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Introduction
Coronary heart disease (CHD) is one of the most common causes of mortality in the Netherlands,
with mortality rates of 5724 in men and 4125 for women, in the year 2011 [1]. Multidisciplinary
cardiac rehabilitation (CR) reduces mortality rates by 32 % [2]. The main goals of CR are to
increase physical and psychosocial recovery after a cardiac event and to reduce the risk for
recurrent cardiac events by improving lifestyle (‘cardiovascular risk management’) [3–7].
Exercise training constitutes an important part of CR and is usually conducted by
physiotherapists (PTs). The intervention is aimed at improving exercise capacity and optimising
daily physical functioning in relation to individual physical activity limitations and participation
restrictions [8]. Also, exercise programs should induce inactive patients to develop and maintain
an active lifestyle, and consequently lower their future cardiovascular risk [9].
The importance and the exact content of an adequate CR exercise protocol is not always
sufficiently appreciated [10]. Recently, it was reported that among Dutch CR centres,
considerable variation exists in methods for determination of exercise intensity, training intensity
and volume, and uniformity of physiotherapeutic interventions [11]. A possible explanation for
this is that both the 2011 multidisciplinary CR guideline [12] and the 2005 CR guideline by the
Dutch Royal Society for Physiotherapists (KNGF) [13] lack clear practical guidance for PTs.
Moreover, many international guidelines and position statements are not specifically aimed at the
practical application of exercise-based CR [3–7, 14]. Therefore, an updated clinical practice
guideline on exercise-based CR was developed by the KNGF, describing optimal physiotherapy
care during all phases of CR, including assessment, treatment and evaluation. This paper sums
up the main conclusion and recommendations.
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Methods

Guideline development
This guideline was systematically developed according to the Physiotherapy Guidelines
Development in the Netherlands method [15]. The guideline development group (GDG)
consisted of the following disciplines: PTs representing the KNGF, movement scientists,
epidemiologists, a representative of the 2011 Dutch multidisciplinary CR guideline committee
and a cardiologist representing the CR section of Dutch Society of Cardiology. An external
group from relevant disciplines reviewed the draft versions of the guideline. The members of the
GDG and the external members did not have any conflicts of interest.

Literature search and recommendations

A computerised literature search was undertaken in the Cochrane library, Medline, PEDro-
database, Cinahl and relevant national and international guidelines of CR [3–7, 12, 14, 16], using
the following keywords: heart disease, acute coronary syndrome (ACS), acute myocardial
infarction (AMI), unstable angina pectoris (UAP), angina pectoris (AP), acute or elective
percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), CR,
preoperative and postoperative care, exercise and physiotherapy.
Recommendations for the efficacy of exercise-based CR were based on systematic reviews or
meta-analyses, if available completed with more recent random-clinical trials (RCT).
Methodological quality of RCT’s was scored on the PEDro scale [17]. Only studies with a
PEDro score of more than 5 points out of 10 were included. The level of evidence of the
conclusions based on literature has been categorised on the basis of the Dutch national
agreements (EBRO/CBO). A distinction was made between four levels, based on the quality of
the articles from which the evidence was obtained (Table 1).
Table 1
Levels of scientific evidence

Level of evidence Quality levels (intervention and prevention)

Level 1: Study at A1 level or at least two A1 Systematic review of at least two independent A2 level studies
independent A2 level studies

A2 Randomised, double-blind, comparative clinical trial of good

quality and sufficient sample size

Level 2: One study at A2 level or at least B Comparative study not meeting all criteria mentioned under A2
two independent B level studies (including case-control studies and cohort studies)

Level 3: One B or C level study C Non-comparative study

Level 4: Expert opinion D Opinions of experts, for instance the members of the guideline
development team

If there was insufficient evidence, recommendations were based on consensus within the GDG.
Additionally, other aspects were used to determine recommendations such as: clinical relevance,
safety, patient and professional perspective, availability of devices and resources, health
organisations, juridical consequences, ethnical and organisational aspects, and possibilities to
confirm this guideline to other monodisciplinary and multidisciplinary CR guidelines.
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Results

The CR process is divided into the following phases

 Preoperative phase (if applicable, preceding CABG);
 Clinical phase;
 Outpatient rehabilitation phase;
 Post-rehabilitation phase.

