Traditionally, CV rehabilitation has three phases (or four, according to some authors) (1, 7).

1. During hospital treatment – in a coronary or cardiac surgery intensive care unit, early mobility therapy is applied, which includes proper positioning of the patient in bed, help with turning in bed, sitting up, and getting up from bed, as well as preparation for walking coupled with vital sign and hemodynamic value monitoring, aimed at improving oxygenation, perfusion, and muscle tone as well as prevention of complications. Patients are informed of secondary prevention measures for CV diseases, which prevents a drop in physical fitness and has a positive psychological impact. Due to application of increasingly advance methods, this period is becoming shorter (less than five days in some patients), it is extremely important to provide timely information on the state of the disease and impending recovery process;

2. During recovery – this phase of CV rehabilitation takes place in specialized institutions characterized by teamwork (an interdisciplinary and transdisciplinary approach), continuous monitoring by a cardiologist, and telemetric electrocardiogram monitoring during physical activity. It is usually performed in hospital centers over 21 days, and in outpatient centers 3-5 times a week over three months. In both cases, physical activity is gradually increased according to generally accepted principles. After non-invasive CV and psychological diagnostics, the patient is informed of the state of their disease. The patient and family are then educated and counseled on the disease as well as further treatment and behavior aimed at encouraging changes in health behavior and reducing negative psychosocial consequences of the disease;

3. Long-term maintenance – this phase takes place in so called cardiac patient clubs that are usually organized in rehabilitation centers, and lasts for the rest of the patient’s life. This phase is characterized by maintenance, and if possible improvement, of existing improvements achieved by CV rehabilitation, along with intermittent evaluations by internist-cardiologists, exercise stress test, and risk factor assessment, but with no telemetric electrocardiogram monitoring during physical activity. Patient follow up is most appropriately performed by a well-informed family physician. Long-term maintenance can also take place in sports facilities or in the patient’s home without medical supervision, which some author consider to be the fourth phase of CV rehabilitation.

In the Republic of Croatia, CV rehabilitation takes place in three centers:

Simply looking at the number and location of rehabilitation centers in Croatia makes it clear that many patients will be unable to participate in CV rehabilitation programs due to their geographical location. Therefore, all patients with CHD or that had had AMI must be advised to take part in physical activity due to its benefits in addition to CV risk factor management. Brisk walking until slightly out of breath is usually advised. All patients must be educated on the methods and importance of heart rate control and arterial pressure, and it would be advisable to explain the talk test (exercise until the point that still allows them to speak short sentences) which would be an appropriate level of exertion for cardiac patients. (8)

The goals of the program do not depend on the type of center CV rehabilitation is being performed in, but are instead focused on the wellbeing of the patient, specifically on:

The second phase of CV rehabilitation is part of the treatment of cardiovascular patients after acute hospital cardiologic or cardiac surgery treatment. In outpatient conditions, it usually takes place over 12 weeks in low and moderate risk patients, whereas in patients with high risk CV rehabilitation takes place in specialized hospitals. (1)

The Institute for Cardiovascular Prevention and Rehabilitation has been working since 1950 in Zagreb. Outpatient cardiovascular rehabilitation (OCVR) at the Institute has been performed continuously since 1982. (7, 9-11) Patients above 18 years of age are included, and the treatment is paid for by the Croatian Health Insurance Fund based on referral by the family physician. An annual contract between the Croatian Health Insurance Fund and the Institute determines the maximum funding available for covering the bills for specialist health care.

Since September 1, 2013, Croatian Health Insurance Fund introduced a special D1 referral form for ambulatory care, which covers the treatment for 365 days from its start.

OCVR treatment is indicated in patients after:

Patient compliance in these programs is high, ranging from 86% and 99%, except during the Croatian War of Independence, when it was below 80%. Data from international studies show 34-75% compliance. (7)

Our follow up for many years found that six-year mortality in patients that went through phases 1 and 2 of CV rehabilitation was 13%, only half of which due to heart-related causes. Mortality in patients that did not take part in phases 2 and 3 of the rehabilitation was 34%, of which as much as three quarters due to cardiovascular causes. (7)

The risk of physical training was extremely low: during 400 000 hours of exercise as part of OCVR we had only one cardiac arrest, one acute myocardial infarction, and one stroke, with no fatalities. (7)

Approximately 450 patients attend the OCVR program annually in our Institute. Figure 2 shows the number of patients in the OCVR program from 1986 to 2014, for a total of 13009 patients.

