2. Perform case conferences among multidisciplinary team members routinely.

3. The program consists of exercise prescription, exercise therapy, patient education, and counseling.

2. Establish a closely collaborated system to other institutions specialized in cardiac rehabilitation intervention.

2. Check whether the rehabilitation program is patient’s specific intervention or not.

3. Review the program on a regular basis in terms of continuity and effects of interventions.

2. Encourage all medical professionals to attend training courses and academic congress on a regular basis to improve the quality of the cardiac rehabilitation intervention.

2. Improve the environment for outpatient cardiac rehabilitation program (facilities such as a dressing room, scheduling of the program).

1. Obtain information on medical history from patients.

a) Identify present illness and history of diagnosis and treatment of cardiovascular diseases and results of heart function tests.

b) Identify complications (peripheral arterial disease, cerebrovascular disease, lung disease, renal disease, diabetes, orthopedic diseases, psychiatric/nervous system disease).

c) Identify cardiac symptoms: precordial symptoms, palpitation, shortness of breath, dyspea, NYHA classification.

d) Identify the drugs being used (including type, dosage, frequency, and medication status compliance). In particular, check the medication status of antiplatelet agents such as aspirin and clopidogrel, anticoagulant agents such as warfarin, β blockers, antihyperlipidemic agents, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).

e) Identify coronary risk factors: hypertension, dyslipidemia, diabetes, smoking, obesity, physical inactivity, family history.

2. Examination of physical findings.
a) Examine circulation/respiratory status: pulse, blood pressure, heart sound/cardiac murmur, respiratory sound, respiratory status, palpation of lower limbs and pretibial edema, extremity/carotid pulse extremity.

b) Killip classification

3. Analyze laboratory test findings.

a) Resting 12-lead electrocardiograms: presence of Q wave and arrhythmia

b) Chest X-ray images: CTR, pulmonary congestion

c) Blood biochemistry: peak CK (CK-MB), BNP or NT-ProBNP, liver/renal function tests, coronary risk factors (diabetes, dyslipidemia)

d) Echocardiography: left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left ventricular wall motion.

e) Exercise tolerance test: Perform a 200-300 m walking test before starting machine exercise in the cardiac rehabilitation room and a submaximal or symptom limited exercise tolerance test after the patient is accustomed to the exercise.

f) Coronary angiography or coronary CT angiography: check for residual stenosis/occlusion

4. Review the treatment policy.

a) Schedule of future revascularization for treatment of residual stenosis/occlusion

b) Schedule of future device treatment such as ICD and CRT

1. Radioisotope examination: exercise tolerance or pharmacologic stress testing with myocardial perfusion imaging

2. Cardiopulmonary exercise

3. Intracardiac pressure measurement/ hemodynamics: pulmonary artery wedge pressure, cardiac output, pulmonary arterial pressure, right atrial pressure

2. Evaluate appropriate activity level.

3. Obtain information on prescribed medications.

2. Evaluate the 6-minute walk test in patients who cannot perform a symptom-limited exercise test due to low physical or cardiac function.

3. Evaluate the lower extremity muscle strength in patients with very low functional reserve.

2. Evaluate exercise related factors including respiratory function, depression and anxiety.

2. Evaluate exercise capacity and clinical status at the same time.

3. Include exercise capacity data in explanation of clinical condition to patients.

2. Check who cooks meals at home.

3. Obtain information on history of alcohol intake and current alcohol consumption.

4. Check for obesity, hypertension, diabetes, and dyslipidemia.

2. Evaluation of food intake at home for 3 to 5 days after discharge.

2. Explain the importance of nutrient balance and the adverse influence of excessive food intake and alcohol consumption.

2. Provide advice on use of a food-composition table.

3. Evaluate food intake on a regular basis after discharge to promote improvement of eating behavior.

2. Evaluate sodium intake before hospitalization in an interview, using a list of sodium contents of food.

3. Assessment of sodium intake using a simple sodium intake measurement device or other approaches.

2. Promote self-control to reduce sodium intake using a list of sodium contents of food.

3. Set goals of gradual sodium reduction at 1-2g per 3 months to achieve 8g/day sodium intake.

2. Explain the importance of sodium reduction and caution regarding cooking with less sodium to patients and family members (mainly spouses and persons in charge of cooking), and construct a social support for sodium reduction.

2. Establish conditions that maintain the prescribed diet behavior and sodium intake.

1. Explanation to patient that obesity is a risk factor for recurrence of coronary artery disease.

2. Establishment of a habit to measure body weight during hospitalization through giving an example, such as a measurement time after urination in the morning.

3. Prescribe lifestyle behavior to manage weight loss including dietary habit or exercise (physical activity), and set an appropriate goal by identification of modifiable factors.

