Disease prevention has been targeted as a national goal, 1 declared a medical imperative, 2 and identified as a major component of the proposed healthcare reform plans, and cardiovascular disease, the most significant contributor to the nation's morbidity/mortality and healthcare costs, 3 has become a focal point for preventive efforts. Patients with identified coronary disease are at high risk for disease recurrence and cardiac death, and therefore represent good targets for preventive efforts. Modifiable risk factors, such as dyslipidemia, are more concentrated in patients with identified coronary disease, providing opportunity to implement preventive efforts efficiently within traditional forms of cardiovascular care. However, although numerous available guidelines 4-6 support this type of secondary prevention, current efforts at secondary prevention implementation are woefully inadequate. Most patients with established cardiovascular disease do not receive life-saving therapies directed at modifiable risk factors, 7 and among treated patients, most are not meeting the National Cholesterol Education Program (NCEP) targets for low-density lipoprotein (LDL) cholesterol or Joint National Committee VI targets for blood pressure control. 8,9

We proposed in the 1990s that remodeling existing cardiac rehabilitation programs into secondary prevention programs offered the most effective, efficient, and comprehensive approach to multifactoral risk factor modification for established coronary disease patients. 10 Working within the existing structure of the cardiac rehabilitation setting, targeted secondary prevention program components would include smoking cessation, serum cholesterol reduction, exercise, stress management, and psychological and occupational counseling. With the burden of cardiovascular illness increasing by 30% to 40% over the next 20 years, 11 and with more than 12 million cases of coronary heart disease and 2 million cases of congestive heart failure in the United States currently, 12 the need for these types of programs has never been greater.

What progress have we made in remodeling cardiac rehabilitation programs into comprehensive secondary prevention programs? In their article, Wyman et al 13 systematically review the surveillance and treatment of dyslipidemia among cardiac rehabilitation programs in Wisconsin. The answer is not good. Among the 1477 patients in the 16 programs reviewed from their state web-based database, 71% were taking lipid-lowering medication, 43% had been treated to the recommended goal, and 18% had received dietary counseling by a registered dietitian. This is disappointing documentation that cardiac rehabilitation currently is neither comprehensive nor effective at one of the easiest secondary preventive opportunities: implementation of pharmacologic dyslipidemia treatment.

What is the reason for such a disappointing report card? A number of key barriers clearly block successful delivery of preventive services, including poor leadership, lack of effective communication between programs and referring physicians, decreasing time that healthcare workers spend with the patients, absent and inadequate reimbursement for preventive services, and inadequate medical informatics support. 14 Underappreciation for the value of prevention, resulting from a lack of prioritized preventive training in essentially all levels of medical education 15 may be the fundamental issue from which these multiple barriers spring. Although curriculum revision efforts are underway to rectify this fatal educational flaw, 15 efforts directed at future healthcare providers cannot address the clear danger evident from the rising epidemic of cardiovascular disease we are seeing currently.

What can be done? Bad report cards should trigger action. It is time for large national organizations such as the American Heart Association, the NCEP, and the American College of Cardiology to facilitate cardiac rehabilitation program remodeling, demand adequate preventive service reimbursement, and include cardiac rehabilitation as a key component of their secondary prevention guidelines and quality improvement efforts. It is time for the American Association of Cardiovascular and Pulmonary Rehabilitation to work for its members by developing user-friendly tools and informatics systems that enable programs to provide effective, efficient, and comprehensive secondary prevention care. It is a call to action for cardiac rehabilitation program directors, managers, and staff to make changes in their own local environments toward this remodeling effort rather than be satisfied with the status quo. It is time; hopefully, it is not too late.

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