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The ESC Handbook
of Cardiovascular
Rehabilitation
EUROPEAN SOCIETY OF CARDIOLOGY PUBLICATIONS
The ESC Textbook of Cardiovascular Medicine (Third Edition)
Edited by A. John Camm, Thomas F. Lüscher, Gerald Maurer, and Patrick W. Serruys
The ESC Textbook of Intensive and Acute Cardiovascular Care (Second Edition)
Edited by Marco Tubaro, Pascal Vranckx, Susanna Price, and Christiaan Vrints
The ESC Textbook of Cardiovascular Imaging (Second Edition)
Edited by Jose Luis Zamorano, Jeroen Bax, Juhani Knuuti, Patrizio Lancellotti,
Luigi Badano, and Udo Sechtem
The ESC Textbook of Preventive Cardiology
Edited by Stephan Gielen, Guy De Backer, Massimo Piepoli, and David Wood
The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-​based learning with
multiple choice questions
Edited by Harran Burri, Carsten Israel, and Jean-​Claude Deharo
The EACVI Echo Handbook
Edited by Patrizio Lancellotti and Bernard Cosyns
The ESC Handbook of Preventive Cardiology: Putting prevention into practice
Edited by Catriona Jennings, Ian Graham, and Stephan Gielen
The EACVI Textbook of Echocardiography (Second edition)
Edited by Patrizio Lancellotti, Jose Luis Zamorano, Gilbert Habib, and Luigi Badano
The EHRA Book of Interventional Electrophysiology: Case-​based learning with multiple
choice questions
Edited by Hein Heidbuchel, Matthias Duytschaever, and Harran Burri
The ESC Textbook of Vascular Biology
Edited by Robert Krams and Magnus Back
The ESC Textbook of Cardiovascular Development
Edited by Jose Maria Perez Pomares and Robert Kelly
The ESC Textbook of Cardiovascular Magnetic Resonance
Edited by Sven Plein, Massimo Lombardi, Steffen Petersen, Emanuela Valsangiacomo,
Chiara Bucciarelli-​Ducci, and Victor Ferrari
The ESC Textbook of Sports Cardiology
Edited by Antonio Pelliccia, Heid Heidbuchel, Domenico Corrado, Mats Borjesson, and
Sanjay Sharma
The ESC Handbook on Cardiovascular Pharmacotherapy
Edited by Juan Carlos Kaski and Keld Per Kjeldsen

FORTHCOMING
The ESC Textbook of Textbook of Intensive and Acute Cardiovascular Care
(Third Edition)
Edited by Marco Tubaro, Pascal Vranckx, Susanna Price, Christiaan Vrints, and Eric Bonnefoy
The ESC Textbook of Cardiovascular Imaging (Third Edition)
Edited by Jose Luis Zamorano, Jeroen Bax, Juhani Knuuti, Patrizio Lancellotti,
Bogdan Popescu, and Fausto Pinto
The ESC Handbook of
Cardiovascular Rehabilitation
Editors
Ana Abreu
Cardiovascular Rehabilitation Centre of CHULN and FMUL,
Department of Cardiology, Hospital Santa Maria, CHULN, Lisbon
Faculty of Medicine of the University of Lisbon (FMUL),
Lisbon, Portugal

Jean-​Paul Schmid
Department of Cardiology, Clinic Barmelweid, Barmelweid,
Switzerland

Massimo Francesco Piepoli

Heart Failure Unit, Cardiology, Guglielmo da Saliceto Hospital,
Piacenza, University of Parma
Institute of Life Sciences, Sant’Anna School of Advanced Studies,
Pisa, Italy

Editorial Assistant
Jorge A Ruivo
Cardiovascular Rehabilitation Centre of CHULN and FMUL,
Department of Cardiology, Hospital Santa Maria, CHULN,
Lisbon, Portugal

1
3
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 Foreword

Until recently cardiac rehabilitation has been the poor relation of cardiovascular
medicine. For several years it was only performed in a few places where enthusiasts
organized rehabilitation programmes. It was a long time before scientific evidence
was provided which changed the way the medical community now regards cardiac
rehabilitation.
Today cardiac rehabilitation has been ‘rehabilitated’ and is present and recom-
mended in all the guidelines produced by the main organizations around the world.
Many cardiovascular departments in a number of countries now have organized pro-
grammes of cardiac rehabilitation. However, there are still several obstacles that have
to be identified in order to apply the best solutions. A fundamental obstacle is the
need for appropriate education of the medical community that is potentially more
involved with the use and recommendation of cardiac rehabilitation. That is where
this book plays a central role. It provides comprehensive information, from basic
principles to the organization of cardiac rehabilitation centres, including a detailed v
description of the practical aspects of developing and implementing cardiac rehabili-
tation in a variety of settings and populations. It is based on the recommendations of
the European Association of Preventive Cardiology (EAPC) of the European Society
of Cardiology (ESC), but also includes relevant information based on the extensive
experience of the authors. It is the first structured comprehensive EAPC publication
dealing with cardiac rehabilitation will certainly be an important milestone in the field.
This book will also make an important contribution to promoting cardiac rehabili-
tation (cardiovascular rehabilitation in a broader sense) on a global scale, particularly
in places where there are difficulties in developing appropriate rehabilitation pro-
grammes, or even reluctance to do so. The World Heart Federation (WHF), as a
global organization, is also engaged in promoting good practice around the world and
identifies itself with projects, such as this one, coming from one of its strategic part-
ners with an enormous potential to help in the global promotion of cardiovascular
rehabilitation.
We live in a very complex world and at the time of writing this foreword we are
facing the greatest challenge of our generation—​the coronavirus pandemic. We will
only be able to overcome this enormous challenge through the global cooperation
by the medical and scientific community. Whatever the outcome of this crisis, the
need for global cooperation will certainly be reinforced, and that is where projects
such as this book can help to disseminate knowledge and implement programmes
that can help people to live longer and better.
Congratulations to the editors, the authors, and EAPC/​ESC.
Fausto J Pinto
University of Lisbon, Portugal
Past President of the ESC
President Elect of the WHF
 Preface

This book is intended as a practical handbook on the implementation of rehabili-

tation for cardiovascular patients in clinical practice. Part of the mission of the
European Association of Preventive Cardiology (EAPC), of the European Society of
Cardiology (ESC), is to promote the education of healthcare professionals on this
subject and this book will help to overcome many barriers.
Despite the fact that ‘cardiac rehabilitation’ is the most commonly used term, the
editors prefer the term ‘cardiovascular rehabilitation’ because of its broader meaning,
covering preventive measures in all cardiovascular patients. Underlying pathophysio-
logical mechanisms and preventive interventions and strategies extend beyond the
heart to the whole cardiovascular system, and to other systems too. Also, the scope
of rehabilitation has grown fast and includes increasingly complex patients. More indi-
cations will surely be present in future editions.
In this respect, although the term ‘cardiac rehabilitation’ is often used in the book,
vi ‘cardiovascular rehabilitation’ should be considered a more appropriate, inclusive,
precise, and less restrictive term. The editors expect that this term will become the
predominant term in the near future and therefore decided to keep it in the title of
this book.
We hope you will enjoy reading this book as much as we enjoyed preparing it.
Please do not hesitate to contact us with your advice, comments, and criticism, all of
which will be considered for future editions.
Ana Abreu
Jean-Paul Schmid
Massimo Francesco Piepoli
 Introduction

Why cardiovascular or cardiac rehabilitation?

