Clinical cardiology treatment is no longer only the treatment of heart disease itself, but also should include the prevention of heart disease and rehabilitation of heart disease; especially after the occurrence of heart disease such as myocardial infarction, rehabilitation training and clinical drug therapy are two complementary and indispensable treatment links, and appropriate drug therapy can relatively enhance the exercise ability of patients and improve the level and effect of training. The beneficial effects of exercise training can also help to gradually reduce the amount of medication, and in some patients, even stop some of the medication.
The three pillars of cardiac rehabilitation refer to: rehabilitation education and counseling, rehabilitation programs and training, and implementation of healthy behaviors, with exercise exercise as the core of rehabilitation treatment. Specific elements of rehabilitation are explicitly written into today’s treatment guidelines for various cardiac diseases.
The effects of rehabilitation exercise on the cardiovascular system have been clearly defined as follows: 1, peripheral effects: increase the oxygen uptake capacity of skeletal muscle, improve the oxygen utilization capacity of skeletal muscle, increase the maximum oxygen uptake of the body, and improve hemodynamics. 2, the heart itself: promote coronary collateral formation and coronary diastole, increase heart beat volume and coronary blood flow, increase heart ejection fraction, and increase electrical stability. 3, reduction of risk factors. Improve lipid and glucose metabolism, lower blood pressure, and reduce platelet aggregation.
I. Indications for cardiac rehabilitation
Cardiac rehabilitation is applicable to almost all patients with heart disease, such as: 1, coronary heart disease: recovery from myocardial infarction without comorbidities, stable myocardial infarction with comorbidities, post-coronary intervention, post-coronary artery bypass surgery, chronic stable angina. 2, rheumatic heart disease / congenital heart disease: those with good prognosis after surgery, those who cannot be operated or whose damage is too complicated, post-surgery still with significant residual damage 3.Cardiomyopathy: hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy. 4.Other heart diseases: patients with chronic heart failure, pacemakers, heart transplantation and heart-lung transplantation.
Second, cardiac rehabilitation function assessment – classification of injury assessment
Heart disease has different effects on the morphology and function of the heart. It can cause impairment at three different levels: impairment, mobility and social participation, and therefore needs to be evaluated at three different levels. The assessment of the level of cardiac injury can be broadly divided into two categories: clinical assessment and rehabilitation assessment.
I. Clinical assessment: mainly by means of the conventional functional and morphological diagnostic tools in cardiology.
1, cardiac functional and morphological examination
l. Clinical symptoms and signs: such as dyspnea, fatigue and weakness, headache, insomnia, memory loss, anxiety, lack of energy, etc. Signs vary depending on the type of heart disease. When heart failure is present, the functional classification method and treatment classification method of the New York Heart Association NYHA are generally referred to.
2. Ultrasound examination of the heart: directly observe the morphology and structure of the heart and large blood vessels, and also project the pump function, systolic function and diastolic function of the heart. Such as left ventricular expulsion per beat SV ,, ejection fraction EF ,, left ventricular short-axis shortening rate, left ventricular local systolic function, left ventricular diastolic function, etc. Doppler echocardiography and exercise echocardiography can further record the Doppler echographic spectrum and morphological changes of the heart during exercise. Esophageal ultrasound is used to understand intra-atrial thrombus formation.
3, Cardiac catheterization: selective left ventriculography, dilution method to measure cardiac function.
4, CT and MRI: morphological changes of the heart can be clearly observed.
2, the examination of myocardial ischemia
Clinical symptoms: mainly judged by the presence or absence of angina pectoris and its degree.
2.Electrocardiogram performance: mainly observe the morphology and changes of ST segment and T wave. Among them, the change of ST segment is the most important. On the general ECG, the changes of ischemic ST segment can be shown as horizontal depression, downward sloping depression, arch-back depression, and sagging depression. Changes in the ischemic ST segment are usually measured and calculated using the methods of ST-segment depression, ST-segment slope, and ST-segment index. changes in the T wave are less significant than characteristic changes in the ST segment in determining myocardial ischemia. The ECG exercise test is of great value in determining myocardial ischemia.
3, myocardial acoustic imaging and radionuclide examination have more visual value in understanding the myocardial blood supply.
Second, the rehabilitation of injury assessment: can refer to the United States on the assessment of permanent damage to the cardiovascular system standards.
