Cardiac rehabilitation in patients with heart failure Joint recommendations of the German Cardiac Society (DGK) and the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR)

Cardiac rehabilitation (CR) aims to re-establish the best possible physical and psychological health in patients with chronic heart failure (HF) by holistic interventions within a multiprofessional team to stabilize health in the long term and to facilitate social and occupational reintegration. The cornerstone of CR is exercise therapy in order to enhance physical capacity during activities of daily living. In addition, psychological support is essential to promote coping with the disease and to reduce anxiety as well as depression, thus enhancing the quality of life. Education is mandatory to increase self-efficacy in handling the disease by the patients themselves, to improve adherence to medication and for healthy lifestyle changes. In patients with chronic HF, implementation, combination and dose titration of evidence-based medication is crucial to reduce morbidity and mortality. By means of frequent monitoring of the clinical status, laboratory values and full physical examination, it is possible to establish oral HF therapy in most patients within the typical duration of CR (big 4 in 4 weeks). In patients with chronic HF, participation in CR is recommended by all national and international guidelines (ACC/AHA, ESC, AWMF, NVL). Reduction of mortality by CR has not been proven so far and studies concerning the decrease of hospital admissions due to decompensated HF by CR are inconclusive. The physical capacity and quality of life, however, have proven to be significantly increased by CR to a clinically relevant level in numerous studies. An early start of CR within days after hospital discharge is crucial to avoid short-term readmission due to recurrent congestion (revolving door effect). The success of CR is essentially affected by patient selection at entry and by adherence to nonpharmacological therapy in the long term. Age, frailty or occupational status should not be used to exclude patients from exercise-based CR. Patient adherence to lifestyle changes should be supported by local multiprofessional teams at the place of residence. The dissemination of further heart failure networks includes the possibility to integrate cardiac rehabilitation as an inherent part of an evidence-based therapy in patients with HF.