Cardiovascular disease (CVD) prevention is defined as a coordinated set of actions,
at the population level or targeted at an individual, that are aimed at eliminating
or minimizing the impact of CVD and their related disabilities. Despite the signifi-
cant reduction in morbidity and mortality over the past decades, CVD remains the
number one cause of death in the world. More than four million people die from
CVD each year in Europe, mainly due to coronary heart disease.
A lot of progress has been made in the treatment of the disease, with greater access
to procedural interventions and pharmacological treatment. Nevertheless, up to one
in every five patients admitted to the hospital for a myocardial infarction (MI) has a
subsequent MI or stroke within the first year. Secondary prevention is crucial in re- vii
ducing these recurrence rates and improving cardiovascular health in the long-​term.
An important and cost-​effective secondary prevention strategy is cardiac rehabili-
tation (CR), a multifactorial, multidisciplinary and comprehensive intervention which
started in the 960s. It has been shown to reduce mortality, hospital readmissions,
and costs, and to improve exercise capacity, quality of life, and psychological well-​
being. CR programmes, or better-named cardiovascular rehabilitation programmes,
should be well organized and meet minimal criteria to ensure optimal quality to be
able to prove their merit.
The ESC prevention guidelines recommend participation in a CR programme
for all hospitalized patients following an acute coronary event or revascularization,
and for patients with heart failure. Even with these recommendations, CR remains
under-​utilized with less than 50% of patients participating in a CR programme after
an acute event. CR uptake needs to be promoted and healthcare professionals
should be made aware of the importance of CR and given proper guidance on how
to implement the recommendations. Prevention seems more important than ever.
Why should we treat a disease if we can prevent it? This handbook is part of the pre-
ventive cardiology curriculum and is the next step in the transition towards our own
unique subspecialty, the Preventive Cardiologist.

Improving the quality of care

The European Association of Preventive Cardiology (EAPC) provides a comprehen-
sive approach towards CVD prevention by incorporating it as a key aspect in every
phase of life. One of the objectives is to promote excellence in education about and
practice of CR, not only in the short run but throughout life. There are many ways
 in which the EAPC contributes to this objective. CR has a prominent place at the
annual congress organized by the EAPC. New evidence is presented, new guidelines
are explained, and new developments are discussed. Multiple courses on preventive
cardiology and CR are organized and endorsed regularly by experts from the EAPC.
In addition, educational materials and webinars are created and shared. Various
decision-​making tools, such as the Expert tool and HeartQoL, have been developed
to support healthcare professionals in their daily practice. A patient education web-
site has been created to offer concise and reliable information on primary and sec-
ondary prevention, including CR, to the public. Raising awareness among patients will
increase adherence to therapy. The quality of care in CR centres throughout Europe
is monitored and promoted through the EAPC accreditation system. Every centre
that meets a set of predefined criteria, which ensure that the care delivered is up to
date and of sufficient quality, can request accreditation for a minimum of three years.
All of these actions have the purpose of further improving the quality of cardiovas-
cular rehabilitation throughout Europe and support centres in all possible ways.
Introduction

Why is this handbook needed?

A lot of information is available on why CR should be performed and in which types of
viii patient. It has a permanent place in any book on secondary prevention. There are also
many academic textbooks focusing on the pathophysiological aspects of exercise and
rehabilitation. However, there is currently no book available that provides guidance on
adequate organization of a CR centre and the management of CR patients in a compre-
hensive, structured, and practical manner that is consistent with the guidelines.
Because of the diversity of healthcare organizations and infrastructure in ESC
member states, the information in this handbook can be tailored to your own
context. For example, it answers questions on alternative models of CR (such as
hospital-​based versus home-​based rehabilitation) and on changing technologies.
CR requires the input and expertise of a whole range of healthcare professionals,
and this handbook was developed using this holistic approach. The perspective of all
healthcare professionals involved is taken into account. As CR is not a ‘one size fits
all’ solution, different patient types and the different aspects of CR are described.
How do you deal with high-​r isk patients? What about low-​r isk patients? And the eld-
erly and frail? How to deal with depression? Return to work?
A particular challenge is adherence to medication and lifestyle recommendations.
This book provides a specific chapter on the factors that are important for adher-
ence and the strategies that can be used to improve it.
This handbook is the perfect supplement to the ESC Handbook of Preventive
Cardiology and the ESC Textbook of Preventive Cardiology and provides practical tools
for use in everyday clinical situations, supported by science and evidence. It is the
result of the contribution of and collaboration between the best experts in cardiac
rehabilitation in Europe. I would like to congratulate and thank the authors for this
excellent endeavour and I hope that you enjoy reading this handbook on cardiovas-
cular rehabilitation and that it will guide you in your daily practice.
Paul Dendale
Arne Janssen
 Contents

Contributors xv
Reviewers xviii
Acknowledgements xix
Abbreviations xxi

. Evidence for cardiac rehabilitation in the modern era 

Summary 
Introduction 
The evidence 
Conclusion 8
References 9
Further reading 0 ix

2. Different settings for cardiac rehabilitation 

Summary 
Introduction 
Organization of cardiac rehabilitation 2
Alternative models of cardiac rehabilitation 2
The core components of home-​based cardiac rehabilitation 5
Effects of home-​based cardiac rehabilitation compared with
hospital-​or centre-​based cardiac rehabilitation 5
Conclusion 6
References 6
Further reading 7
3. Cardiac rehabilitation: referral and barriers 9
Summary 9
Introduction 9
Barriers to CR uptake 20
Conclusion 24
References 24
Further reading 26
 4. Human and material resources, structural, and organizational
recommendations 27
Summary 27
Introduction 27
Human resources and organizational issues 28
Organizational aspects, infrastructural and material resources 30
Conclusion 33
References 33
Further reading 33
5. Recovering from acute heart events 35
Summary 35
Introduction 35
Cardiac rehabilitation after acute heart events 36
Contents

Conclusion 38
References 38
Further reading 39
x 6. Early assessment and risk stratification 4
Summary 4
Introduction 4
Early assessment 4
Risk profile 43
Conclusion 46
References 46
Further reading 47
7. Modalities of physical activity and exercise in the management
of cardiovascular health in individuals with cardiovascular
risk factors 49
Summary 49
Introduction 49
Effects of physical activity and exercise training on CVD
risk factors 50
How to prescribe exercise for improvement of CVD
risk factors 52
Conclusion 55
References 55
Further reading 57
 8. Exercise training for low-​risk patients 59
Summary 59
Introduction 59
Assessment of low-​risk patients 60
Prescription for aerobic endurance training 6
Prescription for dynamic resistance training 65
Precautions and safety in exercise training for low-​risk patients 67
Conclusion 68
References 68
9. Exercise training programmes for high-​risk and specific
groups of patients 7
Summary 7
Introduction 7

