Original Article
Cardiac rehabilitation in Portugal: Results from the 2013-14 national survey
Reabilitação cardíaca em Portugal. Inquérito 2013-2014
Conceição Silveira, , Ana Abreu
Grupo de Estudo de Fisiopatologia do Esforço e Reabilitação Cardíaca, Sociedade Portuguesa de Cardiologia, Portugal
Received 08 February 2016, Accepted 01 June 2016
Related article:
Abstract
Introduction

In recent years, cardiac rehabilitation (CR) programs have evolved from being limited to exercise training to comprehensive secondary prevention programs. Given the solid scientific evidence supporting them, they are given a class I recommendation in the American and European guidelines for various cardiovascular diseases, but they continue to be underused in Portugal.

Objective

To analyze the situation of CR programs in Portugal in 2013-14 and to assess developments in recent years.

Methods

In November 2014, a questionnaire was sent to the centers offering CR programs that included the following items: name of the center; composition of the team; phases and components; number of participants and diagnoses; and funding bodies. The percentage of patients with myocardial infarction admitted to phase II CR programs in 2013 was calculated based on data from the Directorate-General of Health (DGS).

Results

Twenty-three centers offering CR programs were identified, 12 public and 11 private. The number of centers rose from 16 in 2007 to 23 in 2014. In 2013, 1927 patients participated in phase II programs, nearly three times the number rehabilitated in 2007 (638 patients). Myocardial infarction was the referral diagnosis in 999 patients, accounting for 51.8% of admissions. On the basis of DGS data, 8% of patients with myocardial infarction were admitted to phase II CRPs in 2013, as opposed to 3% in 2007.

Conclusion

The number of patients admitted to CR programs, as well as the number of centers, increased considerably between 2007 and 2014 in Portugal. Despite these favorable developments, further improvements are still needed.

Resumo
Introdução

Nos últimos anos os programas de reabilitação cardíaca (PRC) evoluíram, deixaram de se basear apenas no exercício físico e são atualmente programas abrangentes de prevenção secundária. Dada a evidência científica sólida que os suporta, mereceram recomendação classe I para várias patologias cardiovasculares, nas recomendações americanas e europeias. Continuam, no entanto, a ser subutilizados em Portugal.

Objetivos

Conhecer os PRC nacionais em 2013-14 e analisar a sua evolução.

Material e métodos

Em novembro de 2014 foi enviado aos centros um questionário com os seguintes itens: identificação do centro; constituição da equipa; fases e componentes; número de participantes, respetivas patologias e entidades pagadoras. Considerando os dados da Direção Geral de Saúde (DGS), calculou-se a percentagem de doentes com alta após enfarte admitidos em PRC, fase 2, em 2013.

Resultados

Identificaram-se 23 centros com PRC, 12 públicos e 11 privados. O número de centros evoluiu de 16 em 2007 para 23 em 2014. Em 2013 participaram em PRC, fase 2, 1927 doentes, o triplo dos 638 reabilitados em 2007. O enfarte foi o diagnóstico de admissão de 999 doentes, representando 51,8% das admissões. Considerando os dados da DGS, constata-se que 8% dos doentes com alta após enfarte frequentaram PRC, fase 2, em 2013. Em 2007 esse valor era de 3%.

Conclusão

O volume de doentes em PRC e o número de centros aumentou consideravelmente em Portugal entre 2007-2014. Apesar da evolução favorável é necessário continuar a desenvolver estratégias de divulgação e implementação de PRC no nosso país.

Keywords
Cardiac rehabilitation, Secondary prevention, National survey
Palavras-chave
Reabilitação cardíaca, Prevenção secundária, Inquérito nacional
Introduction

Mortality from coronary artery disease (CAD) has decreased in recent decades in developed countries, but morbidity associated with CAD has increased. Improvements in diagnostic techniques and treatment in the acute phase of myocardial infarction (MI) have improved survival in these patients,1,2 which makes it particularly important to develop strategies for secondary prevention.

At the same time, cardiac rehabilitation (CR) programs have evolved from being limited to exercise training to comprehensive secondary prevention programs. They now include certain essential components: patient assessment, therapeutic optimization, diet/nutritional counseling, risk factor management, psychosocial management and vocational advice, physical activity counseling and exercise training.3,4 Such comprehensive CR programs aim not only to improve functional capacity but also to foster healthy behaviors and compliance with therapy, with a view to delaying progression of atherosclerotic disease and preventing future cardiac events.

