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https://doi.org/10.47803/rjc.2020.30.1.1

Magda Mitu1, Mihaela Suceveanu3, Florin Mitu1,2

1 Hospital of Rehabilitation, Iasi, Romania „Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
2 Cardiovascular Recovery Hospital „Dr. Benedek Geza”, Covasna

Abstract: Cardiovascular rehabilitation (CR) is part of cardiovascular prevention and the objectives are the improvement of functional capacity, control of cardiovascular risk factors, adoption of a healthy lifestyle, education and adherence to the recommended therapies, aiming the reduction of the risk of adverse events, disability, cardiovascular mortality and the increase in quality of life. In Romania, CR is delivered only in a in hospital basis, at 2nd phase of rehabilitation in patients, in fi ve dedicated centers that have the necessary equipment and a multidisciplinary team, but an insuffi cient number of beds compared to a great number of patients with an indication for rehabilitation. Issues related to addressability, adherence, incomplete legislation regarding ambulatory rehabilitation, and lack of recognition of CR as a part of cardiology or internal medicine are still unsolved.
Keywords: cardiac rehabilitation, secondary prevention, indications.

Rezumat: Recuperarea cardiovasculară este parte a prevenţiei cardiovasculare şi are ca obiective ameliorarea capacităţii funcţionale, controlul factorilor de risc cardiovascular, adoptarea unui stil de viaţă sănătos, educaţie şi aderenţă la terapia recomandată, cu scopul reducerii riscului de evenimente adverse, a disabilităţii, a mortalităţii cardiovasculare şi creşterea calităţii vieţii. În România, recuperarea cardiovasculară este efectuată exclusiv în spital, la pacienţi în faza 2 de recuperare, în cinci centre specializate, care au dotarea şi echipa multidisciplinară necesare, dar un număr insuficient de paturi raportat la numărul mare de pacienţi cu indicaţie de recuperare. Probleme legate de adresabilitate, aderenţă, lacune legislative în ce priveşte recuperarea ambulatorie, precum şi nerecunoaşterea recuperării cardiovasculare ca parte a cardiologiei sau medi-cinei interne rămân încă nerezvolvate.
Cuvinte cheie: recuperare cardiacă, prevenţie secundară, indicaţii.