Contents
Definition of ‘high-​risk’ patients 7
Assessment of high-​risk patients 72
Determination of exercise intensity 73
Exercise modalities 77 xi
Specific populations (patients with ICD, CRT, and assist devices) 80
Conclusion 83
References 84
Further reading 85
0. Diet and nutritional aspects of cardiac rehabilitation 87
Summary 87
Introduction 87
Diet and nutritional aspects in patients with
cardiovascular disease 88
Accounting for comorbidities, diabetes mellitus,
and hypertension 90
Nutritional aspects in patients with malnutrition issues 90
Weight management and risk of cachexia and frailty 9
Conclusion 94
References 94
. Educational intervention 97
Summary 97
Introduction 97
General considerations 97
Conclusion 0
 References 0
Further reading 0
2. Intervention for depression, anxiety, and stress in
cardiovascular patients 03
Summary 03
Introduction 03
How does depression increase cardiac mortality? 04
How do we diagnose depression in cardiac patients? 04
How do we treat depression? 05
Is treatment of depression in cardiac patients able to
reduce mortality? 08
Conclusion 09
References 09
Further reading 0
Contents

3. Management of non-​conventional risk factors 

Summary 
xii Introduction 
Uric acid 2
Circulating and urinary biomarkers 2
Genetic markers 3
Vascular damage 3
Kidney dysfunction 4
Conclusion 4
References 4
4. How to improve adherence to medication and lifestyle measures 7
Summary 7
Introduction 7
Factors influencing non-​adherence, non-adherence risk groups,
and facilitators of adherence 8
How to measure adherence 9
Specific strategies for promoting pharmacological adherence 20
Specific strategies for promoting non-​pharmacological adherence 2
Cardiac rehabilitation: secondary prevention programmes
and adherence 22
Models and theories of change and adherence 23
Techniques for behavioural change 23
New electronic technologies 24
Conclusion 24
 References 25
Further reading 26
5. Cardiac rehabilitation for geriatric and frail patients 27
Summary 27
Introduction 27
Cardiac rehabilitation in the elderly 28
Frailty definition and evaluation 30
Cardiac rehabilitation in frail elderly patients 30
Exercise interventions in frail patients 3
Other components of cardiac rehabilitation interventions
in elderly patients 32
Conclusion 33
Case  33
Case 2 35

Contents
References 36
Further reading 38
6. Return to work 39 xiii

Summary 39
Introduction 39
Predictors of return to work 40
Conclusion 43
References 43
Further reading 44
7. Specific issues with physical activity after cardiac rehabilitation 45
Summary 45
Introduction 45
How to promote regular physical activity after phase II
cardiac rehabilitation 46
How to prescribe and/​or recommend regular physical activity
after phase II cardiac rehabilitation 47
Conclusion 49
References 49
Further reading 49
8. Cardiopulmonary exercise test 5
Summary 5
Introduction 5
How to perform a cardiopulmonary exercise test 54
Interpreting the results of cardiopulmonary exercise tests 55
 Conclusion 6
References 6
Further reading 62
9. Technological issues 63
Summary 63
Introduction 63
Monitoring in cardiac rehabilitation 64
Digital health 66
Future directions 67
References 68
Further reading 70
20. eHealth in cardiac rehabilitation 7
Summary 7
Contents

Introduction 7
How to implement cardiac tele-​rehabilitation: organizational
aspects 72
xiv How to implement cardiac tele-​rehabilitation: practical aspects 73
How to cope with legal frameworks and changing technologies 74
Conclusion 75
References 75
Further reading 76
2. The EXPERT tool: how to make exercise prescription easy 77
Summary 77
Introduction 77
The EXPERT tool: features and functionalities 79
The EXPERT training centre 83
Conclusion 84
Acknowledgement 84
References 84
Further reading 85

Index 87
 Contributors
Ana Abreu
Cardiovascular Rehabilitation Centre
of CHULN and FMUL, Department of
Cardiology, Hospital S. Maria, CHULN,
Lisbon; Faculty of Medicine of the
University of Lisbon (FMUL),
Lisbon, Portugal
Chapters 4, 4, and 5
Manuela Abreu
Department of Psychiatry, Hospital
Santa Maria, CHULN
Faculty of Medicine of University of
Lisbon, Lisbon, Portugal
Chapter 2
Marco Ambrosetti
Istituti Clinici Scientifici Maugeri,
Care and Research Institute of Pavia,
Department of Cardiac Rehabilitation,
Pavia, Italy
Chapter 7
Cindel Bonneux
Expertise Center for Digital Media,
Faculty of Sciences, Hasselt University,
Diepenbeek, Belgium
Chapter 9
Karin Coninx
Expertise Centre for Digital Media,
Faculty of Sciences, Hasselt University,
Diepenbeek, Belgium
Chapter 2
Ugo Corrà
Department of Cardiology, Istituti
Clinici Scientifici Salvatore Maugeri,
IRCCS Veruno, Veruno, Italy
Chapters 2, 5, and 9
Margaret E. Cupples
Centre for Public Health, Queen’s
University, Belfast, Northern Ireland
Chapters 3 and 
Constantinos H. Davos
Cardiovascular Research Laboratory,
Biomedical Research Foundation,
Academy of Athens, Athens, Greece
Chapters  and 0
Paul Dendale
Department of Cardiology, Jessa
Hospital, Hasselt, Belgium
Faculty of Medicine & Life Sciences, xv
Hasselt University, Hasselt, Belgium
Chapters 9 and 20
Wolfram Doehner
BCRT—​Berlin Institute of Health
Centre for Regenerative Therapies,
Charité Universitätsmedizin Berlin,
Berlin, Germany
Department of Cardiology (CVK);
German Centre for Cardiovascular
Research (DZHK), Partner Site Berlin,
Charité Universitätsmedizin Berlin,
Berlin, Germany
Chapter 0
Ines Frederix
Department of Cardiology, Jessa
Hospital, Hasselt, Belgium
Faculty of Medicine & Life Sciences,
Hasselt University, Hasselt, Belgium
Faculty of Medicine & Health Sciences,
Antwerp University, Antwerp, Belgium
Antwerp University Hospital (UZA),
Antwerp, Belgium.
Chapter 9 and 20
 Esteban Garcia-Porrero
Cardiologist, Complejo Asistencial
Universitario de León, Spain
Chapter 17
Martin Halle
Department of Prevention and Sports
Medicine, University Hospital ‘Klinikum
rechts der Isar’, Technical University
Munich, Munich, Germany
DZHK (German Center for
Cardiovascular Research), partner
site Munich Heart Alliance, Munich,
Germany
Chapter 7
Contributors
Dominique Hansen
REVAL— Rehabilitation Research
Center, Faculty of Rehabilitation
Sciences, Hasselt University,
Diepenbeek, Belgium
xvi
Jessa Hospital, Heart Center Hasselt,
Hasselt, Belgium
BIOMED— Biomedical Research
Center, Faculty of Medicine and
Life Sciences, Hasselt University,
Diepenbeek, Belgium
Chapters 7 and 21
Marie Christine Iliou
Cardiac Rehabilitation and Secondary
Prevention Department, Corentin
Celton, Assistance Publique Hôpitaux
de Paris, France
Chapters 6 and 11
Miguel Mendes
Department of Cardiology, Hospital
de Santa Cruz— CHLO, Carnaxide/
Portugal
Chapter 14
Luca Moderato
Heart Failure Unit, Cardiology,
Guglielmo da Saliceto Hospital,
Piacenza, and University of Parma, Italy
Chapter 18
Catherine Monpere
Cardiac Prevention and Rehabilitation
Center Bois Gibert, Mutuelle Française
Centre Val de Loire, Tours, France
Chapter 6
Roberto Pedretti
Cardiovascular Department, IRCCS
MultiMedica, Sesto San Giovanni (MI),
Italy
Chapter 13
Massimo Francesco Piepoli
Heart Failure Unit, Cardiology,
Guglielmo da Saliceto Hospital,
Piacenza, University of Parma
Institute of Life Sciences, Sant’Anna
School of Advanced Studies,
Pisa, Italy
Chapters 3 and 18
Bernhard Rauch
Institut f ür Herzinfarktforschung,
Ludwigshafen, Germany
Chapter 1
Rona Reibis
Center of Rehabilitation
Research, University of
Potsdam, Germany
Cardiac Outpatient Clinic, Am Park
Sanssouci, Potsdam, Germany
Klinik am See, Rehabilitation Center
for Internal Medicine, Rüdersdorf,
Germany
Chapter 16
Jorge A Ruivo
Editorial Assistant, Lisbon Medical
School/Cardiovascular Centre of
University of Lisbon, Portugal
Martijn Scherrenberg
Department of Cardiology, Jessa
Hospital, Hasselt, Belgium
Faculty of Medicine & Life Sciences,
Hasselt University, Hasselt, Belgium
Chapter 19
Jean- Paul Schmid Heinz Völler
Department of Cardiology, Clinic Department of Rehabilitation Medicine,
Barmelweid, Barmelweid, Switzerland Faculty of Health Science, University of
Chapters 2, 4, 5, and 9 Potsdam, Germany
Klinik am See, Rehabilitation Center
Aimilia Varela for Internal Medicine, Rüdersdorf,
Cardiovascular Research Germany
Laboratory, Biomedical Research Chapter 16
Foundation, Academy of Athens,
Athens, Greece Matthias Wilhelm
Chapter 10 Department of Cardiology, Inselspital,
Bern University Hospital, University of
Carlo Vigorito Bern, Switzerland
Department of Translational Medical Chapter 8
Sciences, University of Naples