In 1993, the American Medical Association developed a “permanent injury assessment guidelines” Guides to the Evaluation of Permanent Impairment,. Among them, the assessment of permanent impairment of the cardiovascular system standards made specific provisions: A, the cardiovascular disease injury and exercise capacity. B, a variety of common heart disease injury grading, which the heart valve disease, coronary heart disease, congenital heart disease, hypertensive heart disease, cardiomyopathy, pericardial disorders, arrhythmias and other common heart disease cardiac function grading and percentage of systemic injury are clearly described. c, metabolic equivalent metabolite equivalents , METs, is in the exercise test METs are calculated by direct measurement of oxygen consumption through exercise cardiopulmonary function equipment. Since oxygen consumption is related to body weight, it is often expressed as an absolute value: ml / kg ? min-1 . Under quiet conditions, a normal person has an oxygen consumption of 3.5 ml/kg per minute, which is defined as 1 MET metabolic equivalent. We use metabolic equivalents to express the magnitude of exercise intensity and energy metabolism in rehabilitation exercise programs, and to assess the level of cardiac function and ADLs during rehabilitation, which is a recognized objective indicator. In the absence of exercise cardiopulmonary function instrumentation is also commonly used as an indicator of maximum heart rate, age maximum heart rate = 220 an age, target heart rate during exercise = 170 180, an age for those with mild disease and good physical condition. In the exercise test, in addition to using the objective indicators mentioned above, the patient’s subjective exertion level is also an important indicator. The Borg rating of perceived exertion, RPE, is commonly used to quantify this, as shown in the following table.
Borg rating of perceived exertion
Grading 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
→
RPE very, very light, very relaxed, lightly strained, somewhat tired, very tired, extremely tired
Assessment of Cardiac Rehabilitation Function – Assessment of Physical Activity
The activity level of an individual is not necessarily parallel to the level of cardiac function. Physical activity is evaluated by the activities of daily living (ADL). In cardiac rehabilitation, the number of METs required for various activities of daily living and occupational activities is often determined and tabulated. The following table shows the energy requirements for common daily activities.
Activity
Metabolic equivalent METs.
Activities of daily living and housework bowel movements: lying down
Defecation: sitting
Sitting: Sitting
Independent standing.
Dressing.
Eating.
Sitting on the edge of the bed.
Making the bed
Showering
Simply cleaning the room
4.0
3.6
1.0
1.0
2.0
1.4
2.0
3.4
3.5
2.3
Occupational therapy activities: light carpentry, sanding boards, polishing, basket weaving
Light mechanical activities
2.5
2.3
Physical activity: walking 1.6 km/h
Walking 2.4 km/h
Walking 4.0 km/h
Walking 5.0 km/h
Bicycling at slow speed
Cycling medium speed,
ballroom dancing slow,
volleyball non-competitive,
ballroom dancing fast,
Badminton
Aerobic dance
Swimming slow,
swimming fast,
Jump rope
Tennis
Table tennis
1.5-2.0
2.0-2.5
3.0
3.4
3.5
5.7
2.9
2.9
5.5
5.5
6.0
4.5
7.0
12.0
6.0
4.5
Gardening labor: watering with buckets
Digging
Planting flowers and vegetables
Digging with a sharp pick
Pruning tree branches
2.0
1.5
2.1
2.3
2.8
Clinically, the cardiac functional capacity DMETs during exercise are measured first to determine the physical activity capacity more precisely and quantitatively, and the number of METs obtained is compared with the energy requirements of the activities in the table to determine the physical activities that can be safely performed by the patients.
Assessment of cardiac rehabilitation function – assessment of social participation ability
The ability to resume various social activities is the most important indicator of the outcome of cardiac rehabilitation. Can the patient go home and live independently? Can the patient resume normal interaction with family and friends as well as cultural and recreational activities? Can patients of working age resume their occupational activities? Can the patient return to a social role with which the patient is comfortable? This involves not only increasing the work capacity of the patient’s heart to adapt to the needs of the social environment, but also directly intervening in the patient’s living environment. The main assessment tools are the patient’s social quality of life (QOL), especially the subjective-based QOL and the disease-related QOL. The SF-36, WHOQOL-100 and other scales are widely used.
