What are the recommended follow-up protocols for patients who have completed a cardiac rehabilitation programme?

After completing a cardiac rehabilitation programme, patients should have ongoing follow-up tailored to their clinical status and individual needs. This includes regular monitoring of physical and psychological health, reinforcement of lifestyle advice, and support for adherence to secondary prevention measures. Follow-up should consider the patient's physical and psychological status, work environment, and social circumstances when advising on returning to normal activities and work. Stress management and health education components should continue to be reinforced as part of comprehensive care. Patients should be offered continued support and information on economic, welfare, housing, and social issues as needed. Additionally, follow-up should include monitoring for any complications or comorbidities that may affect the patient's condition or rehabilitation progress. For patients with heart failure, follow-up intervals depend on clinical stability, with at least 6-monthly reviews for stable patients and more frequent monitoring if the condition changes. Communication with patients should be clear, culturally sensitive, and inclusive of carers or partners if the patient wishes. If patients do not attend or complete rehabilitation, proactive contact such as motivational letters or phone calls should be made to encourage engagement. Finally, follow-up should be part of a structured care system with clear responsibility for ongoing management and secondary prevention after myocardial infarction (MI) or heart failure.

Key follow-up elements include:

• Regular clinical reviews tailored to stability and comorbidities.
• Reinforcement of lifestyle and secondary prevention advice.
• Psychological and social support continuation.
• Monitoring and managing medication and complications.
• Encouragement and support to maintain physical activity and stress management.
• Clear communication and involvement of carers if desired.
• Structured care pathways with clear responsibility for follow-up.

This approach aligns with NICE guidance on acute coronary syndromes and chronic heart failure management, emphasizing personalised, ongoing care after cardiac rehabilitation completion ¹,².