Preoperative phase
 Recommendation 1. Preoperative physiotherapy (PPT)
PPT is recommended for patients at increased risk of developing postoperative pulmonary
complications (PPC) after CABG (Table 2) [18]. PPT reduces mortality, morbidity (fewer
airways infections), duration of ventilation and length of hospital stay (Level 1) [19].
Table 2
Risk of pulmonary complications after coronary artery bypass grafting (CABG)*

Parameters Score

Age > 70 years 1

Productive cough 1

Diabetes mellitus 1

Smoking 1
 Parameters Score

COPD: FEV1 < 75 % predicted or requiring medication 1

BMI > 27.0 kg/m2 1

Lung function: FEV1 < 80 % predicted and FEV1/FVC < 70 % predicted 2

* The risk is low at a total score ≤ 1, high at a total score ≥ 2. COPD chronic obstructive pulmonary
disease; FEV1forced expiratory volume in 1 s; FVC forced vital capacity

If a patient is referred for exercise-based CR prior to CABG, the following information should be
provided: diagnosis, comorbidities, medication, and the time span before surgery. PPT should
comprise inspiratory muscle training (IMT) using an inspiratory threshold device, coughing,
huffing and breathing techniques (to promote sputum evacuation and stimulate optimum
ventilation). In addition, aerobic training to preserve or improve physical fitness should be
considered (in consultation with the patient’s cardiologist). It is recommended to start IMT at
least 2 weeks, and if possible 4 weeks before surgery, at a frequency of 7 days a week using
20 min sessions at an intensity of 30 % of maximum inspiration pressure (PI max). The
resistance should be adjusted once a week on the basis of the Borg scale (0–10). If the Borg
score (0–10) is < 5, the resistance should be increased by 5 %.
During this phase the following goals should be pursued:
 No detectable pulmonary problems (patient is functionally able to cough up sputum);
 An increased PI max (and inspiratory endurance time) to the highest possible extent –
measured using a PI max meter.

Clinical phase
 Recommendation 2. Stay on the intensive care unit (ICU) or coronary care unit (CCU)
Relative rest is recommended during the patient’s stay on the CCU after an acute cardiac event
or after their stay at the ICU following CABG (level 4).
The PT checks for problems of mucus clearance and ventilation. Treatment is given if necessary
(as indicated by the pulmonologist or other specialist). The perioperative pulmonary treatment by
the PT involves explaining the purpose of physiotherapy, teaching the patient techniques to
improve ventilation and to mobilise and cough up sputum (breathing, huffing and coughing
techniques).
  Recommendation 3. Mobilisation phase
Dynamic mobilisation exercise results in a faster recovery and a better physical health at
discharge in CABG patients (level 1) [20, 21] and other CHD patients (level 4) compared with
rest, and is therefore recommended during the clinical phase.
The cardiologist provides the PT prior to the mobilisation phase with the following medical
referral information: reason for referral, diagnosis, date of the event or treatment, medication use
(type and dosage regime), complications or comorbidities, planned date of hospital admission,
and any further diagnostic information deemed relevant by the cardiologist. The clinical
mobilisation phase should include functional exercises, such as ADL-related exercises, walking
and stair climbing, at an early stage. Exercise intensity should be decreased or exercise should be
discontinued if the patient shows signs of excessive strain, such as angina, impaired pump
function (shortness of breath disproportionate to exertion, abnormal fatigue disproportionate to
exertion, increased peripheral/central oedema), arrhythmias (high heart rate not in proportion to
exertion, irregular heartbeat, changes in known arrhythmias), abnormal increase or decrease of
blood pressure, fainting, dizziness and vegetative reactions (excessive perspiring, pallor). During
this phase, the PT explains the nature of the patient’s CHD and/or the surgery, the further course
of the CR program, ways of coping with cardiac and other symptoms and the CHD itself, ways
to recognise signs of excessive strain and the way the intensity of activities at home can be
gradually increased.
During this phase the following goals should be pursued:
 The patient is able to function at the intended ADL level. Moderate exertion is possible
(≥ 3–4 METs);
 The patient has at least some knowledge of their CHD;
 The patient knows how to cope with their symptoms and is able to intensify and expand
their ADL activities.
In some exceptional cases, patients may not have met these goals at the time of discharge from
hospital, due to psychosomatic, social or severe physical problems. Such patients may be
referred for clinical admission to a specialised multidisciplinary CR centre.