V. Development of exercise prescription
A complete exercise prescription should include
l. Intensity of exercise: too much exercise intensity will increase the risk; too little exercise will not achieve the purpose of making cardiac function improve. The appropriate amount of exercise should be at 60% of the maximum heart rate -85% or 50% of the maximum oxygen consumption a 75% of the aerobic metabolic zone, natural walking is the most efficient way of aerobic metabolism. In the absence of exercise cardiorespiratory equipment conditions, it is best to determine the actual maximum heart rate limit volume exercise test or symptom-limiting exercise test results, of the individual through exercise testing, and then calculate the appropriate exercise intensity heart rate index, of the individual based on the above percentages. In practice, it is important to emphasize the role of conscious exertional grading, and not to blindly force or encourage the patient to pursue the heart rate “standard” according to the results of the checklist. With regard to the monitoring strategy of exercise intensity under medication conditions, the target heart rate should be changed accordingly when the drug dose is adjusted. The subjective exertional scoring RPE, method and metabolic equivalent method are not affected by vasoactive drugs. Signs of excessive exercise intensity: inability to talk freely during exercise due to shortness of breath, profuse sweating, pallor, inability to sustain exercise, palpitations. Signs of excessive exercise: feeling fatigue the next morning after exercise, accelerated or slowed heart rate, abnormal blood pressure, and reduced exercise capacity.
2, the duration of each exercise: the duration of exercise is not the longer the better. Research has proved that: in reaching 75% of the maximum oxygen consumption, as long as 20-30min will be able to achieve the best results. In other words, it is enough to maintain 20-30 min when reaching 80% of the individual’s maximum heart rate. Some studies have shown that a reduction in exercise intensity and an increase in duration can also lead to better cardiac function. For example, reaching 60% of an individual’s maximum heart rate for 45-60 minutes can achieve the same recovery effect. This kind of exercise program with lower exercise intensity and longer exercise duration is more easily accepted by elderly heart patients.
3, the frequency of weekly exercise: as long as you adhere to 3 or 4 times a week can get satisfactory results.
4, the choice of exercise: the choice of exercise, must be treated individually and follow the principle of interest. Only if the patient is interested can he or she be motivated to participate and adhere to the scheduled rehabilitation program. Recommended forms of exercise: endurance sports, such as hiking, biking, jogging, volleyball, non-competitive, etc. Forms of exercise that must be used with caution: skiing cold and alpine,, swimming warming circulatory load,, strength exercise to raise high blood pressure,.
5, means of monitoring: For patients in the intermediate and low risk strata, continuous monitoring is not required even during the acute phase of AMI. Patients in the intermediate and low risk groups only need to be monitored for a short period of time in a rehabilitation facility when they increase the intensity and duration of exercise; most of the time, they only need to self-monitor such as counting their pulse and evaluating their level of self-exertion,. Patients in the high-risk group, on the other hand, need to undergo rehabilitation exercise training under continuous monitoring.
6. Review: This includes changes in exercise intensity, exercise time, and exercise style. Patients need to go to the rehabilitation doctor for review. Special care should be given to patients in the high-risk and intermediate-risk tier to prevent cardiac accidents and other errors caused by patients changing their own rehabilitation procedures.
VI. Medical measures for rehabilitation of common cardiac diseases
I. Acute myocardial infarction AMI.
1. Acute phase of rehabilitation during hospitalization, I.
The purpose of cardiac rehabilitation in the acute phase of AMI is threefold: first, to start physical activity early, to maintain the existing level of function and prevent the emergence of “wasting”, to relieve anxiety and depression, and to safely transition to ADL self-care; second, to assess the response of the heart and the whole body to activity and exercise; third, to provide education and counseling to patients and families, and to lay the foundation for post-discharge rehabilitation. foundation for post-discharge rehabilitation. The main measures of cardiac rehabilitation in Phase I
1.Early out-of-bed activities
1, indications: patients with stable vital signs, quiet heart rate ≤ 110 beats/min, no obvious angina, no heart failure, serious arrhythmias and cardiogenic shock, no serious comorbidities.
2, Methods: The following seven-step procedure is generally advocated.