Various studies and meta-analyses have demonstrated the benefits of CR, particularly in CAD patients, in whom they have reduced overall mortality by 20%, cardiac mortality by 26%, and rehospitalization by 25%.5–7 Based on this evidence, CR is a class I recommendation for CAD in both the American Heart Association/American College of Cardiology Foundation and the European Society of Cardiology guidelines.8–12 In recent years, this recommendation has been extended to heart failure (HF) patients.13

Despite the well-documented benefits of CR, it continues to be underused and few programs have been implemented in Portugal. The Portuguese Society of Cardiology's Working Group on Exercise Physiology and Cardiac Rehabilitation has periodically performed national surveys assessing CR in Portugal, first in 1998, and again in 2004 and 2007.14–16 The survey reported here continues this work, assessing the situation regarding CR in Portugal in 2013-14 and analyzing how it has developed by comparing the results with previous surveys.

Methods

In November 2014, a questionnaire including the following items was sent to all centers offering CR programs:

  • -

    General information on the center (name, location, public or private, year of beginning CR programs)

  • -

    Composition of team and coordinators

  • -

    Description of CRP phases offered

  • -

    Program components

  • -

    Total number of participants and distribution by diagnosis in 2013

  • -

    Funding bodies.

The responses were analyzed and compared with the results of previous surveys. Based on Directorate-General of Health (DGS) data for hospital morbidity17 and the total number of patients with MI admitted for CR by each center, the percentage of patients admitted for a phase II CR program following discharge after MI in 2013 was calculated.

ResultsCardiac rehabilitation centers

Twenty-three centers offered CR programs in 2014, 12 public and 11 private (Table 1). There were nine new centers compared to 2007, six public (Hospital de São João, Hospital de Vila Franca de Xira, Hospital de Faro, Hospital Beatriz Ângelo, Hospital Pulido Valente and Hospital Garcia de Orta) and three private (Hospital da Luz, Instituto de Cardiologia Preventiva de Almada and Clínica da Cruz Vermelha, Sabrosa), while three centers (one public and two private) had discontinued CR programs. Following the merger of military hospitals, the CR program of the Belém Military Hospital was moved to the Estrela Military Hospital at the end of 2010 and continued operating there until 2013, and was then transferred to the Hospital das Forças Armadas, Lumiar, in 2014.

Table 1.

Cardiac rehabilitation centers in Portugal in 2014.

  Location  Year of beginning activity  Coordinator  Specialty 
Public centers
Hospital das Forças Armadas Polo de Lisboa (Belém/Estrela)  Lisbon  1988  Conceição Silveira  Cardiologist 
Centro Hospitalar Vila Nova de Gaia/Espinho  Vila Nova de Gaia  1993  Madalena Teixeira
Fátima Miranda 
Cardiologist
Physiatrist 
Centro Hospitalar do Porto, Hospital de Santo António  Porto  2000  Preza Fernandes
Sofia Viamonte 
Cardiologist
Physiatrist 
Centro Hospitalar Entre Douro e Vouga, Unidade S.M. Feira, Hospital São Sebastião  Santa Maria da Feira  2000  Tiago Sotto Mayor
Catarina Aguiar Branco 
Cardiologist
Physiatrist 
Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano  Matosinhos  2001  Paula Almeida  Physiatrist 
Centro Hospitalar Lisboa Central, Hospital de Santa Marta  Lisbon  2004  Ana Abreu  Cardiologist 
Centro Hospitalar de São João  Porto  2008  Afonso Rocha  Physiatrist 
Hospital de Vila Franca de Xira  Vila Franca de Xira  2009  Luís Nuno Batista
Nuno Tavares 
Cardiologist
Human kinetics specialist 
Centro Hospitalar do Algarve, Hospital de Faro  Faro  2012  Salomé Pereira  Cardiologist 
Hospital Beatriz Ângelo  Loures  2013  Duarte Espregueira Mendes
Miguel Almeida Ribeiro
Ana Borges 
Cardiologist

Cardiologist
Physiatrist 
Centro Hospitalar Lisboa Norte, Hospital Pulido Valente  Lisbon  2014  António Arsénio (2014)
Machado Rodrigues (2015) 
Cardiologist
Cardiologist 
Hospital Garcia de Orta  Almada  2014  Maria Luísa Bento  Cardiologist 
Private centers
Clínica Dr. Dídio de Aguiar  Lisbon  1982  Joaquim Pestana Aguiar

