2017英国SIGN心脏康复指南.（英文版）pdf

SIGN 150 Cardiac rehabilitationA national clinical guideline July 2017 EvidenceKEY TO EVIDENCE STATEMENTS AND RECOMMENDATIONSLEVELS OF EVIDENCE1+High-quality meta-analyses,systematic reviews of RCTs,or RCTs with a very low risk of bias1+Well-conducted meta-analyses,systematic reviews,or RCTs with a low risk of bias1-Meta-analyses,systematic reviews,or RCTs with a high risk of bias2+High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3Non-analytic studies,eg case reports,case series4Expert opinionRECOMMENDATIONSSome recommendations can be made with more certainty than others.The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made(the strength of the recommendation).The strength of a recommendation takes into account the quality(level)of the evidence.Although higher-quality evidence is more likely to be associated with strong recommendations than lower-quality evidence,a particular level of quality does not automatically lead to a particular strength of recommendation.Other factors that are taken into account when forming recommendations include:relevance to the NHS in Scotland;applicability of published evidence to the target population;consistency of the body of evidence,and the balance of benefits and harms of the options.RFor strong recommendations on interventions that should be used,the guideline development group is confident that,for the vast majority of people,the intervention(or interventions)will do more good than harm.For strong recommendations on interventions that should not be used,the guideline development group is confident that,for the vast majority of people,the intervention(or interventions)will do more harm than good.RFor conditional recommendations on interventions that should be considered,the guideline development group is confident that the intervention will do more good than harm for most patients.The choice of intervention is therefore more likely to vary depending on a persons values and preferences,and so the healthcare professional should spend more time discussing the options with the patient.GOOD-PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development group.NICE has accredited the process used by Scottish Intercollegiate Guidelines Network to produce clinical guidelines.The accreditation term is valid until 31 March 2020 and is applicable to guidance produced using the processes described in SIGN 50:a guideline developers handbook,2015 edition(www.sign.ac.uk/sign-50.html More information on accreditation can be viewed at www.nice.org.uk/accreditationHealthcare Improvement Scotland(HIS)is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age,disability,gender,race,religion/belief and sexual orientation.SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline.This methodology is set out in the current version of SIGN 50,our guideline manual,which can be found at www.sign.ac.uk/sign-50.html The EQIA assessment of the manual can be seen at www.sign.ac.uk/pdf/sign50eqia.pdf The full report in paper form and/or alternative format is available on request from the Healthcare Improvement Scotland Equality and Diversity Officer.Every care is taken to ensure that this publication is correct in every detail at the time of publication.However,in the event of errors or omissions corrections will be published in the web version of this document,which is the definitive version at all times.This version can be found on our web site www.sign.ac.uk This document is produced from elemental chlorine-free material and is sourced from sustainable forests.Scottish Intercollegiate Guidelines NetworkCardiac rehabilitationA national clinical guidelineJuly 2017Scottish Intercollegiate Guidelines Network Gyle Square,1 South Gyle Crescent Edinburgh EH12 9EBwww.sign.ac.ukFirst published July 2017ISBN 978 1 909103 58 0Citation textScottish Intercollegiate Guidelines Network(SIGN).Cardiac rehabilitation.Edinburgh:SIGN;2016.(SIGN publication no.150).July 2017.Available from URL:http:/www.sign.ac.ukSIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland.Cardiac rehabilitationContents1 Introduction.11.1 The need for a guideline.11.2 Remit of the guideline.21.3 Statement of intent.42 Key recommendations.52.1 Assessment.52.2 Lifestyle risk factor management.52.3 Long-term maintenance of behaviour change.52.4 Psychosocial health.53 Referral,engagement and partner/carer involvement.63.1 Referral.63.2 Engagement.63.3 Partner/carer involvement.74 Assessment and care planning.84.1 Introduction.84.2 Individual assessment and case management.85 Lifestyle risk factor management.95.1 Introduction.95.2 Smoking cessation.95.3 Physical activity and reducing sedentary behaviour.105.4 Diet.125.5 Long-term maintenance