Prioritising patients for cardiac rehabilitation or cardiac ambulatory services

A guide for clinicians to prioritise patients who are suitable for cardiac ambulatory services.

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Published: April 2024. Next review: 2029.

Cardiac ambulatory services (CAS) are cardiology secondary prevention programs that vary between local health districts. They may include chronic care, cardiac rehabilitation, heart failure services and virtual care or telecoaching. Some of these services have a multidisciplinary team.

They provide support, education and exercise for people with cardiovascular disease, including patients who have had:

  • a recent myocardial infarction
  • cardiac surgery
  • an admission with heart failure
  • other cardiac conditions.

Accessing CAS in a timely manner can lead to reduced morbidity, improved mortality and reduced hospital admissions.1-3

How to use this resource

The provision of CAS varies across NSW. This resource supports clinicians to prioritise patients accessing cardiac rehabilitation or secondary prevention programs in a clinically appropriate time frame that aligns with current evidence. This is not a policy or guideline. It does not supersede NSW Government, NSW Health or local health district policies.

The specified time frames for patients to enrol in CAS programs and mode of delivery (face-to-face, virtual care or remote patient monitoring) are a guide only. Assess enrolment based on patient preference, clinical need and resource availability.4 Prioritise patients depending on:

  • acuity
  • new diagnosis
  • risk.

Enrolment is defined as when the patient is registered into the cardiac rehabilitation program and attends the first visit which includes an assessment, either face-to-face or virtually.4

Prioritising cardiac ambulatory services providing exercise, education and interventions

Having three defined levels of priority enables clinicians to manage capacity and demand while meeting individual patient needs. All patients will be offered entry into an appropriate cardiac rehabilitation or secondary prevention service based on clinical judgment and availability of a local service.

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Priority 1 Enrol in program within 21 days of discharge or referral4

Patients with these conditions:

  • Acute coronary syndrome plus or minus percutaneous coronary intervention
    • acute myocardial infarction, ST elevation myocardial infarction (STEMI, non-STEMI)4
    • unstable angina
  • Cardiothoracic surgery
    • coronary artery bypass graft or valve surgery
    • other cardiac surgery including left ventricular assist device or heart transplant
  • Percutaneous valvular interventions, including transcatheter aortic valve implantation, balloon aortic valvuloplasty and mitral and tricuspid clips
  • Spontaneous coronary artery dissection
  • Cardiac arrest
  • Diagnosed heart failure: heart failure reduced ejection fraction (HFrEF); heart failure preserved ejection fraction (HFpEF)
    • newly diagnosed heart failure (New York Heart Association Class IV)
    • frequent (more than three) heart failure admissions in 12 months5

Patients from priority populations:

  • Aboriginal and Torres Strait Islander peoples at risk of cardiovascular disease or with existing disease6
  • Culturally and linguistically diverse people
  • Living alone with limited carer or social support
  • 65 years or younger and needing to return to work
  • Atrial fibrillation, atrial flutter plus or minus ablation (dependent on service capacity)6

Priority 2 Enrol in program within 28 days of discharge or referral

Patients with:

  • Implantable cardioverter defibrillators
  • Congenital heart disease
  • Planned percutaneous coronary interventions, including angioplasty and stent
  • Insertion of permanent pacemaker, follow-up at device or pacemaker clinic
  • Diagnosed heart failure: HFrEF, HFpEF
    • uncomplicated admission
    • exacerbation due to other comorbidities or non-cardiac cause

Priority 3 Contact within 42 days, consider alternative programs

  • Stable angina: recommend patients join the National Heart Foundation My Heart, My Life program
  • Medically managed and high risk for coronary artery disease: recommend patients access free phone and online health coaching by joining the NSW Get Healthy Service

Definitions

Heart failure reduced ejection fraction (HFrEF)1
Signs and symptoms of heart failure and left ventricular ejection fraction (LVEF) less than 50%.
Heart failure preserved ejection fraction (HFpEF)1
Signs and symptoms of heart failure and LVEF equal to or greater than 50% and objective evidence of relevant structural heart disease, e.g. left ventricular hypertrophy, left atrial enlargement and/or diastolic dysfunction, with high filling pressure.