Luís do Rosário 
Sports medicine (exercise physiologist)
Cardiologist 
Instituto do Coração  Lisbon  1988  Miguel Mendes  Cardiologist 
Faculdade de Motricidade Humana (Corlis)  Lisbon  1991  Helena Santa Clara
Miguel Mendes 
Exercise physiologist
Cardiologist 
Fisimaia  Maia  1992  José Paulo Fontes
Eunice Vouga 
Cardiologist
Physiatrist 
Diprofísio  Porto  1993  Madalena Teixeira
Ana Ramalhão 
Cardiologist
Physiotherapist 
SAMS  Lisbon  2004  Rui Conduto
Cecília Vaz Pinto 
Cardiologist
Physiatrist 
Clínica Fisiatria MCCB Dr. Maria do Carmo Aguiar Branco  Gaia  2006  Marlene Fonseca
Catarina Aguiar Branco 
Cardiologist
Physiatrist 
Clínica das Conchas  Lisbon  2007  Jorge Arsénio Ruivo  Internist 
Hospital da Luz  Lisbon  2010  Daniel Ferreira  Cardiologist 
Instituto de Cardiologia Preventiva de Almada  Almada  2012  Manuel Carrageta  Cardiologist 
Clínica da Cruz Vermelha, Sabrosa  Sabrosa  2012  Fátima Marques
Helder Ribeiro 
Rehabilitation nurse
Cardiologist 

The number of public centers has therefore significantly increased, from only two in 1998 to seven in 2004 and 2007 and 12 in 2014 (Figure 1), but considerable asymmetry persists in the geographical distribution of CR centers, with nine located in the North region, 13 in Greater Lisbon and one in the South region. There are still no CR centers in inland areas (the Central region and the Alentejo) (Figure 2).

Figure 1.
(0.05MB).

Developments in the number of cardiac rehabilitation centers in Portugal.

Figure 2.
(0.06MB).

Cardiac rehabilitation centers in Portugal in 2014.

Team composition and coordinators

As found in previous surveys, all centers have multidisciplinary teams, and all include a cardiologist. There is also a physiatrist in 74% of centers, a physiotherapist in 87%, an exercise physiologist in 22%, a nutritionist/dietitian in 87%, a psychologist in 61%, a psychiatrist in 30%, a cardiopulmonary technician in 57% and a nurse in 48%. Eight centers have various other health professionals, including internists, pneumologists, vascular surgeons, endocrinologists and social workers (Table 2).

Table 2.

Composition of cardiac rehabilitation teams.

Cardiologist  100% 
Physiatrist  74% 
Psychiatrist  30% 
Psychologist  61% 
Nutritionist/dietitian  87% 
Physiotherapist  87% 
Cardiopulmonary technician  57% 
Nurse  48% 
Human kinetics specialist/exercise physiologist  22% 
Other  35% 

The program is coordinated by a cardiologist in eight centers (35%), a physiatrist in two (9%), jointly by a cardiologist and a physiatrist in seven (30%), a cardiologist and an exercise physiologist in three (13%), a cardiologist and a physiotherapist in one (4%), a cardiologist and a cardiac rehabilitation nurse in one (4%), and an internist in one (4%) (Table 1).

Program phases and componentsPhases

In 2013 eight centers offered phase I programs (hospital phase), 19 offered phase II (early outpatient phase) and 13 offered phase III (long-term maintenance phase), of varying duration. Only centers offering phase III exercise training were included in the analysis, but some other centers continue to provide clinical assessments, consultations, complementary exams and guidance on level of physical activity at six and 12 months. Two new centers began offering CR in 2014: Hospital Pulido Valente in Lisbon and Hospital Garcia de Orta in Almada. Both offer phase II programs and the latter also has a phase I program.

Components

Exercise training is offered in all centers but is of varying duration. In most centers, phase II programs include 24-36 sessions, two or three times a week over 8-12 weeks. Only two centers, with large numbers of participants, offer shorter programs of eight sessions only. Programs for HF patients are usually longer (Table 3).

Table 3.

Duration of phase II programs and total number of exercise training sessions.