Contributors
Federico II,
Naples, Italy
Chapter 15

xvii
 Reviewers

Ugo Corrà Constantinos H. Davos

Department of Cardiology, Istituti Cardiovascular Research Laboratory,
Clinici Scientifici Salvatore Maugeri, Biomedical Research Foundation,
IRCCS Veruno, Veruno, Italy Academy of Athens, Athens, Greece

xviii
 Acknowledgements

In addition to all the authors whose expertise has enabled this book, the editors wish
to acknowledge all the members (past and present) of the Secondary Prevention and
Cardiac Rehabilitation who contributed to the concept of this book and, also, to the
Board members of EAPC who answered enthusiastically to this project.
Many thanks to all!
Jorge A Ruivo
Lisbon Medical School/Cardiovascular Centre of University of Lisbon, Portugal

xix
 Abbreviations

ACE angiotensin-​converting enzyme

ACS acute coronary syndrome
AF atrial fibrillation
AI artificial intelligence
AMI acute myocardial infarction
AT angiotensin II type 
BMI body mass index
BNP brain natriuretic peptide
BP blood pressure
BR breathing rate
CABG coronary artery bypass grafting
xxi
CAD coronary artery disease
CANTOS Canakinumab Anti-​Inflammatory Thrombosis Outcomes Study
CBT cognitive behavioural therapy
CCS chronic coronary syndrome
CHF congestive heart failure
CI confidence interval
COPD chronic obstructive pulmonary disease
CPET cardiopulmonary exercise testing
CR cardiac rehabilitation
CROS Cardiac Rehabilitation Outcomes Study
CRT cardiac resynchronization therapy
CV cardiovascular
CVD cardiovascular disease
DASH dietary approaches to stop hypertension
DM diabetes mellitus
EAPC European Association of Preventive Cardiology
EB exercise-​based
ECG electrocardiogram
EE energy expenditure
EM early mobilization
ESC European Society of Cardiology
 EST exercise stress test
ET exercise training
ETS Essential Tool Subset
EXPERT Exercise Prescription in Everyday Practice & Rehabilitative Training
FEV forced expiratory volume in  sec
FITT frequency,intensity, time, type
FVC forced vital capacity
GP general practitioner
HADS Hospital Anxiety Depression Scale
HBCR hybrid cardiac rehabilitation
HDL high-​density lipoprotein
HF heart failure
Abbreviations

HIIT high-​intensity interval training

HR heart rate
HRQoL health-​related quality of life
HRR heart rate reserve
xxii hs-​CRP high-​sensitivity C-​reactive protein
HTN hypertension
ICD implantable cardioverter– ​defibrillator
LDL low-​density lipoprotein
LV left ventricular
LVAD left ventricular assist device
LVEF left ventricular ejection fraction
MET metabolic equivalent
MGE multidmensional geriatric evaluation
MI myocardial infarction
MICE moderate-​intensity continuous exercise
MVV maximum voluntary ventilation
MWT minute walk test
NYHA New York Heart Association
PA physical activity
PAD peripheral artery disease
PCI percutaneous coronary intervention
PDSA Plan– ​Do–​Study–​Act
PETCO2 end-​tidal CO2 partial pressure
PETO2 end-​tidal O2 partial pressure
PHQ Patient Health Questionnaire
PI inspiratory mouth pressure
PM pacemaker
PPG photoplethysmography
RAMIT Rehabilitation After Myocardial Infarction Trial
RCP respiratory compensation point
RCT randomized controlled trial
RD risk difference
ReDS remote dielectric sensing
RER respiratory exchange ratio
RF risk factor
RM repetition management
RPE rate of perceived exertion

Abbreviations
RR risk ratio
RT resistance training
RTW return to work
SDM shared decision-​making
SNRI serotonin norepinephrine reuptake inhibitor xxiii

SOP standard operating procedure

SPE Scale of Perceived Exertion
SPPB Short Physical Performance Battery
SSRI selective serotonin reuptake inhibitor
STEMI ST elevation myocardial infarction
TAVI transcatheter aortic valve implantation
teleCR tele-​rehabilitation
UA uric acid
VAD ventricular assist device
VE maximal ventilation
VO2 oxygen consumption
VO2 /​HR oxygen pulse
VT ventilatory threshold
 Chapter 

Evidence for cardiac rehabilitation

in the modern era
Constantinos H. Davos and Bernhard Rauch

Summary
Management of cardiovascular disease (CVD) has rapidly improved during
recent decades, and is still changing with the introduction of novel medi-
cation and advanced invasive procedures and devices. Notwithstanding
these developments, cardiac rehabilitation (CR) is still a cornerstone of
secondary prevention. Its effectiveness in improving the physical condition
of chronic coronary syndrome (CCS) patients is beyond doubt, but its ef-
fectiveness on extending life expectancy is still a matter of debate. This
chapter provides insights into the latest evidence (mainly presented in a
recent meta-​analysis of randomized controlled trials (RCTs) or controlled 1
cohort studies) on the role of CR on morbidity and mortality in patients
after an acute coronary event.