Background

Method

The Cardiac Rehabilitation Clinical Priority Working Group developed this resource in consultation with the NSW Cardiac Rehabilitation Community of Practice. It was informed by an evidence search on existing clinical guidance for prioritisation for cardiac rehabilitation.

PubMed and Google/Google Scholar were searched on the 7 September 2023 using the terms: ("cardiac rehab*"[Title/Abstract] OR "cardiac rehabilitation"[MeSH Terms]) AND ("practice guideline"[Publication Type] OR guideline[Publication Type] OR "guidelines as topic"[MeSH Terms] OR "guideline*"[Title] OR "guidance*"[Title] OR statement*[title]) AND ("2018/01/01"[Date - Publication] : "3000"[Date - Publication]).

The Cardiac Ambulatory Services Referral and Priority Pathway, developed by South Western Sydney Local Health District Cardiac Ambulatory Nurses Working Party, was used as the framework for this document.

Scope

This resource has been developed to support clinicians working in CAS, such as cardiac rehabilitation, to manage demand and capacity, and to support patients and service needs based on clinically appropriate wait times.

Inclusion criteria: All eligible patients should be offered referral to a CAS that best suits their individual needs or preference (e.g. face to face, virtual care, remote monitoring), as soon as possible after diagnosis or before, or on discharge from hospital or from community settings.3, 7

Exclusion criteria: Patients whom clinicians deem clinically inappropriate.

Why this resource is needed

CAS capacity has been limited due to the ongoing impacts of:

  • COVID-19 requirements for social distancing
  • staffing shortages within the public health system
  • environmental issues such as limitations on allocated space for programs.

Identifying clinically appropriate waiting times for people accessing CAS supports clinicians to manage capacity and demand while meeting individual patient needs.

Aboriginal and Torres Strait Islander peoples and those with specific conditions, such as atrial fibrillation, have a higher risk of premature death from cardiovascular disease. These priority populations would benefit from early intervention from CAS. This information should be read along with the National Quality Indicators for Cardiac Rehabilitation4 and the Core Components of Cardiovascular Disease Secondary Prevention and Cardiac Rehabilitation.6

Acknowledgements

This resource was developed by the Cardiac Rehabilitation Clinical Priority Working Group in collaboration with the NSW Cardiac Rehabilitation Community of Practice.

The community of practice acknowledges the South Western Sydney Local Health District Cardiac Ambulatory Nurses Working Party for developing the original Cardiac Ambulatory Services Referral and Priority Pathway that this document was based upon.

References

  1. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ. 2018;27(10):1123-208. DOI: 10.1016/j.hlc.2018.06.1042
  2. Brieger D, Amerena J, Attia JR, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. MJA. 2018;209(8):356-62. https://www.heartlungcirc.org/article/S1443-9506(18)31778-5/fulltext
  3. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. Sep 2016;25(9):895-951. DOI: 10.1016/j.hlc.2016.06.789
  4. Gallagher R, Thomas E, Astley C, et al. Cardiac Rehabilitation Quality in Australia: Proposed National Indicators for Field-Testing. Heart Lung Circ. Sep 2020;29(9):1273-7. DOI: 10.1016/j.hlc.2020.02.014
  5. Jayakody A, Oldmeadow C, Carey M, et al. Unplanned readmission or death after discharge for Aboriginal and non-Aboriginal people with chronic disease in NSW Australia: a retrospective cohort study. BMC Health Serv. Res. 2018;18:1-11. DOI: 10.1186/s12913-018-3723-4
  6. Woodruffe S, Neubeck L, Clark RA, et al. Australia Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabiliation 2014. Heart Lung Circ. May 2015;24(5):430-41. DOI: 10.1016/j.hlc.2014.12.008
  7. Cartledge S, Thomas E, Hollier K, et al. Development of standardised programme content for phase II cardiac rehabilitation programmes in Australia using a modified Delphi process. BMJ Open. 2019;9(12):e032279. DOI: 10.1136/bmjopen-2019-032279
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