4. Target BMI < 25 kg/m2 and waist circumference < 85 cm in male and < 90 cm in female.

5. Set a desired value as a first target level especially in patients with anxiety or depression and perform a step-by-step approach. DO NOT set strict goals at first.

2. Explain the importance of calorie balance of protein, lipid and carbohydrate to elderly patients, in order to avoid loss of muscle mass due to excessive weight loss.

2. Decrease body weight, waist circumference and BMI, and maintain after discharge.

2. Measure blood pressure in both arms at the initial measurement.

3. Measure blood pressure lying, sitting, and standing immediately after stopping bed rest, in order to exclude orthostatic hypotension.

1. For patients with systolic blood pressure (SBP) 120-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg, give instructions on improvement of lifestyle, including daily physical activities, exercise, and weight control; sodium intake and intake of fresh fruit, vegetables, and low-fat food; appropriate alcohol consumption; and smoking cessation.

2. For patients with chronic kidney disease, cardiac failure, and/or diabetes with SBP ≥ 130 mmHg and DBP > 80 mmHg, start drug therapy and give instructions on improvement of lifestyle.

3. For patients with SBP ≥ 140 mmHg or DBP ≥ 90 mmHg, start drug therapy and improvement of lifestyle.

2. For elderly patients (diuretic, ACEi, ARB, Ca antagonist) or those who develop cardiac failure (diuretic, β blocker, ACEi, ARB), metabolic syndrome (ACEi, ARB), diabetes (ACEi, ARB), atrial fibrillation (ACEi, ARB, β blocker), or renal failure (ACEi, ARB, loop diuretic) regardless of age, select each drug based on guidelines such as the Guidelines for Management of Hypertension.

2. Maintain the target blood pressure for as long as possible.

3. Perform an interview on drug compliance.

4. Reevaluate the lipid profile within 8 weeks after starting lipid-lowering treatment.

5. Determine creatine kinase (CK) and hepatic function on a regular basis to evaluate adverse reactions to lipid-lowering drug therapy.

1. Advice on appropriate total amount of energy (standard body weight  25-30 kcal) and a balanced diet (carbohydrate:protein:lipid = 60:15-20:20-25%).

2. For patients with high LDL cholesterol, advice on maintenance of a strict fat-restricted diet (fat energy ratio: ≤ 20%) and a cholesterol-restricted diet.

3. For patients with a high triglyceride level, advice on restriction of alcohol consumption, intake of energy from carbohydrates, body weight control, and exercise counseling.

4. For patients with low HDL cholesterol, advice on exercise counseling and smoking cessation.

5. Start drug therapy if sufficient improvement is not obtained by lifestyle guidance.

2. Describe the history of complications of cardiovascular disease and systemic complications in the medical record.

3. Check the history of and compliance with diet therapy for hyperglycemia and hypoglycemic episodes at the initial counseling.

4. Check recent fasting blood glucose levels and HbA1c before starting exercise.

2. For patients with diabetes who are receiving treatment with insulin injection or insulin secretagogues

a) Always pay attention to onset of hypoglycemia.

b) Encourage the patient to take a sufficient amount of water to avoid an increase in blood glucose.

c) Monitor closely if plasma glucose levels continuously decrease within 24-48 hours after exercise.

2. Instruct patients to take responsibility for self-care during exercise without supervision.

3. Patients should receive nutritional advice as therapy from a diabetes dietician.

4. Discuss acquisition of knowledge and measures against diabetes, patient compliance, and referral to a diabetologist.

2. Establish that the patient can undertake self-care, including self-measurement of blood glucose levels and self-judgment of activity levels.

2. Decrease the incidence of systemic complications and maintain prevention of hyperglycemia or hypoglycemia at rest and during exercise.

2. Evaluate the past smoking status of former smokers and current smokers, and dependency if there is a history of smoking cessation. Check the risk of passive smoking at home or in the workplace.

3. Ask smokers about their intention to start smoking cessation.

4. Obtain information on the smoking cessation status of former smokers and smokers before and after introduction of cardiac rehabilitation to check physical and psychosocial changes associated with smoking cessation.

2. Continue to evaluate behavior modification phases of smoking cessation in smokers and former smokers (precontemplation, contemplation, preparation, action, maintenance).

3. Determine cigarette dependence and nicotine addiction of smokers. If smokers are still smoking, reevaluate this information.