Introduction
CR is considered a fundamental strategy in the prevention of secondary CVD. It has
received a class IA recommendation in European and international guidelines for
improving outcome in patients after an acute coronary event or revascularization
procedure. As many of the RCTs supporting this recommendation have been of
small size with limited follow-​up periods, the effect of CR on morbidity and mortality
has mainly been evaluated by meta-​analyses.

The evidence
The first meta-​analyses by Oldridge et al. []‌and O’Connor et al. [2] were published
more than 30 years ago, and included 0–​22 RCTs with more than 4300 partici-
pants. These meta-​analyses showed that exercise-​based CR may lead to a 20–​25%
reduction in all-​cause and CVD mortality compared with standard care methods.
Subsequently, the effect of CR on clinical outcome was evaluated in a series of
Cochrane systematic reviews. Cochrane publications are established as a highly re-
liable tool for assessment of scientific evidence with respect to the effectiveness of
 clinical interventions because of the extended systematic literature searches under-
taken, the rigorous study selection and evaluation, and their improved statistical
Evidence for cardiac rehabilitation

methodology. Therefore Cochrane meta-​analyses often serve as the basis for clinical
recommendations and guidelines.
The first Cochrane meta-​analysis on the clinical effect of CR by Jolliffe et al. [3]‌was
published in 200, and subsequently updated by Taylor et al. (2004) [4] and Heran
et al. (20) [5]. The results of these Cochrane meta-analyses did not significantly
change during this 0-​year period, and showed that exercise-​based CR may reduce
all-​cause mortality by 3–​27% and CV mortality by 26–​36%. However, despite their
professionalism, accuracy, and completeness, these meta-​analyses have been criti-
cized for including RCTs of doubtful size and quality, in which women, the elderly,
and high-​risk populations were poorly represented. It has also been argued that
the introduction of statins, angiotensin-​converting enzyme (ACE) inhibitors, and
dual anti-​platelet therapy, as well as modern invasive techniques and devices, has
changed the clinical course of coronary artery disease (CAD) in recent years, leading
to significantly lower mortality after acute CAD events [6]. However, lower baseline
CHAPTER 

mortality may significantly influence the efficacy of traditional therapeutic tools as

represented by CR after acute coronary syndromes (ACS). Therefore, extrapolation
of data on CR effectiveness obtained before the implementation of modern thera-
peutic options may lead to considerable bias. As a consequence, the impression has
2 arisen that the actual benefit of exercise-​based CR may be largely overestimated.
Addressing these doubts, the most recent Cochrane review was published in
206 by Anderson et al. [7]‌(Table .). A significant reduction in CV mortality
(0.4–​7.6%) and hospitalization (30.7–​26.%) compared with controls was dem-
onstrated in the exercise-​based CR group. However, total mortality or the risk
of fatal or non-​fatal myocardial infarction (MI), coronary artery bypass grafting
(CABG) procedures, or percutaneous coronary intervention (PCI) did not differ
between the study groups. With respect to the case mix of the study populations,
CR was particularly effective in reducing the CV mortality of post-​MI patients but
re-​hospitalizations and PCI rates were unchanged. This Cochrane review also dis-
tinguished between the subgroups of RCTs published before and after 995, which
showed an interesting result: CV mortality was significantly reduced by CR in both
subgroups. However, a significant reduction in total mortality could only be shown
in studies published before 995.
The Rehabilitation After Myocardial Infarction Trial (RAMIT) attempted to address
the lack of large prospective RCTs in this field, but failed to show a significant differ-
ence in all-​cause mortality between MI patients who were and were not referred to
CR during 2 years of follow-​up [8]‌. CR delivered in this study was comprehensive,
including exercise training (ET) as the baseline intervention supplemented by health
education and advice regarding secondary prevention. Unfortunately, RAMIT also
had some serious limitations. The sample size was not large enough to reach a suf-
ficient statistical power. Only 23% of the number of patients originally anticipated
were enrolled in each group, and more than 20% of patients dropped out of the CR
programme. Apart from this, the neutral result could be explained by the hetero-
geneity of programmes and participating centres, resulting in variable doses of CR.
The physical exercise dose during CR, the exercise intensity, and the number of CR
sessions including exercise, information, education, and psychosocial support have
Table . Most recent meta-​analyses on the effects of cardiac rehabilitation
Anderson et al, Rauch et al. van Halewijn et al. Sumner et al. Santiago de Araújo Abell et al. Powell et al.
206 [7]‌ 206 [4] 207 [2] 207 [5] Pio et al. 207 [] 207 [7] 208 [8]
No. of 63 25 8 8 33 69 22
trials
Literature Until July, 204 995 onwards 200–​5 2000 onwards Until Nov. 205 Until Jan. 2000 onwards
search 206
No of 4 486 29 702 769 9836 5 33 3 423 4834
participants
Age 56 (median) 53.8–​73.8 50–​76 49.9–​70.0 5.0–​75.4 49– ​8 0 59.5 (mean)
Gender <5% F 57–​90% M 6–​30% F 7–​90% M 80.3% M 83% M 78.4% M
Population MI, CABG or ACS (STEMI, MI, CABG or AMI (medically Post-​MI, HF, CHD (ACS, MI, CABG, PCI,
PCI, angina, NSTEMI, UA), PCI, angina, managed or various cardiac HF, PCI, angina, CHD
CHD CABG, mixed CHD angiography revascularized) diagnoses CABG, MI) defined by
angiography defined angiography
defined
Study design RCT RCT, rCCS, RCT rCCS, pCCS RCT, nRS, pOS, RCT RCT
pCCS rOS (reporting CR
dose)
Minimum 6 months 6 months 6 months 3 months 6 months 3 months 6 months
follow-​up
Follow-​up 2 months 40 months 24 months 3–​24 months 2 years (mean) 3 years 24 weeks –​
(median) (mean) (median) (median) 0 years
24.7months
(mean)

