Guidelines for CHD risk stratification were primarily developed to assess prognosis of CHD patients and used to ensure optimal medical management for those individuals. They were adopted by CR programmes as a tool to direct rehabilitation staff to patients who should be offered the exercise component of cardiac rehabilitation and to screen out those who required further interventions, medical or surgical.

Cardiac rehabilitation professionals worldwide have endeavoured to ensure the efficacy and safety of this post-cardiac event intervention including the exercise component. In the adoption of the risk stratification guidelines, as proposed by the foremost authorities, the classification of low to high risk groupings enabled exercise professionals to prescribe safe exercise and to provide adequate monitoring and supervision for each patient in their programmes.

The criteria used to determine the risk classification, first and foremost, examine the medical phenomena associated with subsequent events. Although these are important aspects of the patient assessment, we have demonstrated that the process of risk stratification for the CHD population for exercise cannot be applied in a purely medical manner; by ignoring other factors, i.e.

co-morbidity, smoking, depression, etc., the exercise leader would be underestimating the risk.

In the past exercise professionals have separated risk classification from risk marker management. Current practice in CR sees the experienced CR leader use a holistic approach to the pre-exercise screening process and, by collating information on a wide range of areas, is able to take account of the numerous factors involved in the complex process of assuring our clients are safely and effectively treated and complete their exercise component of CR.

We suggest that, given the diversity of the client group and the range of personal goals of individual clients, the marrying of risk stratification in the traditional medical sense with the art of the experienced practitioner ensures a safe and effective approach to exercise delivery for this ever-increasing patient group. It will be interesting to monitor whether the UK will adopt the Canadian approach described earlier, which aims to provide a quantifiable indication of overall risk for CHD individuals and mirrors the approach currently used by many experienced practitioners.

In the last 20 years the patient population coming through CR programmes in the UK has changed significantly and there is no doubt that this trend will continue. Although CHD mortality figures are declining, the management of the CHD patient remains a governmental priority. In the years to come, the demographics of the CR population will include many patients we currently consider to be high risk. The implications for future resources of the NHS are considerable. Taking into account the complexity of those most at risk for an exercise-related event, exercise professionals must apply caution in the pre-screening process, if they are to continue to provide safe and effective exercise programmes. CR professionals must not only depend on the traditional risk stratification tools, but must continue to use their clinical reasoning skills and comprehensive assessment to enhance the risk stratification process.

The low-risk patients of today are more often being offered rehabilitation in a community setting. This trend will see our current moderate-risk patients moving to community-based programmes leaving only the high-risk patients to be seen by the CR professional in the hospital setting. This emphasises the importance of training and competence in all the professions delivering this service.

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