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Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update

Cardiac rehabilitation has long been recognized as an important component in the comprehensive care of patients with cardiovascular disease. More recently, this recognition of cardiac rehabilitation has expanded from monitored exercise therapy to multidimensional secondary prevention programs. As such, the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) have identified specific core components that guide strategies to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote active lifestyles for patients with cardiovascular disease.


These core components were first identified and published by the AHA and AACVPR 5 years ago. A recent update to this publication aims to present current information on the evaluation, interventions, and expected outcomes in each of the core components of cardiac rehabilitation/secondary prevention programs in agreement with the 2006 update of the AHA/American College of Cardiology secondary prevention guidelines.1

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The update addresses all key areas of cardiac rehabilitation/secondary prevention including the following: patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counseling and exercise training. The most significant updates are in the area of helping patients meet more aggressive lipid goals with an emphasis on making sure patients are taking the appropriate medications that have shown substantial benefit in reducing cardiovascular events such as angina, myocardial infarction, and stroke.


The recommendations provided in the update recognize the importance of long-term risk management and address strategies related to medication adherence as well as helping patients develop lifelong habits including regular physical activity and healthy eating. The discussion of long-term risk reduction includes the role played by the patient's cardiologist and/or primary care provider to ensure that the important interventions initiated by the cardiac rehabilitation program are continued.


In publishing the Core Components of Cardiac Rehabilitation/Secondary Prevention Programs and providing the 2007 update, the AHA and AACVPR hope that not only will cardiac rehabilitation staff use these recommendations in the design and development of programs, but that healthcare providers, insurers, and policy makers as well as consumers will recognize the comprehensive nature of these programs. In turn, the AHA and AACVPR expect that third-party payers will provide adequate reimbursement of cardiac rehabilitation/secondary prevention programs to ensure that the high quality of these multidimensional programs can be sustained. The Preventive Cardiovascular Nurses Association congratulates AHA and AACVPR in the publication of this important clinical update and supports the contents and its recognition of the key role cardiac rehabilitation/secondary prevention programs play in the treatment of patients with cardiovascular diseases.




Balady GJ, Andes PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. Circulation. 2007:115;2675-2682.


2007 Review of Diabetes News

In recognition of National Diabetes Month in November, here is a review of some important but little-publicized diabetes news of the past year you might have missed:


Lifestyle Interventions as Effective as Drug Treatment in Preventing Onset of Type 2 Diabetes

A recent meta-analysis of 17 randomized controlled trials that included 8,084 patients in multiple countries concluded that lifestyle interventions are as effective as drug treatment in preventing the onset of type 2 diabetes in those who are insulin resistant. The results of the 17 pooled studies were that lifestyle interventions work approximately as well as oral medications and are, of course, less costly and confer fewer side effects. This study furthers the findings from the 2002 Diabetes Prevention Program. Unfortunately, the pooled studies also found that treatment effect was not sustained after discontinuation. Therefore, treatment will be lifelong and must conform to people's lives, goals, and capacities. Members of the Preventive Cardiovascular Nurses Association have the important skills and therapeutic rapport to guide our patients in healthy eating and exercising so that our insulin resistant patients can delay or even stop progression to type 2 diabetes.




Gillies CL, et al. BMJ. DOI: 2007334:299 (epub Jan 19, 2007).


Diabetes and Risk of Stroke-2.8 Times Higher With HgA1c >7!

Members of the Preventive Cardiovascular Nurses Association know well that people with diabetes are more likely to develop cardiovascular disease. Less studied has been the link between blood glucose levels and stroke. A study, published in the journal Stroke, included a diverse group of 10,489 people enrolled in the European Prospective Investigation into Cancer study, a long-term project in the United Kingdom to study men and women who were between 40 and 79 years old. The striking finding from this study is that after adjustment for age, sex, and cardiovascular risk factors, those with an HgA1c of 7 or more were almost 3 times more likely to have a stroke in the 8.5 years of follow-up compared with their normal HgA1c peers. Unlike the relationship between blood glucose and cardiovascular disease, which seems to be a relationship of slightly increased cardiovascular disease risk at each increased level of blood glucose, the risk for stroke skyrockets above a level of 7. Two implications of this study are that we need to work with our patients to help keep their HgA1c under 7 to prevent stroke and there are possibly different mechanisms at work with glucose and stroke than there are with glucose and cardiovascular disease.




Portion-Control Plate Helps Diabetics Lose Weight

A plate and cereal bowl with markers for proper portion sizes appear to help obese patients with diabetes lose weight and decrease their use of glucose-controlling medications, according to a study published in the Archives of Internal Medicine. The average American take in 300 kcal a day more than the average American did 20 years ago. Much of this is blamed on increased portion sizes. The plates for this study were divided into sections for carbohydrates, proteins, cheese, and sauce, with the rest left open for vegetables. The sections approximately totaled an 800 kcal meal for men and a 650 kcal meal for women. The cereal bowl is designed to allow a 200 kcal meal of cereal and milk. Half of 130 obese patients with diabetes (average age: 56 years) were randomly assigned to use the plate for their largest meal and the bowl when they ate cereal for breakfast. The other half of the participants received usual care, which consisted of dietary assessment and teaching by dietitians. A significantly larger proportion of those using the dishes-16.9% versus 4.6%-lost at least 5% of their body weight. As most cases of diabetes can be attributed to the glucose intolerance from excess fat, this low-cost and no-side effect intervention could be useful in delaying progression of diabetes. More information about the diet plates can be accessed at




Pedersen SD, Kang J, Kline GA. Arch Intern Med. 2007;167:1277-1283.