(continued)
Table . Continued
Anderson et al, Rauch et al. van Halewijn et al. Sumner et al. Santiago de Araújo Abell et al. Powell et al.
206 [7]‌ 206 [4] 207 [2] 207 [5] Pio et al. 207 [] 207 [7] 208 [8]
Intervention EBCR Supervised multi-​ CV prevention Supervised/​ Comprehensive EBCR with Supervised or
(supervised/​ component CR and CR (ExTr and/​ unsupervised, CR structured unsupervised
unsupervised Start <3 months or lifestyle based structured multi-​ CR dose subgroups ExTr ExTr alone or
ExTr alone or with after discharge programme with component CR Low: 4-​ sessions (supervised or as part of a
psychosocial and/​ ExTr ≥2 times/​ at least one face-​ with ExTr and/​or unsupervised), comprehensive
or educational to-​face session structured physical Medium: 2–​35 with or CR programme
week plus sessions
interventions) at least one between healthcare activity plus at least without (educational/​
provider and one of information High: ≥36 sessions lifestyle psychosocial
of: information,
motivational patient) provision, education, modification components)
techniques, health behaviour and counseling
education, change, psycho­
psychological logical support or
support & intervention, social
interventions, support.
social and
vocational
support
Setting Inpatient/​ Centre-​based Inpatient/​outpatient/​ Outpatient (≥4 Any (home-​ Hospital-​
outpatient/​ CR: inpatient/​ community-​based/​ sessions of based/​ based/​
community-​ outpatient/​ home-​based structured community-​ community-​/​
based/​ mixed/​teleCR ExTr plus at based/​ home-​based
home-​based least patient outpatient
education) centre based)
Supervised
(hospital-​based/​
medical-​centre-​
based) and/​or
unsupervised
(home-​based/​
community-​
based)
Another random document with
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been so much approved, that we can recommend it with some
confidence, as it stands. Modern taste would perhaps be rather in
favour of rich brown gravy and thick tomata sauce, or sauce
poivrade.
82. A deep oblong dish of suitable size seems better adapted to this purpose.
In dishing the pig lay the body flat in the middle, and the head and
ears at the ends and sides. When very pure oil can be obtained, it is
preferable to butter for the basting: it should be laid on with a bunch
of feathers. A pig of three weeks old is considered as best suited to
the table, and it should always be dressed if possible the day it is
killed.
1-1/4 to 1-3/4 hour.
 BAKED PIG.

Prepare the pig exactly as for roasting; truss, and place it in the
dish in which it is to be sent to the oven, and anoint it thickly in every
part with white of egg which has been slightly beaten; it will require
no basting, nor further attention of any kind, and will be well crisped
by this process.
 PIG À LA TARTARE

When the shoulders of a cold roast pig are left entire, take them off
with care, remove the skin, trim them into good form, dip them into
clarified butter or very pure salad oil, then into fine crumbs highly
seasoned with cayenne and mixed with about a half-teaspoonful of
salt. Broil them over a clear brisk fire, and send them quickly to table,
as soon as they are heated through and equally browned, with
tomata sauce, or sauce Robert. Curried crumbs and a currie-sauce
will give an excellent variety of this dish; and savoury herbs with two
or three eschalots chopped small together, and mixed with the
bread-crumbs, and brown eschalot sauce to accompany the broil,
will likewise be an acceptable one to many tastes.
 SUCKING PIG EN BLANQUETTE. (ENTRÉE.)

Raise the flesh from the bones of a cold roast pig, free it from the
crisp outer skin or crackling, and cut it down into small handsome
slices. Dissolve a bit of butter the size of an egg, and throw in a
handful of button-mushrooms, cleaned and sliced; shake these over
the fire for three or four minutes, then stir to them a dessertspoonful
of flour and continue to shake or toss them gently, but do not allow
them to brown. Add a small bunch of parsley, a bay-leaf, a middling-
sized blade of mace, some salt, a small quantity of cayenne or white
pepper, half a pint of good veal or beef broth, and from two to three
glasses of light white wine. Let these boil gently until reduced nearly
one third; take out the parsley and mace, lay in the meat, and bring it
slowly to the point of simmering; stir to it the beaten yolks of three
fresh eggs, and the strained juice of half a lemon Serve the
blanquette very hot.
 TO ROAST PORK.

When the skin is left on the joint which is to be roasted, it must be

scored in narrow strips of equal width, before it is put to the fire, and
laid at a considerable distance from it at first, that the meat may be
heated through before the skin hardens or begins to brown; it must
never stand still for an instant, and the basting should be constant.
Pork is not at the present day much served at very good tables,
particularly in this form; and it is so still less with the old savoury
stuffing of sage and onions, though some eaters like it always with
the leg: when it is ordered for this joint, therefore prepare it as
directed for a goose, at page 160, and after having loosened the skin
from the knuckle, insert as much as can well be secured in it. A little
clarified butter or salad oil may be brushed over the skin quite at first,
particularly should the meat not be very fat, but unless remarkably
lean, it will speedily yield sufficient dripping to baste it with. Joints
from which the fat has been pared, will require of course far less
roasting than those on which the crackling is retained. Brown gravy,
and apple or tomata sauce, are the usual accompaniments to all
roasts of pork except a sucking pig; they should always be
thoroughly cooked.
Leg of pork of 8 lbs., 3 hours; loin of from 5 to 6 lbs., with the skin
on, 2 to 2-1/2 hours; spare rib of 6 to 7 lbs., 1-1/2 hour.
 TO ROAST A SADDLE OF PORK.

The skin of this joint may be removed entirely, but if left on it must
be scored lengthwise, or in the direction in which it will be carved.
The pork should be young, of fine quality, and of moderate size.
Roast it very carefully, either by the directions given in the preceding
receipt, or when the skin is taken off, by those for a saddle of mutton,
allowing in the latter case from three quarters of an hour to a full
hour more of the fire for it in proportion to its weight. Serve it with
good brown gravy and tomata sauce, or sauce Robert; or with apple
sauce should it be preferred. 20 minutes to the pound, quite [TN: text
missing.]
 TO BROIL OR FRY PORK CUTLETS.

Cut them about half an inch thick from a delicate loin of pork, trim
them into neat form, and take off part of the fat, or the whole of it
when it is not liked; dredge a little pepper or cayenne upon them,
and broil them over a clear and moderate fire from fifteen to eighteen
minutes: sprinkle a little fine salt upon them just before they are
dished. They may be dipped into egg and then into bread-crumbs
mixed with minced sage, and finished in the usual way.[83] When
fried, flour them well, and season them with salt and pepper first.
Serve them with gravy in the pan, or with sauce Robert.
83. If broiled, with the addition of these a little clarified butter must be added to
the egg, or sprinkled on the cutlets.
 COBBETT’S RECEIPT FOR CURING BACON.