of behaviour change.146 Psychosocial health.156.1 Introduction.156.2 Models of psychological care.156.3 Measurement of psychological well-being.166.4 Psychological therapies and interventions.167 Vocational rehabilitation.197.1 Introduction.197.2 Interventions.19Cardiac rehabilitationContents8 Medical risk management.208.1 Introduction.208.2 Prescribing practices.208.3 Medication concordance.209 Provision of information.219.1 Checklist for provision of information.219.2 Sources of further information.2210 Implementing the guideline.2510.1 Implementation strategy.2510.2 Resource implications of key recommendations.2510.3 Auditing current practice.2511 The evidence base.2611.1 Systematic literature review.2611.2 Recommendations for research.2611.3 Review and updating.2712 Development of the guideline.2812.1 Introduction.2812.2 The guideline development group.2812.3 The steering group.2912.4 Consultation and peer review.30Abbreviations.32Annexes.33References.39Cardiac rehabilitationCardiac rehabilitation|1Cardiac rehabilitationCardiac rehabilitation1 Introduction 1 Introduction1.1 THE NEED FOR A GUIDELINEAlthough the incidence of coronary heart disease(CHD)is decreasing in Scotland,it is still a leading cause of illness and mortality,with an incident rate of 375 per 100,000 of the population in 2014/15.Incidence increases with age,with an incidence rate,in 2014/15,of 236 per 100,000 for those under 75 compared to 1,781 per 100,000 for the over-75 age group.In the last ten years there has been an improvement in 30-day survival following hospitalisation for a first heart attack from 85.2%to 92.3%.1 As a consequence a growing number of people in Scotland are living with heart disease.The Scottish Government refreshed its agenda for improving the management of heart disease in 2014,and among the priorities listed are the need to modernise cardiac rehabilitation(CR)services to include all diagnostic subgroups,and the development of self-management programmes for patients with heart disease.2 The 2020 vision statement for cardiac rehabilitation in Scotland is:3“CR will be delivered by an integrated,clinically competent,multidisciplinary team with a central focus on specialised assessment providing an individualised programme of care to improve patient outcomes.”The vision statement places greater emphasis than before on individual assessment of need by CR specialists and the delivery of a range of interventions tailored to the needs of the individual.It recognises that modern cardiac rehabilitation is primarily concerned with the psychological,behavioural and lifestyle implications of a diagnosis of CHD and how these can be modified with effective interventions.It reflects the CR pathway described in the British Association for Cardiovascular Prevention and Rehabilitation(BACPR)Standards and Core Components which replaces the old four phase model with a 06 stage pathway including individualised assessment and care planning.4 The standards describe a biopsychosocial approach to CR in which the overall aim is to equip the patient with the necessary knowledge and skills to enable them to successfully self manage their condition to live a longer,healthier,and more independent life.The approach is centred on patient education using health behaviour change techniques,which are patient centred and sensitive both to patient need and preference.Identifying health beliefs and correcting misconceptions through patient education is the key to this approach.Three further areas of intervention are highlighted:lifestyle risk factor management,psychosocial health,and medical risk management,with the focus on long-term strategies.The core components are outlined in Figure 1.SIGN published its first cardiac rehabilitation guideline in 2002(SIGN 57).The guideline reviewed the evidence for what was then called comprehensive rehabilitation.This term was used to define the prevalent model of cardiac rehabilitation which consisted of two components,exercise and education.The focus was therefore on these two elements and on the evidence for efficacy in various subgroups of patients with CHD.While CR meets the definition of a complex intervention,with studies including some or all of the elements described in the BACPR pathway,systematic reviews have concluded that the reduction in cardiovascular mortality associated with attending CR can be attributed to the exercise component.5,6 The trials used to reach this conclusion involved predominantly middle-aged men who had sustained a myocardial infarction(MI).Nevertheless,they have led to the view that exercise is a compulsory element of CR.There is no comparable evidence for the efficacy of smoking cessation or dietary intervention