01Role and principlesWho benefits and the main preventive aims.
Cardiac rehabilitation is a coordinated clinical pathway, not simply a supervised exercise class. It turns the acute event into a structured programme for recovery, risk reduction and return to everyday roles.
The initial assessment sets personalised goals and exercise prescription while identifying medical instability, mood symptoms, social barriers and rehabilitation preferences. Final assessment compares outcomes and hands a sustainable plan to primary care and the patient.
Equity is an active design requirement: flexible venues and times, language support, accessible formats, home options and re-offer improve participation among groups historically less likely to attend.
Key points
- Offer cardiac rehabilitation with an exercise component to all people after MI irrespective of age; ACS, PCI/CABG and chronic heart failure are NHS England priority cohorts when capacity is constrained.
- Begin the rehabilitation conversation during admission and invite the person to a session that starts within 10 days after discharge following MI.
- NHS England expects provider contact within five working days of referral and a holistic initial assessment within 10 days of receipt of referral.
- A complete programme combines tailored aerobic and resistance exercise with education, risk-factor management, medicines optimisation, psychological support and long-term self-management.
- Offer in-person, remote or hybrid delivery according to preference and access; digital exclusion is a reason to adapt, not to exclude.
- Assess comorbidity and clinical stability before exercise; unstable angina, decompensated heart failure or uncontrolled arrhythmia needs medical review before progression.
- Re-contact people who do not start or who drop out, and record baseline and final outcomes rather than counting referral alone.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Acute coronary syndrome, PCI/CABG and chronic heart failure are priority NHS cohorts; stable angina, valve intervention, ICD/CRT, transplant and VAD patients may also be offered rehabilitation where capacity allows.
New or unstable chest pain, decompensated congestion, syncope, uncontrolled arrhythmia, marked resting hypotension/hypertension or acute systemic illness needs clinical reassessment before exercise.
Anxiety, depression, fear of recurrence, trauma symptoms and loss of confidence can be as limiting as physical deconditioning and must be assessed directly.
Transport, work, caring duties, language, disability, rurality, digital exclusion, cost and cultural needs should trigger adaptation of mode or timing.
A missed start or dropout is a cue for supportive re-contact and problem-solving, not automatic discharge from the pathway.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Holistic baseline assessmentFirst step - Why
- Define goals, comorbidity, function, preferences, social context and readiness for change.
- Interpretation and limitations
- The result determines delivery mode, supervision and which core components need greatest emphasis.
- 02
Resting BP, pulse/rhythm, symptoms and volume status - Why
- Check medical stability before exercise and guide medicines optimisation.
- Interpretation and limitations
- Unexpected instability requires medical review; stable abnormalities inform an individual exercise prescription.
- 03
Functional-capacity assessment - Why
- Set a safe aerobic/resistance starting point and measure progress.
- Interpretation and limitations
- Use a validated service method such as walking or exercise testing with symptom and exertion monitoring; compare like with like at completion.
- 04
Lipids, glycaemic status, weight/body composition and smoking assessment - Why
- Target modifiable vascular risk.
- Interpretation and limitations
- Results should lead to named goals and NICE-aligned treatment, not generic lifestyle advice.
- 05
Validated psychosocial screening - Why
- Identify anxiety, depression, distress and social support needs.
- Interpretation and limitations
- Positive screens require discussion and the appropriate NICE mental-health or urgent safeguarding route.
- 06
Final reassessment - Why
- Measure clinical, functional, behavioural and patient-reported change.
- Interpretation and limitations
- Use the findings to create a long-term plan and communicate unresolved risks to primary/specialist care.
04InterventionsLifestyle, treatment and escalation options.
01First-lineIdentify and referFirst stepFirst lineEligible cardiovascular event, procedure or diagnosis+
- 1Introduce rehabilitation before discharge or at diagnosis and explain exercise, education, medical and psychological components.
- 2Send a direct referral with diagnosis, procedure, ventricular function, medicines, complications, mobility/communication needs and contact details.
- 3For MI, invite to a programme starting within 10 days after discharge; the NHS England service standard is provider contact within five working days of referral.
- 4Give a route for the patient and primary-care team to chase a missing contact.
02Second-lineAssess and prescribeSecond lineFirst rehabilitation contact+
- 1Complete the holistic assessment within 10 days of referral receipt, including clinical stability, function, mood, risk factors, social determinants and preference.
- 2Agree measurable goals and a tailored aerobic/resistance exercise plan with appropriate supervision.
- 3Select in-person, remote or hybrid delivery and provide language, disability or digital adaptations.
- 4Optimise medicines and risk factors through the relevant NICE pathways and communicate changes to the responsible prescriber.
03Third-lineDeliver and reviewThird lineMedically stable participant+
- 1Deliver exercise, education, diet/weight, tobacco cessation, psychosocial support, medical risk management and long-term strategy components.
- 2Monitor symptoms and exertion at each contact; stop and clinically assess new chest pain, presyncope, dangerous rhythm or decompensation.
- 3AlternativeRe-contact non-starters and dropouts using motivational, practical support and alternative delivery modes.
- 4Repeat baseline outcome measures at completion and provide a shared discharge/self-management plan.
04EscalationClinical deterioration or complex needEscalationUnstable symptoms, high-risk exercise response or unmet specialist need+
- 1Pause progression and arrange urgent same-day assessment for possible ACS, decompensated HF, syncope or unstable arrhythmia; use emergency services when indicated.
- 2Seek cardiology, heart-failure, electrophysiology, diabetes, mental-health, smoking-cessation or social-care input as the identified problem requires.
- 3After stabilisation, reassess rather than permanently exclude and agree a modified supervised pathway.
- 4Record the event, response and revised exercise limits across the care team.
05Targets, monitoring and follow-upResponse, safety and longer-term review.
- Attendance, mode offered, time from referral to contact/assessment and reasons for non-start or dropout.
- Symptoms, BP, pulse/rhythm, perceived exertion and adverse responses during exercise progression.
- Functional capacity and personalised goal attainment from baseline to final assessment.
- Smoking, physical activity, diet/body composition, BP, lipids and glycaemic control.
- Anxiety/depression or other psychosocial outcomes and onward-referral completion.
- Medicine reconciliation, adherence, adverse effects and completion of planned cardioprotective titration.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Referral is not uptake
Audit contact, assessment, start and completion separately; each stage has different barriers.
Home is a valid setting
A validated facilitated home or remote programme can provide comprehensive rehabilitation when it includes exercise, education, psychological support and follow-up.
Exercise is prescribed
Intensity and supervision follow assessment, comorbidity and symptoms; generic advice to 'walk more' is not a rehabilitation prescription.
Re-offer matters
People's work, recovery and confidence change; a decline or early dropout should not close the door to later participation.
Return to roles is clinical
Work, caring, driving, sexual activity and travel questions belong in rehabilitation and may need individual cardiology or DVLA/CAA advice.
07Common pitfallsFrequent interpretation and management errors.
- 01
Describing rehabilitation as an exercise class and omitting medicines, risk factors and psychosocial care.
- 02
Excluding a person because of age, comorbidity, disability, language or inability to use digital tools.
- 03
Starting exercise progression despite unstable angina, decompensated heart failure or unexplained syncope.
- 04
Sending a referral without clinical details or any mechanism to confirm contact.
- 05
Measuring success only by sessions attended rather than baseline-to-final outcomes and a long-term plan.