1. Ask smokers about their current intention to stop smoking (at introduction of cardiac rehabilitation).

2. Communicate with smokers clearly and individually about the significance of smoking cessation.

3. Hold an education session to promote understanding of the significance of smoking cessation (including passive smoking). Teach smokers using the 5R’s (Relevance, Risks, Rewards, Roadblocks, Repetition). Explain the relevance and risks of health problems and the effects of smoking cessation; ask about individual factors that interfere with smoking cessation; and hold sessions to repeat the conversation, in order to motivate smoking cessation.

4. Instruct nonsmokers and former smokers about the effects of smoking and how to avoid passive smoking.

5. Conduct an interview for quitters about their physical and psychosocial status (body weight gain, stress, sleep deficit, etc.) to predict increased risks for smoking and the environment and behaviors that promote smoking, and give advice on how to handle or solve these problems.

6. Support family members of patients to obtain assistance with smoking cessation. Inform family members who are smokers about the significance of smoking cessation.

1. Encourage patients to make a plan for smoking cessation: for example, establishing a starting day for smoking cessation.

2. Provide educational materials for smoking cessation and establish continuing opportunities to promote understanding of smoking cessation (including avoidance of passive smoking). Provide continuing personal counseling or group guidance using the 5R’s (Relevance, Risks, Rewards, Roadblocks, Repetition) to smokers and former smokers who started smoking cessation within the previous 6 months.

3. Explain drug therapy to smokers and consider using this therapy when necessary.

4. Introduce a smoking cessation clinic that patients may attend if they wish.

5. Conduct an interview for former smokers and quitters about their physical and psychosocial status (body weight gain, stress, sleep deficit, etc.) to predict increased risks for smoking and the environment and behaviors that promote smoking, give advice on how to handle or solve these problems, and continue to provide advice after the interview.

6. Support patients in obtaining social support for smoking cessation and avoidance of passive smoking, such as cooperation in the workplace.

2. Encourage smokers to be motivated to start smoking cessation. Instruct former smokers on continuation of smoking cessation.

3. Avoid physical and psychological damage to smokers that may be associated with smoking cessation.

2. Improve the physical and mental status of smokers due to smoking cessation.

3. Obtain social support at home and in the workplace to avoid the ill effects of passive smoking.

a) Anxiety and concerns

b) Motivation and adherence for cardiac rehabilitation

c) Presence and degree of drug/alcohol use

d) History of psychiatric disorder

e) Use of drugs that may have psychological effects (e.g., β blocker, antidepressant, hypnotic, psychotropic drugs)

2. Identify an interview to obtain social information.

a) Social support (marital status, family, partner, key person)

b) Use of social resources (certification of required care insurance/long-term care service, care manager)

c) Economic situation (e.g., insurance, pension, public assistance)

d) Availability of a primary care doctor after discharge (for follow-up)

e) Concrete method for continuation of cardiac rehabilitation (e.g., distance, time, commuting)

2. Identify an interview on lifestyle (e.g., exercise, diet, sleep, work, how to spend their spare time).

3. Build rapport between patients and medical staff and consider patients concerns when identifying an interview on psychological and social information, life style.

2. Evaluate QOL (quality of life) using a reliable and validated method *2.

3. Evaluate cognitive functions using a reliable and validated method *3.

4. Identify an interview on stress in spouse and family members.

5. Obtain information on sexual dysfunction/ adjustment.

2. Provide information on cardiac diseases and psychiatric symptoms.

3. Hold patient education sessions and conferences hosted by a multidisciplinary team.

4. Enhance social support.

5. Use the social support system inside or outside the hospital. (e.g., maximum copayment for high medical care costs, assistance by public medical expenses for disease/treatment, sickness and injury allowance/disability pension, long-term care insurance system).

2. Provide stress management and relaxation methods.

3. Provide professional counseling and treatment.

4. Use clinical pathways for acute-phase diseases

5. Use region clinical pathways.

a) Attempt to correct lifestyle for health maintenance.

b) Obtain suitable social support and resources.

c) Obtain further treatment/control if there are serious psychological problems

2. Patients continue to participate in the cardiac rehabilitation program.

3. Depression and anxiety symptoms of patients are reduced.

4. Allow patients and family members to acquire relaxation and stress management skills.

5. Patients can avoid excessive alcohol consumption.

6. Patients can achieve smoking cessation.

*1 e.g., Hospital Anxiety and Depression Scale

*2 e.g., SF-36

*3 e.g., Mini mental state examination (MMSE)

2. Evaluate current physical activity levels using a questionnaire.

3. Quantitatively evaluate physical activities in daily living based on the results of various tests, such as an exercise tolerance test.

