Risk Stratification Following Phase

The ultimate aim of CR is the long-term adoption of healthy behaviours by the patient in an attempt to decrease the risk of further events or mortality and to maintain the benefits gained during the rehabilitation programme (SIGN, 2002).The exercise professional must remember that risk stratification is not a static entity. Continuous reassessment and monitoring by the professional and development of self-monitoring skills by the patient are required throughout the course of rehabilitation.

Post-rehabilitation risk stratification should be formally undertaken to:

• ascertain whether the patient is suitable either for discharge to independent exercise or for referral to structured supervised exercise;

• recommend a specific level of supervision, dovetailing with the exercise leader's training and competencies.

As with Phase III cardiac rehabilitation patients, patients moving to phase IV should not be excluded from continuing exercise as far as possible, with decisions based on health screening, risk stratification and also patient preference.

However, as long-term community-based phase IV exercise opportunities are a relatively new development in CR there does not appear to be an extensive body of evidence for risk stratification specifically for post-phase III rehabilitation assessment. It is likely that local programmes have tended to set their own criteria for discharge or referral to phase IV, based on their local patient population, on the availability and type of phase IV opportunities and on the level of qualification of instructors.

The same principles of risk stratification apply as outlined in this chapter; each patient must be considered individually. The ACSM (2001) and the BACR (2002) have published guidelines for independent exercising and referral to phase IV, which is shown in Table 2.4.

Table 2.4. Guidelines for referral to phase IV

Independent exercise with minimal or no supervision (ACSM, 2001)

Transfer to phase IV (BACR, 2002)

Functional capacity >8 METs Cardiac symptoms stable or absent Appropriate BP response to exercise and recovery

Appropriate ECG response to exercise (i.e. stable/benign arrhythmia, <1 mm ST depression)

Stable heart rate and blood pressure Safe exercise participation Knowledge of disease process, own risk factor management and medication use Clinically stable

Able to sustain activities equivalent of 5 METs (i.e. 5 times resting metabolic rate) or at the discretion of phase III personnel Able to monitor and regulate the intensity of their activity

Able to recognise their optimum level of exercise intensity

Able to acknowledge the importance of and demonstrate a commitment to modifying risk-related behaviour

Many programmes will not have the capacity to continue rehabilitation to individual physical, psychosocial outcomes and individual goals as suggested in Table 2.4. It may be more practical to screen patients prior to discharge using a set of exclusion criteria such as the following, which are currently practiced in the author's programmes.

• SWT <level 7 with cardiac symptoms;

• unable to reach workload of 5 METs/level 7 of SWT with non-cardiac limitation;

• ETT <5METs with cardiac symptoms/2 mm ST depression/silent ischaemia;

• poor LV function (with associated limitation);

• diagnosis of heart failure;

• post-transplant;

• refractory angina;

• awaiting angiogram or PTCA;

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