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Description

Scope and timeframe:
All complex patients (outlined below) with an indication for a comprehensive CV prevention and rehabilitation programme
From referral to follow-up after a structured programme
Setting:
In-patient, out-patient, home based, community, virtual (including online and tele rehabilitation)
Including:
Management of patients with stroke, peripheral artery occlusive disease (PAOD, including amputation), diabetes, chronic kidney disease, chronic obstructive pulmonary disease, rheumatologic disease, orthopaedic disease, and frailty
Management of CIED, LVAD, and HTX patients
Patient global evaluation and risk stratification using appropriate tests
Lifestyle modification, through nutritional, physical activity and psycho-social counselling
Adapted exercise prescription, adapted exercise training structuring and supervision
Cardiorespiratory performance and interpretation (identifying those patients who cannot do it)
Guideline-directed medical therapy implementation
Behavioural change and self-management
Organization and optimization of a patient education programme, including specific information related to the comorbidity
Organization of long-term follow-up
Excluding:
Performing specialist investigations or interventional or surgical procedures, acute or unstable conditions, acute settings

CanMEDS roles

• Medical expert

• Communicator

• Collaborator

• Leader

• Health advocate

• Scholar

• Professional

Knowledge

• Discuss the management of individual comorbidities: stroke, PAOD, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, rheumatologic disease, orthopaedic disease, and frailty

• Discuss the management of CIED, LVAD, and HTX patients

• Describe the current evidence and expected benefits of comprehensive CV prevention and rehabilitation

• Consider appropriate referral and contraindication to comprehensive CV prevention and rehabilitation programmes

• Outline the main core components of comprehensive CV prevention and rehabilitation programmes

• Discuss the global patient evaluation strategy

• Identify the interaction between pharmacological and CIED therapies with exercise

• Explain the different modalities of exercise and how to adapt to specific comorbidities, and frailty

• Outline the principles of the FITT-VP (frequency, intensity, time, type, volume, progression) model for exercise prescription and of using scales of perceived exertion (e.g. Borg)

• Discuss indications and interpretation of exercise capacity tests (ECG exercise testing, CPET, 6MWT, strength tests)

• Know key frailty tests (i.e. timed up and go, walking speed test) and tests for cognitive deficits (mini-mental status test)

• Identify the principles of counselling for secondary prevention, specifically including management linked to comorbidities

• Describe psychological profiles and their impact on CV health

• Describe the patient education management (empowerment, self-management, self-efficacy, adherence promotion)

• Discuss the new technologies and their use for remote monitoring, programme delivery, and education

• Outline the composition of and relationships between the interdisciplinary CV prevention and rehabilitation staff

• Discuss how comorbidities influence CV prevention and rehabilitation delivery and need for adaptation

• Discuss the influence of CV risk factors and diseases in patient prognosis (differentiate mortality and morbidity) and quality of life

• Outline the importance of comprehensive CV prevention and rehabilitation in the pathway and care delivery of the CV patient without and with comorbidities

Skills

• Manage specific aspects of individual comorbidities: stroke, PAOD, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, rheumatologic disease, orthopaedic disease, and frailty

• Manage specific aspects of CIED, LVAD and heart transplant patients

• Perform evaluation including CV risk factors, clinical condition, non-invasive assessment of CV functioning/disease, disabilities, nutrition, psycho-social impact

• Explore patient expectations, values and priorities

• Perform and interpret exercise capacity tests (ECG exercise testing, CPET, 6MWT, strength tests) for tailored exercise prescriptions

• Prescribe endurance continuous/interval training, resistance/strength training, and respiratory training

• Develop exercise training according to settings (residential, ambulatory, community-based, tele-monitoring), patient conditions (age, sex, comorbidities, psychologic status), and preferences

• Conceptualize, organize and drive an educational programme with specificities to the different comorbidities

• Organize a tele-monitoring/tele-rehabilitation programme

• Optimize and up-titrate guideline-directed medical therapies, adapted to the exercise tolerance and comorbidities

• Identify and analyse CIED functioning at rest and during effort

• Manage comorbidities under consideration of possible drug interactions and contraindications

• Recognize and treat emergency cases related to comorbidities or devices

• Manage patients with residual ischaemia (e.g. incomplete optimal revascularization, diffuse atherosclerotic disease)

• Detect post-interventional or post-surgical complications (e.g. early stent thrombosis or restenosis, pericardial tamponade)

• Apply effective communication and behavioural change techniques (e.g. motivational interviewing for smoking cessation and patient education)

• Make end of life discussions possible for terminal patients

• Organize the follow-up, links with general practitioners and/or cardiologists, and other health professionals

Attitudes

• Work with interdisciplinary teams of health professionals involved in secondary prevention and rehabilitation

• Educate and encourage patients to reduce their CV risk factors with help of all the professional resources

• Educate patients on how his/her entourage can support prevention

• Support patients with genetic disorders (psychological counselling, explain consequences for disease management and for relatives)

• Motivate patients to sustain long-term adherence with lifestyle, exercise training, and medical therapy, despite their comorbidities

• Actively involve patients in shared decision-making to promote optimal self-management and long term adherence to behaviour change

• Advocate for comprehensive CV prevention and rehabilitation programmes to improve referral and uptake

Assessment tools

• MCQs

• Direct observation, workplace-based assessments (e.g. DOPS, mini-CEX, fieldnotes)

• Case-based discussions, entrustment-based discussions

• Multiple consultant reports

• Multi-source feedback

Level of independence

• Level 5 (perform the activity without supervision, teach and supervise others)

Related ESC guidelines and EAPC position papers

• Pedretti RF, Iliou MC, Israel CW et al. Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients. A consensus document from the European Association of Preventive Cardiology (EAPC; Section on Secondary Prevention and Rehabilitation) and European Heart Rhythm Association (EHRA). Eur J Prev Cardiol 2021;28:1736–1752.

• Ambrosetti M, Abreu A, Corra U, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: from knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2020;doi:10.1177/2047487320913379.

• Abreu A, Frederix I, Dendale P, et al. Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: the avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2020;doi:10.1177/2047487320924912.

• Scherrenberg M, Wilhelm M, Hansen D, et al. The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2020;doi:10.1177/2047487320939671.

• Hansen D, Kraenkel N, Kemps H, et al. Management of patients with type 2 diabetes in cardiovascular rehabilitation. Eur J Prev Cardiol 2019;26:133–144.

• Kemps H, Krankel N, Dorr M, et al. Exercise training for patients with type 2 diabetes and cardiovascular disease: What to pursue and how to do it. A Position Paper of the European Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2019;26:709–727.

• Vigorito C, Abreu A, Ambrosetti M, Belardinelli R, Corra U, Cupples M, Davos CH, Hoefer S, Iliou MC, Schmid JP, Voeller H, Doherty P. Frailty and cardiac rehabilitation: A call to action from the EAPC Cardiac Rehabilitation Section. Eur J Prev Cardiol 2017;24:577–590.

• Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315–2381. Update in 2021.

• Mezzani A, Hamm LF, Jones AM, et al. Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation. Eur J Prev Cardiol 2013;20:442–467.

• Piepoli MF, Conraads V, Corra U, et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail 2011;13:347–357.