Outpatient rehabilitation phase

Outpatient rehabilitation consists of an intake / assessment procedure, a treatment phase and an
evaluation, which will be discussed chronologically in the following section.

Intake / assessment procedure

At the start of the outpatient rehabilitation phase, all eligible patients should be referred for an
intake procedure, carried out by a member of the rehabilitation team, preferably by using the
Dutch Clinical Algorithm for patient needs in CR [22]. During this screening procedure, it is
decided which interventions are indicated (Fig 1.).
Fig. 1
Flowchart of multidisciplinary rehabilitation screening for cardiac rehabilitation

If a patient is referred for an exercise program, an additional assessment should be performed to

evaluate the nature and severity of the patient’s health problem in relation to their physical
functioning and the extent to which it can be modified.
This assessment focuses on identification of impairments of bodily functions, limitations of
activities, restrictions of participation and health problems that may influence the choice of
exercise activities to be included in the exercise program (Fig. 2). Limitations of activities may
regard their nature, duration and/or quality. The PT analyses the performance of problematic
activities that were identified using the patient-specific symptoms instrument [23]. The
performance of the problematic activities can be graded in terms of duration and intensity,
perceived fatigue (Borg Rating of Perceived Exertion (RPE) scale 6–20) and in terms of anxiety,
chest pain and dyspnoea. When a maximum or symptom-limited exercise test has not been
performed at baseline, or for (interim) evaluation of the exercise goals, the functional capacity
can be determined by the Shuttle walk test (SWT) [24, 25] or the 6-minute walk test (6MWT)
[26]. The MET method and/or the Specific Activity Scale (SAS) [27] can be used to estimate
whether any discrepancy between the actual performance level and the target level can be
eliminated with a suitable exercise program, and also for (interim) evaluation of the exercise
program. Based on the results of the assessment procedure, rehabilitation goals will be defined
(Fig. 2).

Fig. 2
Flowchart of the assessment procedure prior to exercise training. PSC; patient-specific complaints, SWT;
shuttle walk test, 6MWT; 6 minute-walk test

Treatment phase

The physiotherapeutic treatment during the outpatient rehabilitation phase comprises 3

modalities: information / advice, a tailored exercise program and a relaxation program (Fig. 3).
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Fig. 3
Flowchart of the treatment phase. ICD; implantable cardioverter defribillator

Information / advice
In the context of the physiotherapy treatment, the PT offers the patient assistance (guidance),
information and advice, geared towards their personal goals. Aims of information and advice
may include:
  Improving the patient’s understanding of their disorder and of cardiac rehabilitation;
 Encouraging compliance (including a physically active lifestyle);
 Promoting a suitable way to handle symptoms;
 Promoting return to work.

Tailored exercise program

Based on the individual goals, patients’ preferences and limitations established during the
assessment procedure in combination with results of the maximum or symptom-limited exercise
test and safety criteria, a definite exercise program is composed. These safety criteria are shown
in Table 3.
Table 3
Safety criteria for exercise training

• Implantable cardioverter defribillator (ICD)

- Cardiologist informs physiotherapist about safe heart rate range

- First 6–8 weeks after implantation no (submaximal) strength training of the upper extremities*

• Diabetes mellitus

- Check for wounds and sensory defects (monofilament test)

- Check blood glucose values before, during and after the exercise session. Blood glucose values ≤5 and
≥15 mmol/l are relative contraindications for exercising
 - Retinopathy of grade ≥3 is a relative contraindication for exercising

• Pulmonary problems

- No desaturation; this usually means that O2 saturation (SaO2) should remain ≥90 % during exercising (and
should not fall by ≥ 4 %)+

* Symmetrical functional movements below the patient’s pain threshold (with comfortable rather than forceful
movements and controlled breathing) can be started within 6 weeks after surgery (which can also help to prevent the
development of a frozen shoulder)
+
The physiotherapist should consult the patient’s pulmonologist or cardiologist to decide on the minimum individual
saturation value