“All other parts being taken away, the two sides that remain, and
which are called flitches, are to be cured for bacon. They are first
rubbed with salt on their inside, or flesh sides, then placed one on
the other, the flesh sides uppermost in a salting trough, which has a
gutter round its edges to drain away the brine; for to have sweet and
fine bacon, the flitches must not be sopping in brine, which gives it
the sort of taste that barrel-pork and sea-junk have, and than which
is nothing more villainous. Everyone knows how different is the taste
of fresh dry salt from that of salt in a dissolved state. Therefore,
change the salt often; once in four or five days. Let it melt and sink
in, but let it not lie too long. Change the flitches, put that at the
bottom which was first on the top. Do this a couple of times. This
mode will cost you a great deal more in salt than the sopping mode;
but without it your bacon will not be so sweet and fine, nor keep so
well. As to the time required for making the flitches sufficiently salt, it
depends on circumstances; the thickness of the flitch, the state of
the weather, the place wherein the salting is going on. It takes a
longer time for a thick than for a thin flitch; it takes longer in dry than
in damp weather, it takes longer in a dry than in a damp place. But
for the flitches of a hog of five score, in weather not very dry or very
damp, about six weeks may do; and as yours is to be fat, which
receives little injury from over-salting, give time enough; for you are
to have bacon till Christmas comes again. The place for salting
should, like a dairy, always be cool, but always admit of a free
circulation of air; confined air, though cool, will taint meat sooner
than the midday sun accompanied with a breeze. With regard to
smoking the bacon, two precautions are necessary: first to hang the
flitches where no rain comes down upon them, and next, that the
smoke must proceed from wood, not peat, turf, nor coal. As to the
time that it requires to smoke a flitch, it must depend a good deal
upon whether there be a constant fire beneath, and whether the fire
be large or small. A month will do if the fire be pretty constant, and
such as a farm house fire usually is. But oversmoking, or rather, too
long hanging in the air, makes the bacon rust. Great attention
should, therefore, be paid to this matter. The flitch ought not to be
dried up to the hardness of a board, and yet it ought to be perfectly
dry. Before you hang it up, lay it on the floor, scatter the flesh-side
pretty thickly over with bran or with some fine saw-dust, not of deal
or fir. Rub it on the flesh, or pat it well down upon it. This keeps the
smoke from getting into the little openings, and makes a sort of crust
to be dried on.
“To keep the bacon sweet and good, and free from hoppers, sift
fine some clean and dry wood-ashes. Put some at the bottom of a
box or chest long enough to hold a flitch of bacon. Lay in one flitch;
and then put in more ashes, then another flitch, and cover this with
six or eight inches of the ashes. The place where the box or chest is
kept ought to be dry, and should the ashes become damp they
should be put in the fire-place to dry, and when cold, put back again.
With these precautions the bacon will be as good at the end of the
year as on the first day.”
Obs.—Although the preceding directions for curing the bacon are
a little vague as regards the proportions of salt and pork, we think
those for its after-management will be acceptable to many of our
readers, as in our damp climate it is often a matter of great difficulty
to preserve hams and bacon through the year from rust.
 A GENUINE YORKSHIRE RECEIPT FOR CURING HAMS AND
BACON.

“Let the swine be put up to fast for twenty-four hours before they
are killed (and observe that neither a time of severe frost, nor very
damp weather, is favourable for curing bacon). After a pig has been
killed and scalded, let it hang twelve hours before it is cut up, then
for every stone or fourteen pounds’ weight of the meat, take one
pound of salt, an ounce and a quarter of saltpeter, and half an ounce
of coarse sugar. Rub the sugar and saltpetre first into the fleshy
parts of the pork, and remove carefully with a fork any extravasated
blood that may appear on it, together with the broken vessels
adjoining; apply the salt especially to those parts, as well as to the
shank-ends of the hams, and any other portions of the flesh that are
more particularly exposed. Before the salt is added to the meat,
warm it a little before the fire, and use only a part of it in the first
instance; then, as it dissolves, or is absorbed by the meat, add the
remainder at several different times. Let the meat in the meanwhile
lie either on clean straw, or on a cold brick or stone floor: it will
require from a fortnight to three weeks’ curing, according to the state
of the atmosphere. When done, hang it in a cool dry place, where
there is a thorough current of air, and let it remain there until it is
perfectly dry, when the salt will be found to have crystallized upon
the surface. The meat may then be removed to your store, and kept
in a close chest, surrounded with clean outer straw. If very large, the
hams will not be in perfection in less than twelve months from the
time of their being stored.”
Pork 20 stone; salt, 20 lbs.; saltpetre, 20 oz.; sugar, 10 oz.; 14 to
21 days.
 KENTISH MODE OF CUTTING UP AND CURING A PIG.

To a porker of sixteen stone Kentish weight (that is to say, eight

pounds to the stone, or nine stone two pounds of common weight),
allow two gallons of salt, two pounds of saltpetre, one pound of
coarse sugar, and two pounds of bay-salt well dried and reduced to
powder. Put aside the hams and cheeks to be cured by themselves;
let the feet, ears, tail, and eye-parts of the head be salted for
immediate eating; the blade-bones, and ends of the loins and ribs
reserved for sausage-meat should it be wanted, and the loin and
spare-ribs for roasting. Divide and salt the remainder thus: Mix well
together the saltpetre, sugar, and bay-salt, and rub the pork gently
with them in every part; cover the bottom of the pickling tub with salt,
and pack in the pork as closely as possible, with a portion of the
remaining salt between each layer. A very little water is sometimes
sprinkled in to facilitate the dissolving of the salt into a brine, but this
is always better avoided, and in damp weather will not be needed. If
in a fortnight it should not have risen, so as almost entirely to cover
the meat, boil a strong brine of salt, saltpetre, sugar, and bay-salt; let
it remain until perfectly cold, and then pour it over the pork. A board,
with a heavy stone weight upon it, should be kept upon the meat to
force it down under the brine. In from three to four months it will be fit
for table, and will be delicate and excellent pickled pork.
The pickling parts of a porker of sixteen stone (Kentish weight, or
nine stone two pounds of common weight, or fourteen pounds to the
stone); common salt, 2 gallons; saltpetre, 2 lbs.; coarse sugar, 1 lb.:
bay-salt, 2 lbs.
 FRENCH BACON FOR LARDING.

Cut the bacon from the pig with as little lean to it as possible. Rub
it well in every part with salt which has been dried, reduced to
powder, and sifted; put the layers of bacon close against and upon
each other, in a shallow wooden trough, and set in a cool, but not a
damp cellar; add more salt all round the bacon, and lay a board, with
a very heavy weight upon it. Let it remain for six weeks, then hang it
up in a dry and airy place.
Pork, 14 lbs.; salt, 14 oz.: 6 weeks.
 TO PICKLE CHEEKS OF BACON AND HAMS.

One pound of common salt, one pound of the coarsest sugar, and
one ounce of saltpetre, in fine powder, to each stone (fourteen
pounds) of the meat will answer this purpose extremely well. An
ounce of black pepper can be added, if liked, and when less sugar is
preferred, the proportion can be diminished one half, and the
quantity of salt as much increased. Bacon also may be cured by this
receipt, or by the Bordyke one for hams. A month is sufficient time
for the salting, unless the pork be very large, when five weeks must
be allowed for a ham. The ingredients should be well mixed, and all
applied at the same time.
To each 14 lbs. of pork, salt, 1 lb.; coarse sugar, 1 lb.; saltpetre, 1
oz.; pepper (if used), 1 oz.: 4 to 5 weeks.
 MONSIEUR UDE’s RECEIPT, HAMS SUPERIOR TO
WESTPHALIA.