HISTORICAL CONTEXT
The traditional treatment of myocardial infarction was represented, until the 1930s, by six weeks of absolute bed rest, and this time was considered to be necessary for the healing of infarcted area1. In the late 1940s, the so-called “armchair therapy” (periods of resting in an armchair instead of bed rest) began to be accepted, and then, in 1950s, short daily walking of 3-5 minutes for four weeks were recommended after the acute event. It was also in the 1950s when Levine and Lown produced great controversies and opposition from the medical world as they advocated early mobilization of patients after myocardial infarction2. In 1968, Saltin and coworkers demonstrated the negative effects of a long bed bed rest and proved the importance of physical exercise in the outcome of the patients3.
The first program of progressive physical activity after an uncomplicated myocardial infarction was de-veloped in 1952 by Newman and coworkers. In the 1960s, a series of studies published by Braunwald, Sar-noff, Sonnenblick, Hellerstein, Naughton, and Ekblom described the physiological background of the cardi-ovascular benefits of physical exercise and developed cardiac rehabilitation programs. At the beginning of the 1970s, Varnauskas and coworkers revealed the cellular and mitochondrial alterations induced by phy-sical training; these studies continued till nowadays and new scientiphic proves in favor of physical rehabilitation after myocardial infarction were published4.
In 1967, the scientiphic bases of CR were settled at Noordwijk aan Zee (Holland) and the practical approach modalities were described. New CR centers appeared, in Europe, United States and other regions of the world5. After 1970s, CR widens its core com-ponents with diet approach, psychotherapy, group re-habilitation, health education and becomes multidisci-plinary, comprehensive6,7.
The indications of CR were gradually extended, beyond the classical one represented by uncomplica-ted myocardial infarction. The studies demonstrated positive effects in heart failure, stable angina, arterial hypertension, peripheral vascular diseases. Cardiovas-cular surgery and invasive procedures developed spec-tacularly and such patients were referred to CR too. Old patients with cardiovascular diseases are more frequently included in rehabilitation and need the indi-vidualization of the training programs8.
In Romania, rehabilitation of cardiovascular disea-ses has a tradition of more than 50 years. Before the 1960s, in Cluj-Napoca, a medical gym dedicated to cardiac patients was established. Ten years later, at Ascar Clinic Bucuresti, and then at the Cardiology Department of Fundeni Hospital (Bucuresti), the first unit of preventive cardiology and rehabilitation was established, under the coordination of prof. I. Orha, who was the first one that elaborated, in Romania, a program and a methodology of rehabilitation for car-diac patients6.
In the 1970s, the concept of medical rehabilitation is expanding, and the objective was the fast social, fami-lial and professional reinsertion of the patients; during these years the rehabilitation hospitals were built in the university centers of Iaşi, Cluj-Napoca, Timişoara, Târgu-Mureş, and the Cardiovascular Rehabilitati-on Hospital in Covasna. It cannot be overlooked the enthusiasm associated with high professionalism and dedication of the pioneers of CR from these centers, and specialist trainers too: prof. I. Branea (Timişoa-ra), prof. D. Zdrenghea (Cluj-Napoca), prof. P. Kikely (Târgu-Mureş), prof. G.I. Pandele (Iaşi), dr. G. Bene-dek (Covasna), prof. E. Apetrei (Bucureşti)6.
In 1991, after the reorganization of the Romanian Society of Cardiology, the Working Group of Cardi-ac Rehabilitation is born, under the coordination of prof. I. Branea. As the Romanian Society of Cardiology affiliated to the European Society of Cardiology, the Working Group of Cardiac Rehabilitation became part of the European Association of Cardiovascular Preven-tion and Rehabilitation and redefi ned itself, according to the progress of the concept, as Working Group of Cardiovascular Prevention and Rehabilitation. Scientiphic exchanges with European experts in this field became more intensive and resulted in a progressive increase of knowledge and competence of the cardiac rehabi-litation centers from the country. The constant and enthusiastic support of prof. H. Saner (Switzerland), I. Graham (Ireland), J. Perk (Sweden) has to be mentio-ned in particular.
Concerning the scientiphic, research, and experti-se level, the activity of the Working Group became more and more obvious. In 1999, the Guideline of re-habilitation for cardiovascular patients was included in the first Medical Practice Guidelines elaborated by the Cardiology Commission9. There have been edited and permanently updated manuals, monographies, books, chapters dedicated to cardiovascular prevention and rehabilitation, in Romania and in collaboration with European specialists. The Romanian participation at European meetings in this fi eld is constant, due to yo-ung specialists coordinated by dedicated mentors, like prof. D. Gaiţă (Timişoara), prof. Dana Pop (Cluj-Na-poca), prof. F. Mitu (Iaşi), dr. Mihaela Suceveanu (Co-vasna), dr. D. Gherasim (Bucureşti, who left us prema-turely), prof. M. Popescu (Oradea), all of them former or current presidents (or secretaries) of the Working Group of Cardiovascular Prevention and Rehabilitation10-13.

CR: definition, objectives, indications, phases, components
World Health Organization defines CR as “the sum of activities and interventions necessary in order to en-sure the best physical, mental, and social conditions such that patients with chronic or post-acute cardio-vascular disease may keep, by their own efforts, their place in the society and may have an active life”. CR aims to prevent the disabilities determined by the pre-sence of the cardiac disease, other cardiovascular ad-verse events, hospitalizations and deaths14.
The objectives of CR are: improvement of the func-tional capacity of the patients, psychological adaptation at the chronic disease, and adoption of measures for lifestyle changes, development of a long-term behavior that favorably influences the prognostic, maintaining of the independence in the daily activities15.
Certain indications, class IA recommendation, pre-sented in actual international guidelines for CR are: chronic ischemic heart disease (myocardial infarcti-on, stable angina), surgical or invasive cardiac inter-ventions (surgical or percutaneous revascularization, surgical or percutaneous valvular interventions, and corrected cardiac defects), vascular interventions (aortic or peripheral arteries), heart failure (stable he-modynamic patients), heart transplantation. The guidelines add new recommendations, like patients with cardiac devices (pacemakers, implanted defibrillators, resynchronization therapy), or ventricular assisted devices. Cardiovascular recommendation guidelines include also patients with diabetes mellitus and meta-bolic syndrome16,17.

