Introduction

During the coronavirus disease 2019 (COVID-19) pandemic many elective and outpatient healthcare activities have been cancelled or postponed. Also, a decline in admissions due to cardiac disease has been observed [1]. In many Dutch hospitals and specialised rehabilitation clinics, cardiac rehabilitation (CR) programmes have been shut down partially or even completely. In particular, group-based exercise training interventions and exercise testing are hardly possible. In addition, the public health measures implemented during the COVID-19 pandemic, above all quarantine and isolation, have been shown to be associated with anxiety, anger and stress, which is associated with unhealthy lifestyle behaviour, including a reduction in physical activity and an unhealthy diet [2]. Therefore, there is an urgent need for upscaling and reorganisation of CR and secondary prevention services. Recently, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for CR during the COVID-19 pandemic. These recommendations are partly based on a recent statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology [3], supplemented with insights from the recently published Dutch Telerehabilitation guidelines [4] and practical experiences from the largest Dutch CR centres. The importance of continuing the delivery of (cardiac) rehabilitation during the COVID-19 pandemic by means of telerehabilitation programmes without face-to-face contact is emphasised by the prompt reimbursement of these programmes by the Netherlands Health Institute (NZa) and with support from the Netherlands Health Institute (ZiN).

General recommendations

  • Support acute cardiac wards in providing summarised but highlighted important information/recommendations on secondary prevention (not forgetting physical activity and mental impact) before hospital discharge.

  • In the case of shortened CR programmes, concentrate efforts on the main core components (i.e. lifestyle risk management, psychosocial support, medical advice, education) with an individualised approach based on psychological symptoms, residual cardiac risk and lifestyle assessment.

  • Replace face-to-face sessions by remote assessment and monitoring/guiding, according to local equipment and expertise (telephone, text messaging, e‑mails, video consultations, web-based platforms and applications).

  • Perform patient assessment and risk stratification with an exercise test whenever possible. If not possible, use other tools to assess the cardiovascular risk and physical fitness in order to provide personalised exercise advice and to guide telerehabilitation (see Tab. 1).

  • For COVID-19-positive patients, postpone the exercise programme if fever, symptoms or other signs of COVID-19 infection are present [3]. Evaluate exercise resumption on an individual basis. In general, in patients with light-to-moderate symptoms, gradually restart the exercise programme after a fever-free period of 1 week and a symptom-free period of 48 h. Whenever possible, do not postpone all other CR components but provide them remotely (see Tab. 1).

  • For general safety and hygiene measures take into account the recommendations of the Dutch National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu,RIVM) and the Dutch Federation of Medical Specialists (Federatie Medisch Specialisten, FMS) [5, 6].

Table 1 Modes of delivery of cardiac rehabilitation (CR) according to current guidelines and recommendations for alternatives during the coronavirus disease 2019 (COVID-19) pandemic
Full size table

Specific recommendations are presented in Tab. 1.