within CR.Implicit in an individualised patient-centred approach to CR,however,is that equal importance should be placed on all lifestyle risk factors,based on an individual assessment of need.The pathway described in the BACPR Standards and Core Components is achievable but aspirational and the concept of individualised assessment and delivery of CR differs significantly from reality as teams struggle to move away from existing delivery models to resource a model which is potentially more complex to implement.It therefore seemed likely that the evidence available for this novel approach within a CR setting would be limited,and that evidence from the wider CHD literature and beyond would need to be considered.Highlighting the need for further research within CR has therefore assumed greater importance in this guideline.2|Cardiac rehabilitationFigure 1:BACPR core components for cardiovascular disease prevention and rehabilitation4AUDIT AND EVALUATIONLONg-TErm STrATEgIESPsychosocialhealthHealth behaviour change and educationmanagementmedical riskLifestylerisk factormanagementThe Six Core Components for Cardiovascular Disease Prevention and RehabilitationReproduced from:British Association for Cardiovascular Prevention and Rehabilitation(BACPR).The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation London:British Cardiovascular Society;2017,1.2 REMIT OF THE GUIDELINE1.2.1 OVERALL OBJECTIVESThis guideline provides recommendations based on current evidence for best practice in the rehabilitation of patients with heart disease.It reflects existing standards,recommendations,and practice by including all patients with heart disease regardless of primary diagnosis,clinical condition,comorbidity,or stage of disease.Therefore the primary objectives of the guideline are to:y identify evidence-based approaches for the delivery of the model of CR described in the BACPR Standards and Guidelines and the Scottish Government 2020 Vision4,7 y identify evidence-based strategies for implementing the recommendations for lifestyle risk factor modification set out in the guideline SIGN 149:Risk estimation and the prevention of cardiovascular disease8 yprovide greater emphasis on long-term self-management strategies ypromote further research in CR where evidence is lacking.|3Cardiac rehabilitationThe group also considered the implications of government policy in relation to greater integration of services and partnership working.The guideline is not only forward looking in relation to the BACPR pathway,but outwardly looking in considering questions such as the role of non-NHS organisations in delivering dietary interventions.The recommendations in the guideline can only reflect the key questions considered(see Annex 1)and as such there are inevitably areas where a recommendation cannot be made.For example,the group did not consider the question of timing of the assessment but rather supported the BACPR view that earlier assessment is logical if CR is to impact on hospital readmission rates.4 It was also considered that this model of CR might be delivered in a range of settings so the evidence comparing one setting with another was not addressed.1.2.2 DEFINITIONSThe BACPR defines cardiac rehabilitation as:“The co-ordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease,as well as to provide the best possible physical,mental and social conditions,so that the patients may,by their own efforts,preserve or resume optimal functioning in their community and through improved health behaviour,slow or reverse progression of disease”.4 The term cardiac rehabilitation is widely accepted to encompass the processes described in this definition,but is itself a dated and potentially misleading term.It was established at a time when patients were hospitalised for long periods after MI or cardiac surgery,advised to rest for several months,and in need of carefully monitored exercise-based rehabilitation to enable them to return to normal activities.The majority of patients with CHD no longer need rehabilitation in the traditional sense of the word,but benefit from a holistic,person-centred approach to their care,which imparts knowledge and understanding of their condition and its implications,and provides lifetime skills to assist in self managing this long-term condition.This guideline is based on such an approach and utilises the available literature on long-term conditions in making its recommendations.It was,however,beyond the remit of the guideline to recommend changing the term cardiac rehabilitation to one which better reflects current practice.This guideline was developed as part of a programme to review all SIGN CHD guidelines.8-10 Patients attending CR include many