CR is divided into three phases18:
1st phase includes patients hospitalized for acute coronary syndrome or after surgical cardiac or vas-cular interventions. The objective is the prevention of prolonged bed rest complications and early mobiliza-tion of the patients; during this period they receive the first recommendations regarding diet and lifestyle advice.
2nd phase includes patients after the acute episode that completed 1st phase and patients newly diagno-sed with chronic heart disease, chronic heart failure. At the beginning of this stage, they undergo a clinical and functional assessment, are stratifi ed according to cardiovascular risk, then the short and long-term ob-jectives are settled, and the first rehabilitation mea-sures are initiated. The duration of 2nd phase is 8 (12) weeks till one year. This phase can be delivered in specialized CR centers (patients with high or mode-rate risk), in an ambulatory department (patients with moderate or low risk) or at home (patients with low risk).
3rd phase, or long-term rehabilitation, aims to maintain the benefits achieved in 2nd phase. It can be delivered in specialized services (ambulatory or in-ho-spital) or at home.
The core components of a CR program are: super-vised physical training, drug therapy, smoking cessa-tion, dietary advice, education in favor of a healthy lifestyle, psychological and behavioral therapy. Reha-bilitation can be achieved only in a multidisciplinary approach.

CR in Romania: the current state Now-a-days, inpatient CR in Romania is delivered in the following centers: Cluj-Napoca – 89 beds (10 of them dedicated to intensive care), Iaşi – 45 beds, Ti-mişoara – 35 beds, Târgu-Mureş – 25 beds, Covas-na – 677 beds. Cardiovascular Rehabilitation Hospital from Covasna has a unique profile, as it is located in a balneoclimateric resort in the mountains area, in a place called “Valley of the Fairies”, and is addressed to patients in 2nd or 3rd phase of rehabilitation from all the country.
CR programs are delivered according to the gui-delines. Patients are evaluated, included in a risk class and individualized training programs, therapy group, relaxation techniques are then recommended. The departments of cardiovascular rehabilitation from the university centers and the Cardiovascular Rehabilitati-on Hospital from Covasna have the equipment needed for the assessment of the patients, concerning cardi-ac performance, exercise capacity, associated clinical conditions that could influence the rehabilitation pro-grams.
The assessment of the patients includes clinical history, symptoms, physical examination, electrocar-diogram, cardiac imaging (echocardiography), blood testing, and Holter monitoring or ambulatory blood pressure measurement if needed. Exercise testing is usually indicated before the prescription of the phy-sical training. All departments have exercise testing equipment, and some of them (departments from Iaşi, Cluj-Napoca, Timişoara) also have cardiopulmo-nary exercise testing equipment, which represent the gold standard in the assessment of functional capacity (Figure 1). Physiotherapy rooms have specific equip-ment, including cicloergemeter systems with monito-ring of cardiac rate, blood pressure and electrocardi-ogram and kinetotherapists are trained in developing CR programs19 (Figure 2).
The rehabilitation team is multidisciplinary and in-cludes trained cardiologists or internal medicine spe-cialists, kinetotherapists, dieticians, psychologists, nur-ses. Rehabilitation programs are individualized, accor-ding to the indication, the risk class of the patient, the exercise tolerance, and associated conditions.

Benefits of CR
The 2016 Cochrane meta-analysis, which included 14486 patients with myocardial infarction, angina, or myocardial revascularization, highlighted a decrease in cardiovascular mortality with 26%, in hospital admis-sions with 18% and an improvement of the quality of life in favor of those who attended CR programs20. The effi cacy of CR is similar to secondary prevention medication such as aspirin, beta blockers, angiotensin converting enzyme inhibitors, statins21 (Table 1).
More recent trials and meta-analyses showed that multifactorial rehabilitation programs that included secondary prevention measures like smoking cessa-tion, dietary interventions, risk factors management, psychosocial management, patient and family educati-on, cardio protective medication, together with exer-cise training are more effective in influencing cardio-vascular mortality and morbidity22.