Most patients are referred by their cardiologist, internist, family physician, or cardiac surgeon. About a third of the patients began participation after a mail invitation based on data on patients with acute coronary syndrome from all hospitals in Zagreb, directly acquired by an employee of the Institute.

Figure 3 shows the analysis of patients in OCVR programs based on primary diagnosis between 2005 and 2014. Approximately half of the patients had suffered acute myocardial infarction, and about 10% had underwent coronary artery bypass surgery.

In addition to OCVR, the Institute also has education programs for other medical professionals, students, and target high-risk groups (e.g. obese persons (12), vision impaired and blind persons (13), preventive CV exams for people in higher-risk age groups (14), etc).

The Institute is authorized to train residents in the subspecialty of internal medicine – cardiology related to the education about rehabilitation of patients with cardiovascular disease, work fitness assessment, and CV disease prevention. In cooperation with the University of Applied Health Studies, Zagreb, we take part in the education of students for the courses on Rehabilitation of patients with heart disease and Clinical skills II in the professional undergraduate program Physical therapy and for the module Role of medical nurse in diagnostics in the specialist graduate program Clinical nursing.

Health professionals of all profiles take part in constant medical training. Daily results are regularly published on national and international conferences, as well as periodically in indexed journals. A list of published articles is available on the Institute’s webpage. (15)

The organization of OCVR at the Institute is based on the principle of holistic rehabilitation, in line with European guidelines. (16) The OCVR program accepts patients within 12 months from their acute cardiologic state, living up to 50 km from the Institute, requiring less than 60 minutes of transit time. The program takes place during the morning shift, three to five times a week over three months, which allows for 42 to 64 sessions.

The activities included in the OCVR program in the institute are:

Apart from a holistic approach, “optimal dosage” is important in CV rehabilitation as well, to allow the implementation of all the measures. It has been proven that effective OCVR should include at least 36 sessions, which ensures a preventive effect on long-term outcomes (mortality and incidence of myocardial infarction) over the four years. (17)

After an initial examination and evaluation, the patient is placed into one of five existing intensity level groups based on the extent of the disease, heart function, age, functional status, and comorbidities. The general state of the CV and locomotor system is improved through measured training that also improves the patient’s self-confidence. An appropriate psychological approach is used to ascertain possible psychological risk factors, help modify inappropriate behaviors, and develop relaxation and stress-reduction exercises. In particular, we aim to relieve the fear and depression that are almost always present after an acute cardiologic event. Education helps patients form healthy lifestyle habits and avoid factors that led to the disease, as well as improve treatment compliance. The social goals include achieving an independent lifestyle, returning to work and everyday duties, and resuming familial and social roles. (7, 9-11)

The organization process of the OCVR program at our Institute can be summarized in seven basic steps:

As the D1 referral form is valid for 365 days, patients who are so inclined are provided with cardiologic evaluation and follow-up examinations during that period.

After the OCVR program, patients are invited to participate in long-term maintenance at the Institute (Heart Patient Club). (7) Patients are assessed for risk and assigned intensity groups, in line with OCVR principles. This phase is voluntary, and the expenses are shared between the patient and the Institute. The focus is on continuing medicinal gymnastics training twice a week, with no telemetric electrocardiogram monitoring. This option can be used by 150 to 200 patients annually, over the course of one or more months.

Education of the patient and family/partner is performed by all members of the rehabilitation team both individually and in groups, using advice, workshops, and lectures from the fields of cardiology, physical medicine and rehabilitation, psychology, and psychiatry.

Weekly education of patients participating in OCVR takes place in the lecture hall of the Service for outpatient rehabilitation and lasts 45 to 60 minutes. A twelve-lecture cycle is held four times per years, dealing with the following topics:

Lectures for the families/partners of enrolled patients take place once a month, lastin 60-90. They cover the following topics:

Although the educational activities cannot be reimbursed from the Croatian Health Insurance Fund since April 2014, the Institute’s education team has continued their activities in line with recommendations and the needs of the patients. (18)

Targeted education is performed with small groups of patients (up to five) in workshops lasting for 45 minutes:

All diagnostic services in OCVR are indicated by the cardiologist depending on the clinical picture, the primary disease, and comorbidity. Diagnostic services include:

The decision on longitudinal follow-up of the results of individual diagnostic procedures during AKVR is made by a cardiologist, depending on the indication.