Each patient must be individualized to make certain adjustments to each step of the seven-step process based on specific responses. For patients who are not severely ill, have no comorbidities, and respond well to each step of the procedure, each step takes only 1 or 2 days, and they can usually be discharged in 7 to 10 days. In contrast, for patients who are sicker, have more comorbidities, or have an abnormal response to a step of the procedure, each step or step should be extended until there is no longer an abnormal response, and then proceed to the next step. For unstable angina, serious comorbidities such as severe infection, diabetes, thrombosis and embolism, acute pericarditis, respiratory or renal failure, and complications such as severe arrhythmias, cardiogenic shock, heart failure, etc., the procedure should be contraindicated or postponed until the condition is stable before starting.
2 , to perform the assessment of cardiac function – pre-discharge exercise test: pre-discharge exercise test is an important basis for evaluating cardiac functional capacity and performing risk stratification of patients. The general exercise load starts at a low intensity. A heart rate of ≤120 beats/min or 60%-70% of the age-standardized expected maximum heart rate is usually used as the exercise endpoint. Metabolic equivalent can be used if available, reaching 4 METs as the endpoint.
3. Risk stratification: Analysis of the results of pre-discharge exercise tests allows assessment of the patient’s tolerance level and safety of physical activity after discharge. It also helps to identify the causes of abnormal responses, such as angina pectoris, arrhythmia, ventricular insufficiency, myocardial ischemia, etc., so that a more objective estimate of prognosis can be made. This is risk stratification. The table below shows the risk stratification criteria for patients with coronary artery disease. For patients in the intermediate to high risk stratum, medication should be intensified, or interposition therapy and bypass surgery should be recommended, and medical monitoring should be intensified during rehabilitation. In contrast, for patients in the low-risk stratum, occupational and recreational activities are not excessively restricted, and self-monitoring is mainly relied upon during rehabilitation training.
Risk stratification
Patients in the low-risk stratum are characterized by
No clinical complications at the time of hospitalization, no evidence of myocardial ischemia, cardiac functional capacity ≥7 METs, normal LVEF ≥50%,, and no severe ventricular arrhythmias.
Intermediate risk stratum.
Horizontal or downward sloping ST-segment depression ≥2 mm, reversible coronary nuclear myocardial perfusion abnormalities, moderate or better LVEF 35%-49%, and episodes of unstable angina pectoris.
High-risk stratum.
Previous or recent myocardial infarction affecting ≥ 35% of the left ventricle, LVEF < 35% at rest, decreased systolic blood pressure or increased systolic blood pressure ≤ 10 mmHg on exercise stress test, persistent or recurrent ischemic chest pain ≥ 24 h after admission, cardiac functional capacity < 5 METs, hypotensive response on exercise test or ST-segment decrease > 1 mm, symptoms of congestive heart failure during hospitalization.
ST-segment depression ≥ 2 mm at peak heart rate ≤ 135 beats/min, severe abnormal ventricular arrhythmias.
5. Develop a post-discharge home rehabilitation plan: A complete home rehabilitation plan should be developed before discharge to implement phase II rehabilitation at home. The content should include.
Understanding the degree of awareness and understanding of patients and their families about coronary artery disease, especially myocardial infarction, and the key points of post-home management; How to change the lifestyle of patients and families to get rid of or mitigate the effects of risk factors
Reducing the patient’s fear, anxiety and depressive state and building confidence to resume a normal life again.
Detailing the exercise prescription for Phase II rehabilitation: the amount of exercise to be trained as an indicator of self-monitored heart rate,, the duration of daily training exercise, the frequency of weekly training, and the manner and method of exercise. Explaining how to perform general physical activities after returning home, how to reduce energy expenditure, how to perform self-monitoring during activities, and how to deal with emergencies in case they occur, etc.
Teach family members CPR techniques.
Emphasize the importance of adhering to Phase II rehabilitation training at home and explain the precautions to patients and family members.
2, Subacute phase of cardiac rehabilitation in the home, phase II.
The purpose of rehabilitation in the subacute phase of AMI is fourfold: first, to prevent the decline of cardiac function and to maintain and further improve the level of cardiac function at the time of discharge; second, to gradually transition from self-care of daily life to the restoration of normal social life; third, to start with low-level physical training according to the exercise prescription on the basis of the pre-discharge exercise test, so that the physical cardiac function capacity and recovery to the pre-disease level. Fourth, to obtain psychological recovery, to overcome the mentality of “serious illness” and “disability”, and to change the lifestyle according to their risk factors. The indications for stage II rehabilitation are clinical stability and a functional cardiac capacity of >3METs at the time of discharge.
