p.64 抽出テキスト

13.1 Cardiac rehabilitation

13.1.1. Comprehensive cardiac rehabilitation Secondary prevention is most effectively provided through cardiac rehabilitation (CR).716,717 All ACS patients should participate in a comprehensive CR programme, which should start as early as possible after the ACS event.716,717,719 CR may be performed in inpatient or outpatient settings, taking age, frailty, results of prognostic risk stratification, and comorbidities into account.716 Comprehensive CR is a multidisciplinary intervention, supervised and performed by a team and usually co-ordinated by a cardiologist.716 The core components of CR include patient assessment, management and control of CV risk factors, physical activity counselling, prescription of exercise training, dietary advice, tobacco counselling, patient education, psychosocial management, and vocational support.716 Several studies have found that CR programmes after atherosclerotic cardiovascular disease (ASCVD) events or revascularization reduce CV hospitalizations, MI, CV mortality and, in some studies, all-cause mortality.720–725 Despite proven benefits, the rates of referral to, participation in, and implementation of CR programmes are low.726–730 Another identified issue is that many patients adopt healthier lifestyles during CR but relapse to pre-morbid habits when returning to everyday life.731 Therefore, there is an unmet need for complementary pathways to the classical centrebased CR model. In addition to alternatives to CR, there is also a need for stronger endorsement of CR by physicians, cardiologists, and healthcare professionals.732,733 It is also important to initiate and establish a strong partnership between patients and healthcare professionals as early as possible.732–734

13.1.2 Digital health

Telerehabilitation may be an effective strategy to maintain a healthy lifestyle over time and can support or even partially replace conventional, centre-based CR.729 Telerehabilitation means rehabilitation from a distance, covering all CR core components, including telecoaching, social interaction, telemonitoring, and e-learning.735,736 Studies in patients with CAD have shown that telerehabilitation can be equivalent to traditional CR in terms of achieving functional improvement, managing risk factors, and increasing patient well-being.737–741 Few data are available about the effect of telerehabilitation on recurrent events.742 Nevertheless, in a meta-analysis no significant difference was found between mortality following telehealth interventions and centre-based supervised CR.743 Also, most trials have only focused on one of the CR core components—exercise training and/or physical activity.742 Therefore, more research on the impact of telerehabilitation on outcomes is still needed, as are investigations into health and digital literacy in CR.

13.1.3 Adherence and persistence

Promotion of both adherence (the extent to which a patient adheres to a prescribed treatment or lifestyle advice) and persistence (the length of time between initiation and discontinuation of a prescribed treatment or lifestyle advice) are key in preventing recurrent CV events after ACS. Adherence to medication has been shown to be sub-optimal, ranging from 50% in primary prevention to 66% in secondary prevention. It is estimated that 9% of ASCVD events in Europe occur as a result of sub-optimal medication adherence.646 Contributors to sub-optimal adherence and persistence are multidimensional and include: polypharmacy, drug regimen complexity, the doctor–patient relationship, a lack of patient-centred care and disease acceptance, concern regarding side effects, cognitive ability, mental and physical disorders, financial aspects, living alone, and depression.646,744–749 Polypills, which include guideline-recommended treatments for secondary prevention, have been shown to increase adherence in post-ACS patients and may improve therapeutic targets.750–752 The Secondary Prevention of Cardiovascular Disease in the Elderly (SECURE) study is the only RCT testing the impact of a strategy based on a polypill (containing aspirin, ramipril, and atorvastatin) vs. usual care on hard outcomes in ACS patients. The polypill strategy was associated with a significant reduction in major CV events, driven by a significant 33% reduction in CV mortality.753 The use of technology to improve medication adherence is also generating interest: mobile phone applications and mobile health (mHealth) tools may improve medication adherence, but clinical trials of sufficient size and duration are needed.754–756 Finally, it is important to recognize that adherence has complex underlying psychological drivers, and therefore a whole-systems approach is mandatory. This should include the education of health professionals, the use of patientreported outcomes and experience measures, patient education, and patient-centred care.734,757,758

13.2 Lifestyle management

Lifestyle management is one of the cornerstones of comprehensive CR.716 While most of the evidence regarding the benefits of a healthy lifestyle on prognosis comes from primary prevention, studies in secondary prevention settings indicate similar beneficial effects.716,724,759–763

13.2.1 Tobacco

Tobacco abstinence is associated with a reduced risk of re-infarction (30–40%) and death (35–45%) after ACS.763–765 Measures to promote cessation of smoking are therefore a priority after ACS. Interventions for smoking cessation should begin during hospitalization using a combination of behavioural interventions, pharmacotherapy, and counselling.18,766 Many patients continue or resume smoking after ACS, in particular patients with depression and environmental exposures.646 During encounters with smokers, the ‘very brief advice’ evidence-based intervention should be used to facilitate dialogue between the patient and healthcare worker.646 Drug interventions, including nicotinereplacement therapy (NRT), bupropion and varenicline, should be considered along with behavioural support. All forms of NRT are effective, and the anti-depressant bupropion aids in long-term smoking cessation with similar efficacy to NRT.646,766 Varenicline is the most effective medical treatment to support smoking cessation and is safe to use in ACS patients.767–770 An average weight gain of 5 kg can be expected when a person quits smoking, but it is important to recognize that the CV risk from continued smoking outweighs the CV risk from gaining weight.646 E-cigarettes have been used to help smokers quit, but evidence on their impact on successful smoking cessation is insufficient, particularly with regard to whether using e-cigarettes actually helps the person remain tobacco free. While e-cigarettes do contain nicotine, they do not contain as many tobacco chemicals as cigarettes. Caution should be given with respect to the use of e-cigarettes, as current evidence suggests they are harmful to CV health by increasing arterial stiffness, heart rate and blood pressure, and by causing endothelial dysfunction.771

13.2.2 Nutrition and alcohol

A healthy diet and eating habits influence CV risk. Adopting a Mediterranean-style diet can help reduce CV risk in all individuals, including persons at high CV risk and patients with ASCVD.761,762,772

ESC Guidelines                                                                                                                                                                                          3783

Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026