The members of the outpatient cardiovascular rehabilitation team at the Institute are: cardiologists, a physical medicine specialist with additional training in cardiovascular rehabilitation, a clinical psychologists, bachelors of nursing, physical and work therapy and nurses and physical therapists, and other medical personnel as needed. The bachelors of nursing and physical therapy have additional training in diet therapy. Experts performing cardiovascular consultation are also considered part of our team. (7, 9, 11, 19)

As in other European centers (20), the leader, organizer, and coordinator of the OCVR program at the Institute is a cardiologists with additional training in emergency medicine, who is constantly present in the OCVR facilities. The rehabilitation presses takes place in an atmosphere of active team-work and is not divided within particular fields, aiming at an interdisciplinary, and if possible transdisciplinary, approach. Continuous education and exchange of information of the whole team takes place on regular weekly meetings.

Considering the nature of the diseases these patients suffer from, the risk of serious CV complications is always present, which necessitates adequate diagnostic and treatment equipment and constant readiness for emergency interventions. All team members are trained in performing advanced resuscitation procedures in case of cardiopulmonary arrest.

The role of the cardiologist – the internist-cardiologists takes part in all OCVR activities – patient selection, individual risk evaluation, non-invasive CV diagnostics, monitoring patients during medical gymnastics and training, recommending and correcting medication treatment based on test results, counseling and education of patients and families, and cardiologic consultation. After the patient has finished the OCVR program, the cardiologist performs the final evaluation of the procedure, reassessing risk for every patient and providing a final overview in the discharge letter.

The role of the physical medicine specialist – after cardiologic status evaluation, the physical medicine specialist takes a detailed working anamnesis, performs a clinical examination, and assesses the locomotor status in order to make OCVR as successful for every patient. When further examination is needed, it is requested (X-ray of the cervical, thoracic and lumbar spine, X-ray of the hips or knees; densitometry, etc.). During the examination, the medical documentation related to the locomotor system as well as neurological and neurosurgical documentation is analyzed, in addition to the findings of other specialists that could influence the OCVR process. Finally, the team jointly issues recommendations for medical gymnastics and physical therapy. If there are problems with parts of the locomotor system during OCVR, a control examination is perform and the new medical data is analyzed, and the patient and physical therapists are given further recommendations on dealing with the emerging issues, after which the OCVR program continues. During the OCVR program, the range of movement and general status at first and last examination is monitored.

Medical gymnastics take place under the supervision of a bachelor of physical therapy and a physical therapist, as well as bachelor of occupational therapy.. Exercises include standing, sitting, and lying down on a mat, wall ladders, riding a bicycle using legs or arms and walking on a treadmill. During training, therapeutic correction includes individual exercises for the neck and shoulders in front of the mirror, individual exercised for lumbosacral spine, specialized exercises for the hips and knees, instructions to individual patients on proper sitting, working, lying, and reading positions, and appropriate footwear. Supervision of patients in the exercise room during AKVR is continual, with necessary correction in therapy.

The role of the psychologist – after CV processing, the psychologist performs five groups of tasks in OCVR: psychodiagnostics, patient counseling, education, group therapy based on behavioral-cognitive principles, and participating in cardiovascular consultation. Psychodiagnostics includes two types of activity – testing and conversation/interviews. Testing is focused on the evaluation of the patient’s emotional state (general /Cornell Medical Index/ and individual elements – anxiety /STAI/ and depression /BDI/) and health locus of control /HLK-90/, as well as assessment of current personality functioning (Wartegg, projection test). The interview check for a wide range of emotional, cognitive, physical, social, and professional functionality in the patient, in addition to assessment of the capacity to face the illness and prediction about the communication with health personnel. This assessment generally takes place during a one-time conversation and testing, but heteroanamnestic evaluation is sometimes required.

The contents and scope of the counseling depends on the patient, their primary disease, comorbidities, and possible psychological difficulties. (21) Counseling usually takes place during the interview, and if needed in additional weekly sessions. The psychologist gives two lectures on psychological risk factors for CHD as part of the regular lecture cycle for patients and their families.

Patients attending OCVR are offered to take part in a small, closed relaxation and weight-reduction groups. The relaxation group teaches the following skills: diaphragmatic breathing, facilitating relaxation, adequate communication skills, anger management, assertiveness, problem-solving schemes, recognizing and coping with manipulation, etc. The weight reduction group focuses on the control of the stimuli which lead to eating, and the control of alimentary processes. Gradual reduction of daily energy intake values coupled with proper ingredient choices and combinations depending on individual risk factors. Both groups meet once a week.