(Excellent.)
“Take the hams as soon as the pig is sufficiently cold to be cut up,
rub them well with common salt, and leave them for three days to
drain; throw away the brine, and for a couple of hams of from fifteen
to eighteen pounds weight, mix together two ounces of saltpetre, a
pound of coarse sugar, and a pound of common salt; rub the hams in
every part with these, lay them into deep pickling-pans with the rind
downwards, and keep them for three days well covered with the salt
and sugar; then pour over them a bottle of good vinegar, and turn
them in the brine, and baste them with it daily for a month; drain
them well, rub them with bran, and let them be hung for a month high
in a chimney over a wood-fire to be smoked.”
Hams, of from 15 to 18 lbs. each, 2; to drain 3 days. Common salt,
and coarse sugar, each 1 lb.; saltpetre, 2 oz.: 3 days. Vinegar, 1
bottle: 1 month. To be smoked 1 month.
Obs.—Such of our readers as shall make trial of this admirable
receipt, will acknowledge, we doubt not, that the hams thus cured
are in reality superior to those of Westphalia. It was originally given
to the public by the celebrated French cook, Monsieur Ude. He
directs that the hams when smoked should be hung as high as
possible from the fire, that the fat may not be melted; a very
necessary precaution, as the mode of their being cured renders it
peculiarly liable to do so. This, indeed, is somewhat perceptible in
the cooking, which ought, therefore, to be conducted with especial
care. The hams should be very softly simmered,[84] and not over-
done. They should be large, and of finely-fed pork, or the receipt will
not answer. We give the result of our first trial of it, which was
perfectly successful, the ham cured by it being of the finest possible
flavour.
84. We have not had the trial made ourselves, but we think they would be even
finer baked than boiled.
 Leg of Suffolk farm-house pork, 14 to 15 lbs.; saltpetre, 1-1/4 oz.;
strong coarse salt, 6 oz.; coarse sugar, 8 oz.: 3 days. Fine whitewine
vinegar, 1 pint. In pickle, turned daily, 1 month. Smoked over wood, 1
month.
Obs.—“When two hams are pickled together, a smaller proportion
of the ingredients is required for each, than for one which is cured by
itself.”
 SUPER-EXCELLENT BACON.

For several successive years, after first testing the above receipt,
we had it adopted for curing bacon, with even more highly
satisfactory results, as it was of incomparable flavour, and remained
good for a great length of time, the vinegar preserving it entirely from
becoming rusted. Well-fed pork of delicate size was always used for
it, and excellent vinegar. The ingredients were added in the
proportions given in the receipt for the Suffolk ham which preceeds
this, and the same time was allowed for the salting and smoking.
 HAMS.

(Bordyke Receipt.)
After the hams have been rubbed with salt, and well drained from
the brine, according to our previous directions, take, for each
fourteen pounds weight of the pork, one ounce of saltpetre in fine
powder mixed with three ounces of very brown sugar; rub the meat
in every part with these, and let it remain some hours, then cover it
well with eight ounces of bay-salt, dried and pounded, and mixed
with four ounces of common salt: in four days add one pound of
treacle, and keep the hams turned daily, and well basted with the
pickle for a month. Hang them up to drain for a night, fold them in
brown paper, and send them to be smoked for a month. An ounce of
ground black pepper is often mixed with the saltpetre in this receipt,
and three ounces of bruised juniper-berries are rubbed on to the
meat before the salt is added, when hams of a very high flavour are
desired.
Ham, 14 lbs.; saltpetre, 1 oz.; coarse sugar, 3 oz.: 8 to 12 hours.
Bay-salt, 1/2 lb.; common salt, 4 oz.: 4 days. Treacle, 1 lb.: 1 month.
To heighten flavour, black pepper, 1 oz; juniper-berries, 3 oz.
 TO BOIL A HAM.

The degree of soaking which must be given to a ham before it is

boiled, must depend both on the manner in which it has been cured,
and on its age. If highly salted, hard, and old, a day and night, or
even longer, may be requisite to dilate the pores sufficiently, and to
extract a portion of the salt. To do either effectually the water must
be several times changed during the steeping. We generally find
hams cured by any of the receipts which we have given in this
chapter quite enough soaked in twelve hours; and they are more
frequently laid into water only early in the morning of the day on
which they are boiled. Those pickled by Monsieur Ude’s receipt need
much less steeping than any others. After the ham has been
scraped, or brushed, as clean as possible, pare away lightly any part
which, from being blackened or rusty, would disfigure it; though it is
better not to cut the flesh at all unless it be really requisite for the
good appearance of the joint. Lay it into a ham-kettle, or into any
other vessel of a similar form, and cover it plentifully with cold water;
bring it very slowly to boil, and clear off carefully the scum which will
be thrown up in great abundance. So soon as the water has been
cleared from this, draw back the pan quite to the edge of the stove,
that the ham may be simmered softly but steadily, until it is tender.
On no account allow it to boil fast. A bunch of herbs and three or four
carrots, thrown in directly after the water has been skimmed, will
improve it. When it can be probed very easily with a sharp skewer, or
larding-pin, lift it out, strip off the skin, and should there be an oven
at hand, set it in for a few minutes after having laid it on a drainer;
strew fine raspings over it, or grate a hard-toasted crust, or sift upon
it the prepared bread of Chapter V., unless it is to be glazed, when
neither of these must be used.
Small ham, 3-1/2 to 4 hours; moderate sized, 4 to 4-1/2 hours;
very large, 5 to 5-1/2 hours.
Obs.—We have seen the following manner of boiling a ham
recommended, but we have not tried it:—“Put into the water in which
it is to be boiled, a quart of old cider and a pint of vinegar, a large
bunch of sweet herbs, and a bay leaf. When it is two-thirds done,
skin, cover it with raspings, and set it in an oven until it is done
enough: it will prove incomparably superior to a ham boiled in the
usual way.”
 TO GARNISH AND ORNAMENT HAMS IN VARIOUS WAYS.

When a ham has been carefully and delicately boiled, the rind
while it is still warm, may be carved in various fanciful shapes to
decorate it; and a portion of it left round the knuckle in a semi-
circular form of four or five inches deep, may at all times be easily
scollopped at the edge or cut into points (vandykes). This, while
preserving a character of complete simplicity for the dish, will give it
an air of neatness and finish at a slight cost of time and trouble. A
paper frill should be placed round the bone.
The Germans cut the ham-rind after it has been stripped from the
joint, into small leaves and similar “prettinesses,”[85] and arrange
them in a garland, or other approved device, upon its surface. In
Ireland and elsewhere, bread evenly sliced, and stamped out with
cutters much smaller than a fourpenny-piece, then carefully fried or
coloured in the oven, is used to form designs upon hams after they
are glazed. Large dice of clear firm savoury jelly form their most
appropriate garnish, because they are intended to be eaten with
them. For the manner of making this, and glaze also see Chapter IV.
85. This should be done with a confectionary or paste cutter.
The ham shown in Plate V., which follows the directions for
“Carving,” is of very good appearance; but in common English
kitchens generally, even the degree of artistic skill required to form
its decorations well, is not often to be met with.