Eight of Ten Adolescents Fail Healthy Habits

The lack of healthy habits among adolescents adds a sense of urgency to the work of the Preventive Cardiovascular Nurses Association. Almost 80% of 11 to 15 year olds, in a study published in the American Journal of Preventive Medicine, reported that they had multiple bad habits including failing to meet physical activity guidelines and watching extensive television. More than 30% watched more than 2 hours of television. Especially alarming about this fact is that adolescents have historically been the group of Americans who have watched the least TV.




Sanchez A, et al. Am J Prev Med. 2007;32:124-130.


These research reports underscore the urgency and importance of the role of PCNA members in the health of our patients and our nation.


Preventive Cardiovascular Nurses Association Offers Online Program on Insulin Resistance

Insulin resistance? Insulin resistance syndrome? Metabolic syndrome? Type 2 diabetes? These words continue to dominate the lay and professional press. Insulin resistance syndrome (IRS) affects more than 1 in 5 adults in the United States, and its prevalence is expected to increase as the epidemic of overweight, obesity, and inactivity continues. Are you aware of the clinical abnormalities and consequences associated with the IRS? The Preventive Cardiovascular Nurses Association has developed and is offering a free online course entitled "Reducing Cardiovascular Risk in the Insulin Resistant Patient." This course is comprised of 5 modules using narrated downloadable PowerPoint slides and handouts. Once a module has been viewed, a corresponding online exam is available. Participants may earn 1 contact hour of continuing education upon successful completion of each exam.


The titles of the 5 modules provide a clear overview of the content. The first module focuses on the pathophysiology and consequences of insulin resistance (IR). It reviews the current guidelines for IR and the criteria for identifying individuals at risk. Several pathophysiologic mechanisms may be involved in the development of type 2 diabetes in patients who first exhibit IR. The second module provides extensive information on how to conduct a detailed assessment and health history for diagnosing these conditions.


The third module tackles the myriad of lifestyle interventions that play a critical role in the treatment of IR and the risk factors associated with IRS. These lifestyle modifications (eg, changing dietary composition, reducing caloric intake, reducing body weight, and increasing exercise) can have a positive impact on increasing insulin sensitivity and help in achieving target goals for the risk factors associated with IRS.


The fourth module is devoted to pharmacologic management of IR and IRS. Many patients require medications to achieve target goals for associated risk factors of hypertension, dyslipidemia, and diabetes mellitus. This module is a great drug resource.


The epidemic of overweight and obesity in children and adolescents in the United States has increased attention on IR, type 2 diabetes, and risk factors for cardiovascular disease in these population groups. Thus, the fifth module presents an overview of the research that has informed current recommendations for identifying and assessing children at risk for IR and related comorbidities. Individual, clinical, and population-based approaches to the prevention of overweight and obesity are addressed with emphasis on strategies designed to promote heart-healthy patterns of dietary intake and physical activity.


This online program is a must for anyone working with at-risk or diagnosed patients with IR. To take advantage of this free offer, visit and click on Education.


This continuing education activity is supported by an educational grant from GlaxoSmithKline.


Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL

New! Preventive Cardiovascular Nurses Association online program, clinical and patient education tools


The Preventive Cardiovascular Nurses Association is pleased to announce the release of its latest educational program "Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL." This program is comprised of 3 components: a free online continuing education Web cast, a laminated card for the healthcare provider, and a tear-off patient piece.

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The online Web cast provides a scientific overview of lipid metabolism, paying special attention to the role that triglycerides and high-density lipoprotein (HDL) cholesterol play in the development of cardiovascular disease. Current national guidelines are reviewed, identifying treatment targets for each of these lipid particles as well as non-HDL cholesterol. The program addresses patient assessment, including physical exam, laboratory tests, secondary causes of hypertriglyceridemia, and low HDL as well as a review of lifestyle. The relationship between triglycerides, HDL, and the metabolic syndrome are also discussed. Treatment options, based on the severity of hypertriglyceridemia, are presented in detail. These range from counseling patients about nutrition, exercise, weight loss, and alcohol control to the appropriate use of prescription and over-thecounter pharmacotherapies.


This Web cast may be viewed at There is no charge for this online program, which is approved for 1 contact hour of continuing education.


As a companion piece to the online program, the Preventive Cardiovascular Nurses Association has developed the "Elevated Triglycerides & Low HDL-A Quick Look at Patient Evaluation" laminated card for use by the healthcare professional in their practice. This 5 x 7 card includes information on triglyceride and HDL screening and Adult Treatment Panel III Guidelines. Also included are common causes of elevated triglycerides and low HDL, performing a clinical assessment, assessing for metabolic syndrome, supporting lifestyle change, and pharmacologic therapy.


The patient piece, "What You Need to Know-Triglycerides and HDL," comes in the form of a tear-off pad with approximately 50 sheets per pad. This education piece outlines risk reduction strategies, including how to lower triglycerides and raise HDL through healthy eating and exercise. Easy to read tables provide examples of heart-healthy activities for adults, as well as common medications used to lower triglycerides and raise HDL cholesterol.


Members of the Preventive Cardiovascular Nurses Association will receive the laminated card for healthcare professionals and copies of the patient tool by mail, this fall. Members and all other recipients of the laminated card and patient piece are asked to visit to provide their comments on this tool. Everyone who provides feedback before January 1, 2008 is entered into a drawing to win a $50 American Express Gift Card!

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Section Description

The Journal of Cardiovascular Nursing is the official journal of the Preventive Cardiovascular Nurses Association. PCNA is the leading nursing organization dedicated to preventing cardiovascular disease through assessing risk, facilitating lifestyle changes, and guiding individuals to achieve treatment goals.