  Location  Phase II: no. of exercise training sessions 
Public centers
Hospital das Forças Armadas Polo de Lisboa (Belém/Estrela)  Lisbon  3 times a week, 12 weeks; 36 sessions 
Centro Hospitalar Vila Nova de Gaia/Espinho  Vila Nova de Gaia  3 times a week
CAD: 24 sessions, 8 weeks
HF: 48 sessions, 16 weeks 
Centro Hospitalar do Porto, Hospital de Santo António  Porto  Twice a week; 8-24 sessions 
Centro Hospitalar Entre Douro e Vouga, Unidade S.M. Feira, Hospital São Sebastião  Santa Maria da Feira  2-3 times a week, 12-24 weeks; 24-72 sessions 
Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano  Matosinhos  Twice a week, 6-14 weeks (10); 12-28 sessions (20) 
Centro Hospitalar Lisboa Central, Hospital de Santa Marta  Lisbon  2-3 times a week, 12 weeks; 36 sessions 
Centro Hospitalar de São João  Porto  Twice a week; 16-24 sessions 
Hospital de Vila Franca de Xira  Vila Franca de Xira  3 times a week 
Centro Hospitalar do Algarve, Hospital de Faro  Faro  3 times a week, 8 weeks; 24 sessions 
Hospital Beatriz Ângelo  Loures  Twice a week
CAD: 8 sessions
HF: 24 sessions 
Centro Hospitalar Lisboa Norte, Hospital Pulido Valente  Lisbon  3 times a week, 12 weeks; 36 sessions 
Hospital Garcia de Orta  Almada  3 times a week, 12 weeks; 36 sessions 
Private centers
Clínica Dr. Dídio de Aguiar  Lisbon  Not specified 
Instituto do Coração  Lisbon  3 times a week, 8-12 weeks 
Faculdade de Motricidade Humana (Corlis)  Lisbon  Phase III only 
Fisimaia  Maia  Twice a week, 12 weeks; 24 sessions 
Diprofísio  Porto  3 times a week, 12 weeks; 36 sessions 
SAMS  Lisbon  3 times a week, 12 weeks; 36 sessions 
Clínica Fisiatria MCCB Dr. Maria do Carmo Aguiar Branco  Gaia  2-3 times a week; 24-72 sessions 
Clínica das Conchas  Lisbon  Phase III only 
Hospital da Luz  Lisbon  3 times a week; 36 sessions 
Instituto de Cardiologia Preventiva de Almada  Almada  3 times a week; 36 sessions 
Clínica da Cruz Vermelha, Sabrosa  Sabrosa  Twice a week; Minimum 22 sessions 

CAD: coronary artery disease; HF: heart failure.

Risk factor management is now offered in almost all centers, having increased from 75% in 2007 to 96%. The other components are available in a significant percentage of centers, as shown in Table 4.

Table 4.

Cardiac rehabilitation program components.

Components  No. of centers 
Exercise training  23  100% 
Risk factor management (hypertension and dyslipidemia)  22  96% 
Not specified   
Diet/nutritional counseling and weight control  22  96% 
Not specified   
Appointment with a nutritionist/dietician  20  87% 
Smoking cessation counseling  22  96% 
Not specified   
Appointment with a specialist  15  65% 
Psychological counseling  19  83% 
Not specified   
Appointment with a psychologist  14  61% 
Number of participants, distribution by diagnosis and total activity in 2013

In 2013, 1927 patients participated in phase II CR programs, 1659 in public and 268 in private centers. The number of rehabilitated patients thus tripled in Portugal between 2007 (638) and 2013 (1927). This increase was due mainly to the rise in the number of patients rehabilitated in public centers (from 455 in 2007 to 1659 in 2013). Two factors contributed to this increase: new centers that between them rehabilitated 427 patients; and a tripling of the number rehabilitated in existing centers, from 455 in 2007 to 1232 in 2013. The increase in patients rehabilitated in private centers was less marked (from 183 in 2007 to 268 in 2013) (Table 5).

Table 5.

Total numbers of participants in cardiac rehabilitation programs in Portugal in 2013.

