Cardiac rehabilitation is a structured, medically supervised programme that combines exercise training with risk-factor control, education and psychosocial and vocational support. It is recommended after every acute coronary syndrome — myocardial infarction or unstable angina — and it is the part of treatment that converts a survived infarction into a return to ordinary activity.
Who it is for
Every patient after an acute coronary syndrome should take part in a comprehensive rehabilitation and prevention programme, and it should start as early as possible after the event; the 2023 European guideline gives that a class I, level A recommendation. The 2025 American guideline makes the same point in practical terms: referral during the hospital stay and before discharge, with home-based programmes as an option for patients who cannot or will not attend in person. Rehabilitation is the standard of care for secondary prevention, and participation is associated with lower cardiovascular and all-cause mortality and fewer readmissions.
What a programme contains
The core components are patient assessment, cardiovascular risk-factor control, physical-activity counselling, exercise prescription, dietary advice, tobacco counselling, education, psychosocial management and vocational support. Exercise is the component patients picture, but a programme that delivers exercise alone leaves most of the secondary-prevention work undone, which is why the multidisciplinary format is the recommendation rather than a preference.
Delivery follows the patient’s stage and circumstances. It begins during the admission, continues with supervised outpatient sessions, and then settles into a maintenance phase of independent exercise the patient keeps indefinitely. Supervised centre-based sessions are the default; telerehabilitation and remote delivery are accepted alternatives for lower-risk patients who live far from a programme or cannot attend.
Exercise prescription
Exercise is the part that needs a prescription, and the first thing to prescribe is intensity. It is set from a graded exercise test where one is available — a test in which the workload rises in steps — using peak oxygen consumption, the heart rate at which ischaemic changes appear, and the blood-pressure, rhythm and symptom response to exercise. When testing is not available, a talk test (the intensity at which the patient can still hold a conversation), a six-minute walk test or a Borg rating (the patient’s own score of perceived exertion) substitutes.
Two shortcuts should not be used to set intensity: resting heart rate plus 20 to 30 beats per minute, and a percentage of the age-predicted maximum heart rate. Both are common in practice and both estimate the wrong number for a patient after infarction.
Once intensity is set, the amount of exercise is built up rather than fixed. Programmes commonly run 3 supervised sessions a week, and participants who are stable and capable are encouraged to exercise at home on the other days, aiming for activity on 5 or more days a week. An aerobic session consists of 20 to 60 minutes of exercise at moderate-to-vigorous intensity in patients with the stamina for it. Resistance training complements rather than replaces aerobic work. Higher-intensity interval training has been delivered safely inside programmes and improves fitness more than continuous moderate training. Continuous ECG telemetry, remote monitoring of the heart rhythm during sessions, is reserved chiefly for high-risk or symptomatic patients, and that recommendation rests on weak evidence.
These programme details come from an American scientific statement, so the structure and the session format describe how rehabilitation is organised and funded in that system.
Mood, work and ordinary life
Exercise is only one component; a programme also has to address how the patient feels and lives. Depression affects roughly 20% to 25% of patients after myocardial infarction, is associated with higher mortality, and is treatable. It is part of the rehabilitation programme rather than an incidental complaint to be handled separately, and psychosocial management is one of the components a programme is expected to deliver.
Returning to ordinary life is the other half of that work. Discharge education should cover the resumption of physical activity, sexual activity, work and travel, and vocational support is explicitly one of the core components of a programme. The activity target the patient is managed to afterwards — at least 150 minutes of moderate-intensity aerobic exercise a week — is set out with the other prevention targets in Post-MI Long-Term Management.
What the evidence shows
The case for rehabilitation rests on exercise-based programmes. A Cochrane review of exercise-based cardiac rehabilitation after coronary heart disease found that all-cause mortality at 6 to 12 months was probably slightly lower (risk ratio 0.87, 95% confidence interval 0.73 to 1.04; moderate certainty). At longer follow-up, cardiovascular mortality was substantially lower (risk ratio 0.58, 95% confidence interval 0.43 to 0.78) and recurrent myocardial infarction was less frequent (risk ratio 0.67, 95% confidence interval 0.50 to 0.90), but all-cause mortality was no longer clearly different (risk ratio 0.91, 95% confidence interval 0.75 to 1.10).
The honest summary is that exercise-based rehabilitation lowers cardiovascular death and recurrent infarction, while its effect on all-cause mortality is not certain. That gap between a strong recommendation and moderate evidence is worth knowing, because it is the reason programmes are judged on participation and on the risk factors they control, not only on survival figures.