The main measures of stage II cardiac rehabilitation are
l. Initial adaptation: For the first 1-2 weeks at home, the patient maintains the same level of exercise as before discharge. After the patient confirms that he or she is not in any discomfort and has become accustomed to the daily level of physical activity, then slowly and gradually increase the content, duration and frequency of activity. Patients must use self-monitoring methods, including self-measurement of heart rate and self-perceived exertion, to make judgments about their daily rehab results. Initial adaptation may take 2 to 4 weeks.
2. Formal rehabilitation training: Formal rehabilitation training should be conducted according to the exercise prescription. The intensity of exercise should gradually reach 50% to 80% of the maximum oxygen consumption or 60% to 85% of the expected maximum heart rate for age; the duration of exercise should gradually reach 10 to 15 min; and the frequency of exercise should gradually reach 3 to 4 times/week. During this phase, the functional capacity of the heart is gradually increased from 3-4 METs at discharge to about 6-7 METs. For patients in the low-risk stratum who show little abnormality in exercise, the exercise volume can be steadily increased by self-monitoring; however, for patients in the middle or high-risk stratum or those who show more obvious abnormality in exercise, they should go to the hospital rehabilitation clinic for supervised rehabilitation exercise training. Phase II cardiac rehabilitation takes 6 to 12 weeks.
3. Perform exercise tolerance exercise test: At the end of stage II cardiac rehabilitation, submaximal volume exercise test should be performed in the hospital. If the patient can achieve 6 to 7 METs, or the expected target heart rate, then general physical and occupational activities can be resumed, as well as sexual life.
4. Active control of risk factors: Educating and counseling coronary heart patients and their families, and making patients take the initiative to change their poor lifestyles are important elements of rehabilitation. Such as insisting on medication to control blood pressure, reasonable diet to control diabetes, quitting smoking, weight control, limiting the intake of fat, cholesterol and sodium, appropriate physical activity and cultural and sports activities, improving personality, combining work and rest, etc. We also need to explain again to patients and their families the main manifestations of possible disease deterioration and serious reactions caused by exercise after going home, and the ways to deal with them.
3, High level of cardiac rehabilitation recovery, stage III.
The purpose of cardiac rehabilitation during recovery from AMI is threefold: first, to develop an intensive, high-level, individualized rehabilitation exercise training program to maximize the patient’s cardiac function; second, to further improve the patient’s psychological status and proactively control risk factors and maintain a good lifestyle; and third, to maximize the patient’s quality of life. Individualized consideration should be emphasized. The measures for stage III cardiac rehabilitation are as follows.
1. Patient’s assessment: To fully understand the patient’s pre-morbid health condition, lifestyle habits, the type, intensity, duration and frequency of exercises implemented in stage I and II cardiac rehabilitation, which exercises are preferred or disliked, what cultural and sports activities they like to participate in, their occupational status, and the support of their families, etc. The possibility of the patient’s participation in the stage III rehabilitation program is assessed. Secondly, the patient’s own degree of knowledge and understanding of his disease, especially the degree of understanding of risk factors, and the degree of belief in exercise rehabilitation training are key factors in whether he can adhere to Phase III rehabilitation training.
2, develop a high-intensity rehabilitation training program that can be adhered to: the traditional Phase III rehabilitation prescription requires that 80% of the maximum oxygen consumption or 85% of the maximum age-expected heart rate, and a longer duration should generally exceed 30 min, and a greater weekly frequency generally five times a week, is a high-intensity aerobic exercise training. However, current research shows that moderate intensity rehabilitation training below the limit or even the sub-limit of 50 to 80% of the maximum oxygen consumption or 60% to 85% of the maximum age-expected heart rate for a duration of 10 to 15 min, can also achieve better functional recovery results with long-term adherence. A high level of phase III cardiac rehabilitation may take 6 to 12 months.
3. Extreme exercise test: After a long period of high level of stage III rehabilitation, most patients can expect their heart function to exceed the pre-morbid level. This is because most patients have not trained systematically before the disease and rarely even participate in physical or sporting activities. Systematic rehabilitation not only improves the state of the heart and coronary arteries themselves, but also improves the health of the entire body.