Center  Phase I: no. of patients with MI  Phase II: total no. of patients (MI)  Phase III: total no. of patients 
Public centers
North region    1314 (612)   
Centro Hospitalar Vila Nova de Gaia/Espinho  308  129 (100)  NS 
Centro Hospitalar do Porto, Hospital de Santo António  360  301 (182)  NA 
Centro Hospitalar entre Douro e Vouga, U.S.M. Feira Hospital São Sebastião  112  636 (112)  693 
Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano  NA  100 (82)  NS 
Centro Hospitalar de São João  494a  148 (136)  NA 
Greater Lisbon and South regions    345 (285)   
Hospital das Forças Armadas, Polo de Lisboa (Belém/Estrela)  NA  6 (3)b  36 
Centro Hospitalar Lisboa Central, Hospital de Santa Marta  70  60 (40)  NA 
Hospital de Vila Franca de Xira  94  20 (20)  NA 
Hospital Beatriz Ângelo  230  228 (198)  NA 
Centro Hospitalar do Algarve, Hospital de Faro  536  31 (24)  NA 
Private centers
North region    149 (66)   
Fisimaia  NA  34(14)  32 
Diprofisio  NA  6 (4)  24 
Clínica de Fisiatria MCCB Dr. Maria do Carmo Aguiar Branco  NA  67 (26)  67 
Clínica da Cruz Vermelha, Sabrosa  NA  42 (22)  63 
Greater Lisbon    119 (36)   
Clínica Dr. Dídio Aguiar  NA  36 (16)  NS 
Instituto do Coração  NA  9 (6)  18 
Faculdade de Motricidade Humana (Corlis)  NA  NA  20 
SAMS  NA  4 (2)  NA 
Clínica das Conchas  NA  NA 
Hospital da Luz  NA  12 (4)  NA 
Instituto de Cardiologia Preventiva de Almada  NA  58 (8)  10 
Total    1927 (999)   

MI: myocardial infarction; NA: not applicable (this phase not offered); NS: not specified.

a

Education, risk factor management and nutritional counseling.

b

Due to the merger of military hospitals, the emergency department of Unidade Hospitalar da Estrela, which at that time provided CR, closed on March 31, 2013, which affected referral of new patients.

CAD was the most common referral diagnosis, accounting for over two-thirds of admissions: 51.8% following MI, 6.5% after coronary surgery, 2.9% after elective percutaneous coronary intervention, and 7.9% due to stable CAD. HF was the reason for referral in 12.7% of patients, followed by risk factor management in 8.2% and arterial disease or vascular surgery in 3.3% (Table 6).

Table 6.

Distribution by diagnosis of participants in phase II cardiac rehabilitation programs.

MI  51.8% 
Coronary surgery  6.5% 
Stable CAD  7.9% 
Elective PCI  2.9% 
Valve surgery  2.5% 
HF  12.7% 
Heart transplantation  0% 
Risk factor management  8.2% 
Arterial disease or vascular surgery  3.3% 
ICD/CRT  1.1% 
Other  0.6 
Not specified  2.4% 

CAD: coronary artery disease; CRT: cardiac resynchronization therapy; ICD: implantable cardioverter-defibrillator; MI: myocardial infarction; PCI: percutaneous coronary intervention.

Comparison with the 2007 survey showed that MI continued to be the predominant referral diagnosis, with similar percentages (50% in 2007 and 51.8% in 2013), while HF, a more recent indication for CR, increased from 5% to 12.7%.

Based on DGS data for hospital morbidity, 12 832 patients were discharged after MI in 2013.17 According to the results of the present survey, 999 patients with MI were admitted to phase II CR programs in that year, corresponding to 8%, up from 3% in 2007.

Funding bodies

Given that most patients attending phase II CR programs in 2013 did so in public centers, the national health system was the funding body in 90% of cases. The patients themselves bore the cost in 4.6%, ADSE in 1.7%, ADM in 1%, and other health subsystems such as ADMG, SADPSP, SAMS, health insurance or other in <1% each (Table 7).

Table 7.

Funding bodies for phase II cardiac rehabilitation programs.

NHS  90% 
ADSE  1.7% 
ADM  1% 
ADMG  <1% 
SADPSP  <1% 
Health insurance  <1% 
SAMS  <1% 
At patients’ own cost  4.6% 
Other  <1% 

NHS: national health system.

Only ten centers responded to this item on the questionnaire, five public and five private, but together these accounted for around 60% of patients attending phase II cardiac rehabilitation programs in 2013.