CR in Romania: challenges
Cardiovascular rehabilitation in Romania is underused, and the explanations are linked to CR referral, patients and health system.
Barriers linked to the CR referral relates to the for-mulation of CR indication by the physicians, essential for a patient’s admission in a rehabilitation program. Unfortunately, few physicians recommend their pati-ents to follow a CR program, despite the well-known benefits. In EUROASPIRE III study, only 44.9% of eli-gible patients received the indication, and the percen-tages are highly different between countries (from 80 – 90% in Lithuania, Ireland to 1% or less in Greece, Spain). In Romania, less than 10% of eligible patients receive the recommendation for CR program23,24. Patients more likely for CR referral are those with myocardial revascularization or cardiac valve interven-tions, male gender, younger ages (under 60-70 years old), higher education and social status; at the opposi-te side are patients with heart failure, cardiac devices, old ages, women, the presence of comorbidities or lower social status.
Barriers liked to the patient relate to the adherence to the rehabilitation programs. The same EUROASPI-RE III study revealed that only 33.9% of eligible pati-ents who received the recommendation were effec-tively included in the programs, and in Romania the percentage is under 10%. There are more explanati-ons: lack of information concerning the benefits of CR, distance from the rehabilitation center, lack of means of transportation and precarious infrastructure, low numbers of rehabilitation centers and longtime till the admission, low compliance to the medical recommendations concerning the drug treatment and change of the lifestyle. The adherence is lower in elderly, wo-men, socially deprived individuals in and county areas.
Barriers linked to the health system relate to the number of the units of cardiovascular rehabilitation and the legislation. In the public health system, the CR departments are those already mentioned above, in regional centers from Iaşi, Cluj-Napoca, Târgu-Mureş, Timişoara, Covasna, with a total of 871 beds, receiving patients in 2nd and 3rd phases of rehabilitation.
The Eurostat 2016 data show that Romania re-ported 112.9 percutaneous coronary interventi-ons/100000 inhabitants, 22.8 coronary artery bypass grafting/100000 inhabitants and 8.6 femuro-popliteous bypass grafting/100000 inhabitants. At a population of 19.76 million inhabitants, these mean 22309 percuta-neous coronary interventions, 4505 coronary artery bypass grafting, and 1699 femuro-popliteous bypass grafting in 201625.

Figure 1. Cardiopulmonary exercise testing before rehabilitation (Depart-ment of Cardiovascular Rehabilitation, Rehabilitation Hospital Iasi).

Figure 2. Individualized training programs and monitoring in the physiotherapy room (Department of Cardiovascular Rehabilitation, Rehabilitation Hospital Iasi).

In 2016, 46 patients with percutaneous coronary interventions and 78 patients with coronary artery bypass grafting were referred to the Cardiovascular Rehabilitation Department from Iaşi. Data from the other centers for 2016 could not be obtained due to the problems related to different informatic systems. Cardiovascular Rehabilitation Hospital Covasna repor-ted, in 2018, 545 patients admitted with the diagnosis of coronary artery bypass grafting. In an attempt to extrapolate these statistical data, it appears that less than 10% of patients with coronary interventions un-derwent a CR program. Information concerning patients with myocardial infarction, heart failure, vascular interventions is missing.
In contrast, there are 165 cardiac rehabilitation centers in Germany, with 12000 beds, that cover the costs for almost 42000 patients (data reported in 2004)26.
Issues related to the legislation and the lack of re-cognition of this subspecialty are added to the lacunar statistical data. At the moment, CR services are recog-nized and reimbursed only for hospitalized patients in 2nd phase. There is no legislation referring to ambula-tory or home CR services, although these are cost-effective for cardiac patients at moderate or low risk who wont to return to an active life. There is also no legislation concerning 3rd phase of rehabilitation. Most of the European states have legislation for at least one type of cardiac rehabilitation, particularly ambulatory rehabilitation for low risk individuals.
In these conditions, the future of CR in Romania remains uncertain, with a negative impact upon the prognosis of cardiovascular patients, and this means a higher burden for the health system. CR and secon-dary prevention are mandatory for the improvement of health status, and are the only interventions that can reduce consistently, for a long term, the costs of care for these patients.
Cardiovascular diseases represent the leading cause of death and disability in our country; thus, the development of cardiac prevention and rehabilitation cen-ters, inside the rehabilitation hospitals already existing, and/or independent centers, could be a correct and cost-effective solution for the health care system.

Conflict of interest: none declared.

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