An evolving journey of cardiac rehabilitation

In the summer of 1832, a young 30-year-old playwright, Alexandre Dumas, journeyed through the Alps and around the highest peak in Western Europe, the Mont Blanc, discovering a region that would profoundly inspire his writings.1 Almost 200 years later, on 5 September 2024, a Geneva University Hospital multidisciplinary team accompanied a group of 29 cardiac patients around that same mountain and journey. Over a 9-day trek, three countries were traversed, covering more than 160 km and climbing almost 10 000 m of vertical ascent, peaking at an altitude of 2700 m. The team was composed of three physicians including myself, nurses, physiotherapists, and three mountain guides. The trek consisted of nine mountain hut-to-hut stages, covering between 15–30 km and ∼1200 m of ascent per day, over a variety of terrain, ranging from lush meadows to rugged mountain paths, scree fields, and rivers, both below and above the tree line (Figure 1). The days began with an early rise and breakfast and a typical start to the hike at around 08:30. Patients carried their own daily gear, food, and water in a 30 L backpack; heavier gear was transported from hut to hut by road. The patients were split daily into three groups with adapted paces and with regular meeting points throughout the day. Harsh weather conditions, including rain, wind, cool temperatures, and snow at high altitude, were encountered on most days. Hiking towards the Fenêtre d'Arpette, Valais, Switzerland Patients were selected from a pool who had completed a structured cardiac rehabilitation programme, had followed a specific training scheme, and had expressed a keen interest in participating in the project. The average age of the patients was 60.9 years; 27 (93%) were male and had presented a cardiac index event at some point in the previous 7 years. All, with the exception of four who withdrew because they experienced fatigue or muscle soreness, were able to complete the trail without any cardiovascular complication, which we believe testifies to the safety of physical exertion during and after cardiac rehabilitation. The project was met with unanimous patient satisfaction. The Tour du Mont Blanc described here was the latest and longest of 10 years of annual projects designed to accompany patients in an innovative and highly participatory cardiac rehabilitation exercise. The projects have been structured and led by the Geneva University Hospitals (HUG) cardiology service and have benefitted from consistent support by the Fondation Privée des Hôpitaux Universitaires de Genève (Geneva University Hospitals Private Foundation). We strongly believe this initiative has done much to enhance the physical health and psychosocial wellbeing of our patients and has created an on-going source of social support among them. It has become a major motivation to us to continue and further strengthen our work in this emerging area of cardiac care. Up until the 1950s, cardiovascular patient care following myocardial infarction typically restricted physical activity, but since then has evolved significantly. In a recent review of cardiac rehabilitation (also referred to as cardiovascular rehabilitation), Thomas states that ‘further innovation is needed today to increase the reach of cardiac rehabilitation’ and that ‘the participation gap in cardiac rehabilitation…..is one of the largest gaps in the quality of care in cardiovascular medicine’.2 There are numerous reasons for the gap that Thomas refers to. They include patients’ level of motivation and adhesion, the health care provider’s degree of familiarity with rehabilitation programmes, and the capacity of health care systems to support these. Cardiac rehabilitation is a multidisciplinary multi-faceted process aimed at providing secondary prevention to cardiac patients. The physical aspect of this rehabilitation is ideally complemented and supported by a pro-active social and psychological environment because patients often present a range of reactions to acute cardiovascular events. For some, it can represent the end of perceived autonomy and hence have an adverse impact on self-image, and their participation is therefore a priority. Cardiac rehabilitation typically comprises three stages starting with the early clinical phase followed by an in- or outpatient structured process that culminates in a long-term maintenance phase that can often present significant challenges. We therefore believe it is essential to accompany patients during this period and help them deal with any questions and doubts they may have. We have previously reported that the implementation of a structured secondary cardiovascular prevention programme after acute coronary syndromes was found to be associated with an improved control of cardiovascular risk factors and a level of attendance to rehabilitation programmes; it was also associated with significant reductions in cardiac death, myocardial infarction, and stroke at 1 year for patients ≤65years old.3 Furthermore, in the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice, beyond a Class IA recommendation for patient participation in multidisciplinary exercise-based cardiac rehabilitation, we recommended that methods to increase referral and uptake and hence encourage long-term adherence to healthy behaviours ‘should be considered’ (Class IIaB), as this remains a major challenge.4,5 Beyond the benefits that this experience brought to the patient participants, it was also evident that there are environmental and climatic changes occurring at our latitudes, notably in the Alps, which may potentially impact health.6 These issues have been previously mentioned in the ESC prevention guidelines and will need to be given further attention and integrated in future cardiovascular patient management strategies. In the quest for innovative approaches to increase the uptake of cardiac rehabilitation, we believe our experience accompanying patients with a history of cardiac events in a challenging outdoor environment further strengthens current day recommendations regarding the value of active patient participation. We hope this initiative will serve as an example of what is possible following a major cardiovascular clinical event and that it can bring hope to some, convince others, and encourage those who are already motivated to engage in healthy lifestyles.