Discussion

The present survey identified 23 centers in Portugal offering CR programs in 2014, 12 public and 11 private. This represents a significant increase in the number of public centers over the years, from only two in 1998 (Belém Military Hospital, a pioneering public center that began activity in 1988, and Centro Hospitalar de Vila Nova de Gaia, which began offering CR in 1993) to seven in 2004 and 2007, and 12 in 2014.

There was also a significant rise in the number of patients attending phase II programs, the number tripling between 2007 and 2013, from 683 to 1927. Public centers were largely responsible for this increase, rehabilitating 86% of patients, while private centers rehabilitated only 14%. It was not possible to compare patient numbers for the other CR program phases since these were not quantified in earlier surveys.

MI was the most common diagnosis of participants in CR programs, as in previous surveys. Nevertheless, based on DGS data for hospital morbidity, only 8% of MI patients attended phase II programs in Portugal in 2013. This figure, while clearly better than the 3% identified in the 2007 survey, is still lower than the European average.18 In the European Cardiac Rehabilitation Inventory Survey by Bjarnason-Wehrens et al. in 2009, the mean percentage of eligible patients admitted to CR programs in Europe was 30%, while in the UK, Sweden, Luxemburg and Germany the figure was around 50%. Almost half of the countries included in this survey had legislation regarding phase II CR; for example, in Germany, CR following MI has been guaranteed by law since 1974, and has led to the development of a network of 170 CR centers.18 There are several reasons for the low percentage of patients undergoing CR in Portugal, including an insufficient number of CR centers and their asymmetrical geographical distribution, incompatibility between program timetables and working hours, economic restraints (such as patients’ share of treatment costs and travel expenses), and a lack of awareness of CR on the part of patients and physicians, leading to low rates of referral.

We hope that publishing the results of the latest survey will encourage the establishment of new CR programs, particularly in centers outside of Porto and Lisbon, thus helping to reduce the considerable asymmetry in geographical distribution that currently exists. It is essential to develop a national network of centers offering CR. All hospitals with cardiology departments should have phase I and II programs,19 and be actively involved in phase III, possibly in association with health centers in the community. Most hospitals already have the various health professionals needed to form a multidisciplinary CR team, but these are usually occupied in other duties and few have specific training in this area. As well as training, investment is also needed in facilities and equipment such as ergometers and telemetry monitors, and so the involvement and commitment of health authority decision-making bodies are also essential.

At the same time, it is important that existing CR programs should continue to grow and that more eligible patients with diagnoses other than MI, notably those who have undergone cardiac surgery or elective percutaneous coronary intervention, should be referred, while not neglecting those with HF and those with cardiac resynchronization therapy (CRT) devices or implantable cardioverter-defibrillators (ICDs).

Improved access to CR could in some cases be achieved by implementing home-based programs based on the model widely used in the UK. Such programs, designed for low-risk patients, are structured interventions with regular patient monitoring, including visits by CR team members to the patient's home and contact by telephone or the internet. A recent review demonstrated that home-based programs appear to be equally effective as those offered in hospitals or clinics. There were no significant differences in outcomes up to 12 months of follow-up or in healthcare costs.20 Each center should develop the model most suited to their particular situation.

Another way to improve access and adherence to CR would be to pass specific legislation promoting secondary prevention and CR programs aimed at, for example, reducing or abolishing patients’ share of treatment costs, subsidizing travel expenses and scheduling sessions to fit in with working hours.

Initiatives to raise awareness of and provide training in CR also have an important role, both for the general population and patients and for health professionals, particularly physicians. Including a CR component in the training program of cardiology interns would dispel the skepticism and unfounded concerns that still exist and help to make CR an integral part of the spectrum of cardiovascular disease treatment.

Although much remains to be done, the latest survey identified several positive developments that show that CR in Portugal is consistently evolving in line with international guidelines. The programs have become more comprehensive: besides exercise training, almost all now include risk factor management. Other components such as advice on diet/nutrition and weight control, psychosocial assessment and smoking cessation counseling are available in a large proportion of centers. Patients with conditions that are more recent indications for CR, including those with CRT devices or ICDs, are now being admitted to CR programs and the percentage of patients with HF as the referral diagnosis has risen from 5% to 12.7%. Most phase II programs last 8-12 weeks (two or three sessions a week, making a total of 24-36 sessions), as found in the rest of Europe18 and the US,21 where Medicare has provided coverage for up to three weekly sessions for 12 weeks after MI, coronary bypass surgery or stable coronary disease since 1982, and coverage was later expanded to other indications.21 Shorter programs offer less opportunity for sustained lifestyle changes.