The psychologist takes part in cardiovascular consultation and informs other members on the psychological risk factors and characteristics of the particular patient’s personality.

The Institute also provides education for psychology students from the Faculty of Philosophy and Centre for Croatian studies.

The role of cardiovascular consultation – expert cardiovascular consultation is provided by representatives of the Cardiology Departments of various hospitals in Zagreb and the employees of the Institute (cardiologists, a psychologist, a bachelor of nursing). A session generally takes place once a week. A patient is presented to the consultants based on medical documentation:

Cardiovascular consultation provides other suggestions for the AKVR Service. (7) With respect to the prescribed decision, the consultation does not take part in the final decision on work ability, i.e. temporary work disability.

The role of the bachelor of physical therapy/physical therapist – physical therapy begins with the application of SOAP (Subjective, Objective, Assessment, and Plan) and ICF (The International Classification of Functioning, Disability and Health) assessment models, setting up and planning goals, and evaluation and monitoring of the effectiveness of the effects of the therapy. (22) Physical therapy assessment (subjective and objective) is defined as:

The physical therapist applies the appropriate cardiorespiratory and vascular therapies:

The physical therapists focuses on individual responses and tolerance, noticing symptoms of deterioration which are noted in the patient’s OCVR chart. Medical gymnastics and functional training are performed in groups of optimally ten patients, and 14 patients at most. Cardiorespiratory training is supervised using telemetric electrocardiogram monitoring that is generally performed on admission, in the middle, and the end of the program and during changes in exertion intensity, and more often in indicated cases. When necessitated by comorbidity or invalidity, training is performed on an individual basis.

The role of the bachelor of occupational therapy/occupational therapist – the role of the bachelor of occupational therapy consist of occupational therapy (OT) evaluation and treatment. (23, 24) The first and most important step in OT assessment with is a result of a testing process and conversation. Every procedure requires an individual approach to each patient. The tests used are Canadian measure of occupational performance, Questionnaire on management/facing stress, and the Hospital Anxiety and Depression Scale. The occupational therapist much gain insights in three areas through conversation with the patient:

Occupational therapy procedures include education and counseling that takes place individually or in smaller groups through application of the OT approach (educational approach, compensated approach, functional approach, biomechanical approach, cognitive-behavioral approach, and human occupation model). Each of these approaches is an integral part of OCVR and includes several factors, ultimately leading to increased functional capacity and improved quality of life. It is important for counselling to increase the capacity for life after rehabilitation, after which it is important to reintegrate the patient into everyday activities in their community. An integral part of the counseling is education on adapting the home and workspace to the patient’s needs..

The role of the bachelor of nursing/medical nurse – the work of medical nurses in OCVR takes place in an atmosphere that fosters an inter- and transdiciplinary approach to each patient. This approach is rooted in the basic medical care that is the determinant of the role of the medical nurse, and as such includes an active relationship with the patient through the creation of a positive and motivational atmosphere during the whole OCVR process. The medical nurse is the person that connects the cardiologist and the patient during the rehabilitation program.

The bachelor of nursing takes part in the work of the OCVR team, performing tasks related to organization, diagnostics, treatment, monitoring, and education:

The medical nurse is also manages the availability and expiration dates of medication and the availability and functionality of equipment necessary for the whole OCVR procedure.

In most European countries, less than half of the patients with indications for CV rehabilitation actually attend a CV rehabilitation program. (20) There are few publications on OCVR program expenses:

Outpatient cardiovascular rehabilitation has been proven to be an effective treatment to continuously apply after pharmacological and invasive and/or surgical treatment of the acute phase of the disease. This treatment allows clinically stable patients to lead active lives in their places of residence, thanks to the efforts of a rehabilitation team of medical workers. Cardiovascular rehabilitation is long-term treatment that increases functional capacity, allows the patient to be fit for work, and improves quality of life.

This form of cardiologic treatment is, in Croatia as in other countries, adaptable and economical, but underused because it is ignored by medical professionals themselves, but also due to possible remoteness of available rehabilitation centers. Outpatient cardiovascular rehabilitation has for 33 years only been available to patients residing in the city of Zagreb and Zagreb County. Therefore, there is a need to organize rehabilitation centers in other Croatian cities as well.