Optimize patient outcomes, given the available resources.

Patients benefit, not only from direct interaction with their physicians, but also from formal cardiovascular risk-factor modification programs. The primary care provider may have initiated risk-factor modification, but additional programs, such as cardiac rehabilitation and health promotion/wellness centers, are frequently available and patient participation should be encouraged as an adjunct to primary care.

Secondary prevention of risk factors for cardiovascular disease is addressed in Module G. Also refer, as needed, to VHA /DoD guidelines for management of the following conditions:

•  Dyslipidemia
  
•  Hypertension
  
•  Smoking cessation
  
•  Depression
  
•  Diabetes mellitus
  
•  Weight management

Cardiac rehabilitation programs offer a comprehensive, multifactorial, and often, multidisciplinary approach to lifestyle management. This includes exercise training, smoking cessation, nutrition counseling, medication adherence, stress management, and behavioral intervention. Among the most substantial benefits are the following:

•  Improvement in exercise tolerance, cardiovascular symptoms, and blood lipid levels
  
•  Improvement in psychosocial well-being and reduction of stress
  
•  Reduction in mortality

On the basis of meta-analytical data from 21 randomized controlled trials (RCTs) on cardiac rehabilitation, total and cardiovascular mortality was reduced by 25%, in comparison with control patients (at 3-year follow-up), in patients who participated in cardiac rehabilitation exercise training after myocardial infarction (MI) (QE = I, R = B). This reduction in mortality was complementary to the pharmacological management of patients following MI (AHCPR Cardiac Rehabilitation, 1995). Cardiovascular mortality was reduced by 26% in multifactorial RCTs of cardiac rehabilitation (Oldridge et al., 1988).

Cardiac rehabilitation exercise training consistently improves objective measures of exercise tolerance, without significant cardiovascular complications or other adverse outcomes. Appropriately prescribed and conducted exercise training is recommended as an integral component of cardiac rehabilitation services, particularly for patients with decreased exercise tolerance. Continued exercise training is required to sustain improved exercise tolerance.