Despite the positive developments in Portugal, challenges remain. Investment in cardiovascular disease prevention is essential and CR plays a crucial role in this. Decision-making bodies should be made more aware of the importance of CR programs, which have been shown to be cost-effective.22,23

Conclusions

The number of centers offering CR programs and the volume of patients rehabilitated increased considerably between 2007 and 2013-14. The percentage of MI patients referred for CR increased from 3% to 8%, and HF patients are increasingly admitted to such programs. The latest survey showed that CR has shown consistent growth and evolved in line with international guidelines. Nevertheless, Portugal remains below the European average in CR, and further improvements are still needed.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgments

The Working Group on Exercise Physiology and Cardiac Rehabilitation thanks the coordinators of CR programs for their cooperation in supplying the data for the survey, without which this study would not have been possible.

  • Centro Hospitalar Vila Nova de Gaia/Espinho – Dr. Madalena Teixeira

  • Centro Hospitalar do Porto, H. S. António – Dr. Sofia Viamonte and Dr. Preza Fernandes

  • Centro Hospitalar Entre Douro e Vouga, Unidade S.M. Feira, H. São Sebastião – Dr. Catarina Aguiar Branco

  • Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano – Dr. Paula Almeida

  • Centro Hospitalar São João – Dr. Afonso Rocha

  • Hospital de Vila Franca de Xira – Dr. Luís Nuno Batista

  • Centro Hospitalar Algarve, Hospital de Faro – Dr. Salomé Pereira

  • Hospital Beatriz Ângelo – Dr. Miguel Almeida Ribeiro

  • Centro Hospitalar Lisboa Norte, Hospital Pulido Valente – Dr. Machado Rodrigues

  • Hospital Garcia de Orta – Dr. Maria Luísa Bento

  • Centro Hospitalar Lisboa Central, Hospital de Santa Marta – Dr. Ana Abreu

  • Hospital das Forças Armadas Polo de Lisboa – Dr. Conceição Silveira

  • Clínica Dr. Dídio de Aguiar – Dr. Joaquim Pestana Aguiar

  • Instituto do Coração – Dr. Miguel Mendes

  • Faculdade de Motricidade Humana (Corlis) – Prof. Helena Santa-Clara

  • Fisimaia – Dr. Paulo Fontes

  • Diprofísio – Dr. Madalena Teixeira

  • SAMS – Dr. Ana Abreu, Dr. Cecília Vaz Pinto

  • Clínica Fisiatria MCCB Dr. Maria do Carmo Aguiar Branco – Dr. Catarina Aguiar Branco

  • Clínica das Conchas – Dr. Jorge Ruivo

  • Hospital da Luz – Dr. Daniel Ferreira

  • Instituto de Cardiologia Preventiva de Almada – Prof. Manuel Carrageta

  • Clínica da Cruz Vermelha, Sabrosa – Nurse Fátima Marques and Dr. Helder Ribeiro