If these criteria are violated or if signs of excessive strain occur during exercise, such as severe
fatigue or dyspnoea, angina, unexpected increase in breathing rate (> 40 breaths per minute),
pulse pressure reduction (≥ 10 mmHg), reduction of systolic blood pressure during exercise (>
10 mmHg) and increasing ventricular or supraventricular arrhythmias, the exercise session will
be terminated. In the early stages of the exercise program, the PT systematically measures the
patient’s blood pressure and heart rate (and rhythm) before, during and after the exercise session.
This supervised period is extended if any arrhythmias, ischaemia, angina, blood pressure
abnormalities or supraventricular or ventricular ectopy occur during exercising.
The tailored exercise program may comprise practising skills and activities (to enable patients to
utilise their general or strength endurance in motor activities), aerobic endurance training, local
and strength endurance training, practising functions/activities, and/or training to reduce risk
factors. In the case of comorbidities, the GDG recommends starting the exercise program based
on the exercise principles relating to the most restrictive pathology or disorder.
 Recommendation 4. Aerobic exercise
Aerobic exercise results in a reduction of general and cardiac mortality and morbidity rates, the
number of non-fatal recurrent AMIs, and risk factors, as well as in a significant increase in
exercise capacity, and is therefore recommended (Level 1) [9, 28–31]. High-intensity interval
training (HIT) may be recommended because it appears to be more effective than moderate-
intensity endurance training (Level 2) [32]. If HIT is applied, the cardiologist should be informed
and safety criteria should be closely adhered to.
The patient’s exercise capacity can be increased by means of aerobic endurance and interval
training, preceded by warming up and followed by cooling down. The exercise principles to be
applied depend on the goals of the physiotherapy and the patient’s physical condition. If the goal
is to improve the patient’s exercise capacity, the training level can be gradually increased over a
number of sessions from 50 to 80 % of VO2 peak/ heart rate reserve, 20–30 min per session, ≥ 2–
3 times a week. HIT typically consists of four 4-minute blocks, during which the patient
exercises at an intensity of 80–90 % of their VO2 peak/ heart rate reserve, with 3 min of active
recovery during which they exercise at 40–50 % of their VO2 peak/ heart rate reserve. Interval
training may be indicated for patients in poor physical condition not able to perform exercise of
long duration; if the patient is in sufficiently good physical condition, both endurance training
and interval training can be used. In both cases an initial 2 week phase of training at 40–50 % of
VO2peak/ heart rate reserve is recommended.
Exercise intensity should be based on the results of a maximum or symptom-limited exercise
test. The optimised exercise zone can be calculated using the Karvonen formula, which
calculates the exercise heart rate as a percentage of the heart rate reserve, added to the resting
heart rate [33]. If respiratory gas analysis was performed during a maximum or symptom-limited
exercise testing (because of unexplained dyspnoea or comorbidity [COPD]), exercise intensity
should preferably be based on a percentage of VO2 peak, VO2reserve or the ventilatory or
anaerobic threshold, converted into heart rate or wattage. If the patient is on beta-blockers, the
exercises should be based on the results of the maximum or symptom-limited exercise test with
beta-blocker use. If the patient’s heart rate increase during the maximum or symptom-limited
exercise test is severely limited, the exercise intensity should be based on a percentage of the
maximum capacity expressed in wattage or METs, and/or a Borg score (6–20).
 Recommendation 5. Submaximal strength training
Strength training is recommended as an adjunct to aerobic exercise [31]. Strength training
increases muscle strength and strength endurance, resulting in a reduction of activity limitations
and increased participation, especially among older (and fragile) patients, who experience
exertion-related limitations due to lack of muscle strength and strength endurance (Level 1) [34].
Submaximal strength training is not advised for patients who underwent surgery by sternotomy
during the first 8 weeks. Symmetrical functional exercises within the pain threshold can be
conducted after 6 weeks (in order to prevent a frozen shoulder) (Level 4).
Muscle strength can be improved using 8–10 exercises of the large muscle groups, at a frequency
of 2–3 times a week (depending on the goals) against a resistance that is gradually increased
from 50 % to 70–80 % of the one-repetition maximum (1RM). Exercising should preferably start
with 2 weeks at 30–40 % of 1RM. The GDG recommends estimating the maximum strength on
the basis of the 4–7RM, and then approaching the training load by using the pyramid diagram
(Fig. 4).
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Fig. 4
Pyramid diagram to determine resistance level

Table 4 shows a broad specification of the training variables for the various priorities within the
exercise program.
Table 4
Broad specification of training variables in the exercise program for the various priorities

Prioritised Specification of training variable

Practising skills and - Content: functional training of functions / skills / activities, including getting patient to
activities enjoy exercise

