Cardiac Rehabilitation and the ASCVD Prevention Pyramid
Pyramid (left) shows how unhealthy lifestyle practices lead to development of risk factors, progression of ASCVD, and, ultimately, to adverse outcomes or clinical endpoints. There are 3 types of prevention: primordial (prevention of risk factors); primary (treatment of risk factors); and secondary (prevention of recurrent cardiovascular events), which can be modulated by environmental (e.g., air pollution) and psychosocial stressors, lifestyle changes, and cardioprotective medications, if appropriate. The first-line strategy to prevent initial or recurrent cardiac events is to favorably modify unhealthy lifestyle habits or practices, including poor dietary habits, physical inactivity, and cigarette smoking. Circular chart (right) shows core components of CR/secondary prevention programs. The current model of CR involves 3 phases. Phase I (inpatient phase) involves physical therapy and patient education after a cardiac event. Phase II (outpatient phase) consists of individualized exercise prescription and risk factor reduction under supervision of a medical team. Phase III (maintenance phase) consists of independent continuation of the exercise program and cardiovascular risk reduction learned during phase II (37,39). CR also provides the referring physician with ongoing valuable surveillance data (such as exertional angina symptoms, onset of AF, heart failure symptoms) that can aid with ongoing medical management of the patient. Adapted with permission from Franklin et al. (5). AF = atrial fibrillation; ASCVD = atherosclerotic cardiovascular disease; CABG = coronary artery bypass graft; CHF = congestive heart failure; MI = myocardial infarction; NSTEMI = non-ST-segment elevation myocardial infarction; PAD = peripheral arterial disease; PCI = percutaneous coronary intervention.