References
1
W.J. Kostis,Y. Deng,J.S. Pantozopoulos
Trends in mortality of acute myocardial infarction after discharge from the hospital
Circ Cardiovasc Qual Outcomes, 3 (2010), pp. 581-589 http://dx.doi.org/10.1161/CIRCOUTCOMES.110.957803
2
V.L. Roger,S.A. Weston,Y. Gerber
Trends in incidence, severity, and outcome of hospitalized myocardial infarction
3
G.J. Balady,M.A. Williams,P.A. Ades
Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update. A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation
Circulation, 115 (2007), pp. 2675-2682 http://dx.doi.org/10.1161/CIRCULATIONAHA.106.180945
4
M.F. Piepoli,U. Corrá,S. Adamopoulos
Secondary prevention in the clinical management of patients with cardiovascular diseases, Core components, standards and outcome measures for referral and delivery. A policy statement from the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology
Eur J Prevent Cardiol, (2012),
5
R.S. Taylor,A. Brown,S. Ebrahim
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials
6
B.S. Heran,J.M. Chen,T. Moxham
Exercise-based cardiac rehabilitation for coronary heart disease
Cochrane Database Syst Rev, (2011), pp. CD001800
7
S.M. Dunlay,R.P. Quin,J.T. Randal
Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction
8
P.T. O’Gara,F.G. Kushner,D.E. Casey
2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation, 127 (2013), pp. e362-e425 http://dx.doi.org/10.1161/CIR.0b013e3182742cf6
9
J.L. Anderson,C.D. Adams,E.M. Antman
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
J Am Coll Cardiol, 50 (2007), pp. 1-157 http://dx.doi.org/10.1016/j.jacc.2006.12.050
10
T.D. Fraker,S.D. Fihn,on behalf of the 2002 Chronic Stable Angina Writing Committee
2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop The Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable Angina
(2002)
11
F. Van de Werf,J. Bax,A. Betriu
Management of acute myocardial infarction in patients presenting with ST-segment elevation, The Task Force on the management of acute myocardial infarction of the European Society of Cardiology
Eur Heart J, 29 (2008), pp. 2909-2945 http://dx.doi.org/10.1093/eurheartj/ehn416
12
A. Kulik,M. Ruel,H. Jneid
Secondary prevention after coronary artery bypass graft surgery. A scientific statement from the American Heart Association
Circulation, 131 (2015), pp. 927-964 http://dx.doi.org/10.1161/CIR.0000000000000182
13
J. McMurray,S. Adamopoulos,S.D. Anker
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 The Task Force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC
Eur Heart J, 33 (2012), pp. 1787-1847 http://dx.doi.org/10.1093/eurheartj/ehs104
14
M. Mendes
Inquérito aos programas de reabilitação cardíaca em Portugal, Situação em 1999
Rev Port Cardiol, 20 (2001), pp. 7-19
15
M. Teixeira,F. Sampaio,L. Brizida
Reabilitação cardíaca em Portugal-evolução entre 1998-2004
Rev Port Cardiol, 26 (2007), pp. 815-825
16
A. Abreu,N. Bettencourt,P. Fontes
Panorama nacional de reabilitação cardíaca em 2007-2009
Rev Port Cardiol, 29 (2010), pp. 545-558
17
R. Cruz Ferreira,R. César das Neves
Portugal – Doenças cérebro-cardiovasculares em números – 2015. Programa nacional para as doenças cérebro-cardiovasculares
Direção-Geral da Saúde, Lisboa Fevereiro, (2016)
18
B. Bjarnason-Weherens,H. McGee,A.D. Zwisler
Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey
Eur J Cardiovasc Prevent Rehabil, 17 (2010), pp. 410-418
19
R. Cruz Ferreira,A. Abreu
Reabilitação cardíaca: realidade nacional e recomendações clínicas
Publicação da Coordenação Nacional para as Doenças Cardiovasculares, (2010)
20
R.S. Taylor,H. Dalal,K. Jolly
Home-based versus centre-based cardiac rehabilitation
Cochrane Database Syst Rev, 8 (2015), pp. CD007130
21
J.A. Suaya,D.S. Shepard,S.L. Normand
Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery
Circulation, 116 (2007), pp. 1653-1662 http://dx.doi.org/10.1161/CIRCULATIONAHA.107.701466
22
S. Papadakis,N.B. Oldridge,D. Coyle
Economic evaluation of cardiac rehabilitation: a systematic review
Eur J Cardiovasc Prevent Rehabil, 12 (2005), pp. 513-520
23
W. Wong,J. Feng,K.H. Pwee
A systematic review of economic evaluations of cardiac rehabilitation
BMC Health Serv Res, 12 (2012), pp. 243 http://dx.doi.org/10.1186/1472-6963-12-243

Please cite this article as: Silveira C, Abreu A. Reabilitação cardíaca em Portugal. Inquérito 2013-2014. Rev Port Cardiol. 2016;35:659–668.


( ! ) Warning: Invalid argument supplied for foreach() in /var/www/html/includes_ws/librerias/html/item.php on line 1202
Call Stack
#TimeMemoryFunctionLocation
10.0002244240{main}( ).../index.php:0
20.42673529744include( '/var/www/html/portugal/plantilla/central.php' ).../index.php:45
30.42743573232include( '/var/www/html/portugal/contenidos/item.php' ).../central.php:11
40.51633685624getAutorCorrespondenciaHTML( ).../item.php:281
Copyright © 2016. Sociedade Portuguesa de Cardiologia

Metrics

  • Impact Factor: 1.195(2016)
  • SCImago Journal Rank (SJR):0,24
  • Source Normalized Impact per Paper (SNIP):0,398