- Frequency: 2–3 times a week

Training aerobic - Frequency: 3–5 times a week

endurance

- Intensity: 50–80 % of VO2 peak / heart rate reserve (Borg score 11–16) , 20–60 min, or
high intensity interval training: 4-minute blocks at 80–90 % of VO2 peak/ heart rate reserve,
with 3 min of active recovery at 40–50 % of their VO2 peak/ heart rate reserve

- Structure: warming up, aerobic training (endurance or interval training), cooling down

Training local and - Content: circuit training and functional exercises geared toward individual goals
strength endurance

- Frequency: 2–3 times a week

- Intensity: 50–80 % of 1RM

- Warming up, strength training (1–3 series, 10–15 repetitions (with 1–2 min intervals), 8–
 Prioritised Specification of training variable

10 exercises), cooling down

Cardiovascular risk - Content: moderate intensity endurance training (Borg score 11–13)
reduction *

- Frequency: preferably every day

- Duration: 45–60 min a day

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* This refers to risk factors that can be modified by physical activity, such as obesity, mild to moderate
hypertension, type 2 diabetes mellitus and abnormal blood lipids composition

Relaxation program
 Recommendation 6. Relaxation program
A relaxation program (including breathing therapy) is recommended in CHD patients. A
relaxation program reduces cardiac mortality and morbidity, and has a favourable effect on
physical, psychological and social parameters (including resting heart rate and fear of exercise)
(Level 1) [35], and appears to be superior in combination with an exercise program compared
with only an exercise program (level 2) [36].
CHD patients should attend 2 sessions to try out the relaxation program. If the program proves
beneficial, they attend a further 4–6 sessions lasting 60–90 min each. The relaxation program
integrates cognitive therapy and physical relaxation exercises. The cognitive themes addressed
include understanding the value of rest, the balance between exertion and rest, the influence of
psychological factors on physical functioning and differentiating between cardiac factors in
relation to stress, anger, depression and pressure of time. Instructions for relaxation can be given
during exercising (active relaxation) or at rest (passive relaxation), partly in the context of
warming up and cooling down, and partly as a separate relaxation program.

Evaluation
In addition to a ‘continuous’ evaluation over the entire course of the exercise program, more
comprehensive interim evaluations should be carried out at least every 4 weeks, as well as at the
end of the CR program. If patients only partially attained their goals, but are likely not to
continue the rehabilitation activities independently (at home), the CR program is prolonged or
the patient is referred to a primary care physiotherapy practice. If patients did not attain their
goals and it seems likely that they have attained their maximum achievable level, they should be
referred back to the multidisciplinary CR team to explore other treatment options.
Table 5 shows the intended outcome for each physiotherapeutic goal, instruments recommended
for interim and final evaluation and the final targets that should be pursued. The PT also
evaluates whether the patient has acquired sufficient knowledge about secondary prevention, and
evaluates the goals of the relaxation program.
Table 5
Evaluation and screening instruments for each domain in physiotherapy for coronary heart
disease

Domain Evaluation instrument When Final outcome

1. Exploring • Ask for 5 most problematic activities At start and end of CR and Patient is aware of
one’s own (PSC) / or exercise program their own physical
physical limits • Ask patient to carry out problematic Monitoring heart rate, limits, i.e. they know
activities and score for duration and measuring blood pressure what level of
intensity, perceived fatigue (Borg RPE and scoring on Borg RPE exertion is possible
scale 6–20) and in terms of anxiety scale before, during and
and/or angina and/or dyspnoea after each session
2. Learning to • Monitor heart rate and blood pressure Patient can cope with
cope with physical limitations
physical
limitations

3. Optimising By physician At start and end of CR and Exercise capacity is

exercise capacity • Maximum or symptom-limited exercise / or exercise program at optimum or target
test (or in very exceptional cases SWT) level
plus Borg RPE scale (6–20); and as
desired scoring anxiety, angina and/or
dyspnoea
By coordinator/nurse
 Domain Evaluation instrument When Final outcome

• Subjective physical score on QoL-H

Questionnaire

By physiotherapist At start, every 4 weeks and Functional exercise

• As for goals 1 and 2 at end of CR and/ or capacity is at
• SWT or 6MWT exercise program optimum or target
• Possibly MET list and/or SAS level

4. Diagnostic • As for goal 3 by physiotherapist At start, every 4 weeks and Patient’s physical
• Scoring on Borg RPE scale (6–20) at end of the CR and/or condition and
exercise program and trainability are clear
continuous monitoring
during (before, during and
after exercise)

