contact, behavioural support, and self-help materials.

Physical Activity and Reducing Sedentary Behaviour

[R] Patients should be offered a cardiac rehabilitation programme that includes an exercise component to reduce cardiovascular mortality, reduce hospital readmissions, and improve quality of life.

[R] Cardiac rehabilitation services should offer individualised exercise assessments, tailor the exercise component of their programmes to individual choice, and deliver them in a range of settings.

[R] Aerobic and resistance exercises should be considered as part of exercise prescription for patients attending cardiac rehabilitation.

[R] Technology-based interventions should be considered for patients participating in cardiac rehabilitation.


[R] A range of strategies, including telephone follow up, educational tools, contracts, nutritional tools, and feedback should be considered for patients in cardiac rehabilitation to enhance adherence to dietary advice.

[R] Referral to weight-loss programmes delivered by experts should be considered for patients requiring assistance with weight management.

Long-term Maintenance of Behaviour Change

[R] Psychoeducation (goal setting, self monitoring) should be considered for patients in cardiac rehabilitation to facilitate adherence to physical activity.

Psychosocial Health

Models of Psychological Care

[R] Cardiac rehabilitation should incorporate a stepped-care pathway to meet the psychological needs of patients.

[✓] To ensure clinical governance and quality, psychological therapies should be evidence based, and delivered by psychologically trained and supervised healthcare professionals within the context of a locally defined care pathway.

Measurement of Psychological Wellbeing

[✓] Assessment tools for anxiety and depression should be repeated over the course of rehabilitation as part of a clinical pathway to ensure ongoing monitoring of symptoms and provide outcome measures of care.

Psychological Therapies and Interventions

[R] All patients should be offered a package of psychological care, based on a cognitive behavioural model (for example, stress management, cognitive restructuring, communication skills) as an integral part of cardiac rehabilitation.

[R] Cognitive behavioural therapy should be the first choice of psychological intervention for patients in cardiac rehabilitation with clinical depression or anxiety.

[R] Cognitive behavioural therapy should be considered for patients assessed to have specific psychological needs such as support with symptom control.

[✓] Cognitive behavioural therapy should only be delivered by healthcare practitioners with accredited relevant competencies and approved clinical supervision.

[R] A supervised course of full relaxation therapy should be considered for patients in cardiac rehabilitation to enhance recovery and contribute to secondary prevention.

Vocational Rehabilitation


[R] Vocational rehabilitation interventions designed to address illness perceptions relating to the likelihood of return to work should be considered for patients in cardiac rehabilitation who have the potential to continue in employment.

[R] Exercise prescription that includes a range of physical activities designed to simulate those anticipated in the workplace should be considered for patients in cardiac rehabilitation who have the potential to continue in employment.

[✓] Cardiac rehabilitation services should enable appropriate patients to return to work while participating in their rehabilitation programme.

Medical Risk Management

Prescribing Practices

[R] Non-medical prescribing should be considered within a cardiac rehabilitation setting.

[✓] Appropriate training and evaluation of non-medical prescribers are vital to ensure safe and effective care.

Provision of Information

Checklist for Provision of Information

This section gives examples of the information patients/carers may find helpful at the key stages of the patient journey. The checklist was designed by members of the guideline development group based on their experience and their understanding of the evidence base. The checklist is neither exhaustive nor exclusive.

Box 1: Checklist for Provision of Information
The information given to patients following a cardiac event should be provided on an individual basis dependent on need and choice. It should be offered in a timely manner working with the patient throughout the CR journey.

Information appropriate to the individual should be provided in various formats—written and verbally, either through a face-to-face conversation, by telephone, or online.

Involving the patient in all discussions is essential, with the aim of informing, empowering, and encouraging the individual to take responsibility to self manage their condition. The involvement of spouses/carers/partners as appropriate, with the patient’s consent should be considered.

Throughout Cardiac Rehabilitation
  • Discuss the impact of a cardiac event/coronary heart disease on emotional wellbeing.
  • Advise about the purpose and use of secondary prevention medication and encourage concordance.
  • Signpost patients to other information sources, peer support, and support groups.
Prior to Hospital Discharge Following a Cardiac Event
  • Provide verbal and written information on:
    • diagnosis
    • chest pain management, including how to use the GTN spray
    • advice on driving
    • return to work
    • appropriate daily activities.
  • Offer further information such as booklets from the British Heart Foundation or Chest, Heart & Stroke Scotland.
  • Discuss any future treatments, interventions, and appointments.
  • Explain the purpose of CR and provide a contact number for CR unit.
  • Discuss the benefits of smoking cessation (if appropriate).
At The Cardiac Rehabilitation Assessment
  • Provide information appropriate to the needs and choices of the patient on:
    • activity
    • exercise
    • smoking cessation
    • weight management
    • diet
    • common emotional adjustment reactions to ill health.
  • Advise on the benefits of maintaining exercise long term and that it can be undertaken safely and effectively in any setting.
  • Provide a contact number for ongoing person-centred advice and/or support.
Abbreviations: CR=cardiac rehabilitation; GN=glyceryl trinitrate.