4. Health education: Patients and their families are required to pay attention to control risk factors throughout their lives, change bad habits, maintain a good lifestyle and actively prevent recurrence. Education and counseling can make patients and their families actively participate in the management of their own heart disease, easily comply with the arrangement of the rehabilitation program and adhere to the implementation of rehabilitation training.
4, Safety and prognosis of rehabilitation
Numerous studies have shown that early rehabilitative activities after AMI and low-level exercise trials after completion of early rehabilitation procedures are quite safe. Medically supervised exercise and exercise trials have been shown to have a mortality rate of only 0.05 ‰—0.1‰, no higher than controls. When conducting exercise training or exercise trials for cardiac patients, it is still necessary to maintain a high degree of vigilance and must be familiar with the contraindications to exercise trials, the indications for termination of exercise trials, and the handling of sudden cardiac accidents to ensure the safety of cardiac rehabilitation.
II. Rehabilitation treatment of chronic coronary heart disease
Patients with chronic coronary heart disease and their family members are often concerned that activity will increase acute attacks or myocardial infarction, and adopt a passive and sedentary lifestyle with reduced activity. Numerous studies have confirmed that appropriate physical activity can reduce the rate of death and sudden death in chronic coronary artery disease. Moreover, cardiac rehabilitation activities can significantly improve patients’ symptoms, reduce fatigue, reduce angina attacks, patients are less anxious and depressed, physical activity capacity is increased, and patients’ subjective perception of quality of life is significantly improved. Together with the control of risk factors and active change of poor lifestyle, patients with chronic coronary heart disease are often greatly benefited.
The rehabilitation method of chronic coronary heart disease can refer to the rehabilitation program of AMI. However, it should emphasize individualization, gradual progress, adherence to systematic and long-term, and pay special attention to interest, so that patients can adhere to the exercise prescription of the doctor for a long time.
1. The principle of individualization: determine the amount of exercise, the duration of each exercise, the number of exercises per week and the type of exercise to be taken according to each individual’s specific situation. Determining the amount of exercise based solely on the values in the charts in books or calculated by formulas, without individualized exercise tests and without considering the patient’s self-perceived fatigue level, may increase the occurrence of serious consequences. However, too small an exercise volume is often difficult to improve the function of the heart. The amount of exercise produced by a greater exercise intensity but shorter exercise time is basically the same as that produced by a smaller exercise intensity but longer exercise time, and the degree of fatigue felt by the patient’s self can be similar, so the effect of rehabilitation is basically the same.
2, step by step: First, patients need to gradually become familiar with and master the skills of a certain exercise; second, the amount of exercise, exercise time, exercise frequency, exercise mode, etc. must also go through a process of gradual adjustment and increase. What kind of exercise training to do at what time requires considerable knowledge and experience.
3. Systematic adherence: After years of research, a number of successful cardiac rehabilitation programs have been developed. Most are rehabilitative exercises and healthy behavior building that require long-term adherence. Without systematic and persistent exercise training, there will be no cumulative functional improvement.
4. Principle of interest: The patient’s interest can increase the patient’s motivation to participate. The activities of the group are a better way, and together with the right encouragement from the medical staff, it often makes the patient unconsciously complete the established rehabilitation plan in a pleasant and more excited state.
VII. Supervision of cardiac disease rehabilitation training by community medical units
At present, urban community medical care and rural health offices and health centers have been sound, and the basis of cooperation with local hospitals at all levels and national central medical units has been formed, and the establishment of a nationwide monitoring network by their own choice of rehabilitation training is sure to be realized in the near future. Among them, urban community health care and rural health offices and health centers are particularly important because they are responsible for the most basic and tedious tasks such as file building, organization, supervision and implementation, feedback and consultation, and health education. According to the experience of Western countries, nationwide uniform and standardized monitoring of rehabilitation training depends on the preparation of three aspects.
First, extensive publicity, education and training to reserve a certain number of talents in management, medical care, psychological guidance, physical training and nutrition allocation.
Second, the significance of cardiac rehabilitation training in a variety of media for sustained, multiform publicity, so that everyone understands rehabilitation, everyone wants to recover, families want to recover, everywhere can recover.
Third, through various channels, we should strive for the financial investment of national and local governments in cardiac rehabilitation training, because cardiac rehabilitation training can greatly reduce the use of drug resources, reduce the disability rate and extend the life expectancy, improve the quality of life, and extend the efficiency and duration of labor force use. Self-confidence