5. Overcoming • History-taking and observation At start and end of CR Patient is no longer

fear of physical • Questionnaire: see Multidisciplinary and/or exercise program afraid of exertion
exertion Guideline CR 2011 (www.nvvc.nl) (in
Dutch)

6. Developing an • History-taking (motivational At start and end of CR Patient has adopted a

active lifestyle interviewing) and/or exercise program physically active
• Monitor Movement and Health lifestyle
(www.tno.nl) (in Dutch)
• Post-rehabilitation activities started
 Domain Evaluation instrument When Final outcome

Focal points

Acquiring • Checklist for risk factors / unhealthy At start and end of CR Patient is familiar
information behaviour and/or exercise program with secondary
about secondary • Post-rehabilitation activities started prevention
prevention

Goals of • Evaluation list At interim and final Patient is familiar

relaxation • Using a flowchart evaluation of CR and/or with the relaxation
program relaxation program program and is able
to relax

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Borg RPE scale Borg Rating of Perceived Exertion; QoL-H Dutch quality of life questionnaire for heart
patients; 6MWT 6-minute walking test; MET metabolic equivalent of task; PSC Patient-specific
complaints; SAS Specific activity scale; SWT Shuttle walk test; CR cardiac rehabilitation

The PT should report to the multidisciplinary CR team about the treatment process, the treatment
outcomes and the recommendations (aftercare). This should happen at least at the end of the
treatment, but possibly also during the treatment period. In addition, the PT informs the patient’s
cardiologist, family physician and, if applicable, their rehabilitation physician or company
doctor. The CR is then either continued or concluded, after consultation with the
multidisciplinary team.

Post-rehabilitation phase
 Recommendation 7. Adoption and monitoring of physically active lifestyle
Patients are advised to continue exercise to reduce the cardiac risk profile after the CR (Level 1)
[37, 38]. A follow-up is recommended to encourage inactive patients to become physically active
again (Level 3) [39].
Patients may be referred to exercise programs offered by certified exercise facilities, but may
also individually make use of regular sports facilities. Patients with CHD who are unable to
maintain an active lifestyle without assistance, or have not yet attained all the physical goals
during the outpatient phase, but are deemed to be capable of doing so, should participate in an
exercise program which is designed in accordance with the KNGF guideline for exercise
interventions in CHD [40], or an equivalent KNGF-accredited intervention, supervised by a
primary care PT who has completed additional training. Monitoring is important in order to
identify any relapses at an early stage and intervene. The GDG recommends monitoring the
patient’s active lifestyle (preferably after 6 and 12 months), by activity monitoring devices and
or telephone or using a web-based or printed questionnaire.
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Conclusions and recommendations

This guideline provides an evidence-based instrument to assist in practical and clinical decision-
making during exercise-based CR in all phases of CR. Strong evidence is found for preoperative
physiotherapy, mobilisation at an early stage in the clinical phase, aerobic exercise, strength
training and relaxation therapy during the outpatient rehabilitation phase, and the adoption and
monitoring of a physically active lifestyle after outpatient rehabilitation.
As compared with the 2005 CR KNGF guideline [13] and the 2011 multidisciplinary CR
guideline [12], several novel topics have been included in the present guideline. First,
recommendations were made with respect to the preoperative phase for patients undergoing
CABG. Second, this guideline provides clear practical guidance on how to tailor exercise with
respect to intensity and duration individually, using results of a maximum or symptom-limited
exercise test. In this way we aim to reduce the considerable practice variation which has recently
been reported in Dutch CR centres [11], and thereby, to increase effectivity of exercise-based CR
in the Netherlands [10]. A third novel topic is the addition of HIT as a training strategy in CHD
patients. Finally, this guideline focuses more on the adoption and monitoring of a physically
active lifestyle after the outpatient rehabilitation phase.
The implementation of this guideline in clinical practice needs further evaluation [41].
Compliance to the guideline needs to be stimulated by, for example, adopting it into the Dutch
clinical algorithm [22]. Also research is needed on strategies to improve monitoring and follow-
up of the maintenance of a physical active lifestyle after supervised CR; for example by
implementing activity monitoring devices combined with telemonitoring, or by web-based
coaching platforms to guide patients [10]. Finally, more research is needed into characteristics
and modalities of physical activity and exercise training in cardiovascular risk management in
the long term [42].