2. Establish an exercise program necessary for individual daily living.

3. Plan routines to increase physical activities based on current routines.

4. Advise elderly patients on low intensity aerobic activity to minimize musculoskeletal injury.

5. Provide advice on slowly increasing physical activities if a patient wants to do this.

6. Suggest a method of enhancing physical activities in daily living (e.g., commuting, leisure activities)

7. Advise the patient to avoid performing unaccustomed vigorous physical activity.

2. Provide educational materials as part of advice, support, and counseling.

3. Reevaluate activities of patients who participate in the exercise training program.

2. Improved psychosocial health and reduced stress.

3. Support opportunities for functional independence to prevent disability.

4. Increase opportunities for independence to achieve recommended goals.

2. Introduce regular physical activities into lifestyle.

a) Orthopedic disease, peripheral arterial disease, cerebrovascular disease, lung disease, renal disease, psychiatric disorder, nervous system disease, etc.

2. Observe abnormal reactions during an exercise tolerance test or exercise training.

a) Perform a symptom-limited exercise tolerance test using a cycle ergometer or treadmill in the recovery phase to evaluate heart rate, blood pressure, 12-lead electrocardiograms, and the rating of perceived exertion (RPE) scale during the test.

b) Reevaluate the above items on a regular basis.

2. Observe abnormalities in heart rate and ventilation responses in cardiopulmonary exercise.

3. Determine muscle strength such as grip strength and knee extension muscle strength.

4. Check full body flexibility.

5. Check balance ability.

6. Monitor mental/psychological characteristics such as depression and anxiety.

7. Evaluate health related QOL.

2. Explain the objectives, individual goals, and contents of the exercise training program to patients and obtain their informed consent.

3. Make an individual program of aerobic exercise and resistance training and provide this to patients.

4. Perform warm-up before starting each exercise session, and cool-down and stretching movements after each session.

5. Perform continuous ECG monitoring during training sessions at least in early phase after starting the program (if the exercise training session is performed at the outpatient department, necessity of continuous ECG monitoring depends on the risk severity).

6. Measure blood pressure before and after exercise. Measure blood pressure during some training sessions immediately after starting.

7. Provide advice to patients on the risk of onset of serious symptoms and on safety management during the exercise training sessions.

8. Modify the exercise prescription according to the condition of each patient.

a) Frequency: 3-7 days/week, every day if possible

b) Intensity: 40-60% of maximal oxygen uptake, 55-69% of maximal heart rate, 40-60% of heart rate reserve (Karvonen: k = 0.4-0.6), heart rate of the anaerobic threshold or intensity 1 minute before the anaerobic threshold

c) Duration: 20-60 minutes

d) Mode: Walking, aerobics, cycling, jogging, light swimming, etc.

2. Define the frequency, intensity, duration, and mode of resistance training.

a) Frequency: 2-3 times/weak

b) Intensity: Upper limb exercise: 30-40% of 1RM, lower limb exercise: 50-60% of 1RM, 1 set consists of 10 to 15 times

Repeatable load, moderate fatigue, Borg Scale: 11-13, Upper limit is set at “a little hard”

c) Duration: 1 to 3 sets of 8-10 kinds of exercises involving upper and lower limbs

d) Mode: rubber band, weights on ankles and wrists, dumbbell, free weights, pulley, weight machine, etc.

3. Start the exercise program during hospitalization, and participate in the program at the outpatient department for approximately 3 months (2 to 5 months) after discharge.

4. Receive supervised exercise training for 30 to 90 days after onset according to the degree of risk, and subsequently receive non-supervised exercise therapy. Finally, patients will be able to manage the exercise program by themselves.

2. Maintain and improve exercise tolerance (maximal oxygen uptake, anaerobic threshold), flexibility, muscle endurance, and muscle strength.

3. Decrease ventilation, heart rate, cardiac work (rate-pressure product) at the same level of exertion, and increase the myocardial ischemia threshold and alleviate cardiac failure.

4. Remove anxiety about exercise and improve activity.

5. Decrease coronary risk factors.

6. Improve health-related QOL and obtain mental and psychological effects.

2. Decrease the incidence of coronary events.

3. Decrease hospitalization caused by exacerbation of cardiac failure.

4. Improve life expectancy (reduce risk of all-cause mortality, decrease cardiac death).

2. Train medical staff who are responsible for cardiac rehabilitation to perform basic life support (BLS) while waiting for doctors who can provide advanced cardiovascular life support (ACLS), in case of sudden changes in a patient’s condition.

2. Provide emergency internal/surgical therapy for onset of complications or recurrence, and have the potential to transfer patients to a partner hospital rapidly if they need emergency surgery.

3. Arrange for availability of cardiac rehabilitation specialists certified by the Japanese Association of Cardiac Rehabilitation.

2. Inspect drugs and equipment for use in emergencies (e.g., a cardioverter) in a crash cart every day.