Cardiac Rehab Phase 4 Gap: A Guide for Clinicians | Healos™
Where Do Your Post-Cardiac Patients Go After Session 36?
The final session of outpatient cardiac rehab tends to end the same way everywhere. A last walk test. A handshake. A discharge summary faxed or uploaded to your office, and the patient's next cardiology appointment booked for three to six months away.
For the patient, session 36 can feel like graduation. For their arteries, nothing has graduated.
The short answer for busy clinicians: after the final cardiac rehab session, most patients return to routine follow-up with no structured support between visits. Rehab reduces heart attacks and hospital admissions, but only about 1 in 4 eligible US patients take part, and the benefits depend on maintaining activity, medication adherence and mood for years afterwards. A structured Phase 4 bridge helps keep those gains from eroding.
写给忙碌临床医生的简短答案： 门诊心脏康复的最后一课在哪里结束得都差不多：最后一次步行测试、握手、出院小结传到您的诊所，下一次心脏科复诊约在三到六个月后。对患者来说第 36 次课像毕业，对他们的动脉来说什么都没有毕业。
最后一次康复课后，大多数患者回到常规随访，复诊之间没有结构化支持。康复能减少心梗和住院，但美国符合条件者只有约四分之一参加，获益取决于之后数年维持运动、依从性和情绪。结构化的第四阶段衔接能帮助获益不被侵蚀。
What cardiac rehab achieves, and for whom
The evidence for cardiac rehab is not in question. The 2021 Cochrane review of exercise-based rehabilitation in coronary heart disease found fewer myocardial infarctions and fewer all-cause hospital admissions among participants, along with improvements in quality of life (Dibben et al., 2021).
The problem is reach. Among eligible US Medicare beneficiaries, only about 24% participated (Ritchey et al., Circulation: Cardiovascular Quality and Outcomes, 2020), and participation is consistently lower among women, older adults, rural patients and people facing language barriers. In Canadian cities with large Chinese-speaking communities, the language gap is not a small detail: a patient who can't follow the education sessions comfortably is less likely to enrol, and less likely to complete.
So the population leaving session 36 is already the more engaged minority. What happens to them next is a useful stress test for the whole system.
心脏康复取得了什么，覆盖了谁： 心脏康复的证据没有争议：2021 年 Cochrane 综述显示参与者心梗和全因住院更少，生活质量改善。问题在于覆盖面：美国符合条件的 Medicare 患者只有约 24% 参加，女性、老年、农村和有语言障碍的患者参与率一贯更低。在华人社区较大的加拿大城市，语言差距不是小问题——听不懂宣教课程的患者更不可能报名和完成。
因此，走出第 36 次课的人本身已是较积极的少数；他们接下来的情况，是对整个体系的压力测试。
What happens after cardiac rehab ends
Four things tend to drift once the structure of supervised sessions disappears.
Activity. Exercise that was scheduled, supervised and social becomes self-directed and solitary. Maintenance studies consistently show physical activity declining in the months after programme completion, particularly in patients without a clear home routine.
Medication adherence. In Ontario, only about 40% of older adults were still taking a statin two years after an acute coronary syndrome (Jackevicius et al., JAMA, 2002). Muscle symptoms, fatigue and the simple absence of symptoms all play a part, and many discontinuations happen without a conversation with the prescriber.
Mood. Roughly one in five heart attack survivors meets criteria for major depression (Thombs et al., Journal of General Internal Medicine, 2006), and depression is independently associated with worse outcomes and poorer adherence. Rehab often provides informal mood support through routine and peer contact; that support ends with the programme.
Risk. None of this happens against a neutral background. About 18% of heart attack survivors have another major cardiovascular event within the first year (Jernberg et al., European Heart Journal, 2015), and risk remains elevated for years afterwards.
心脏康复结束后会发生什么： 有监督的课程结构消失后，四件事容易漂移。
活动：有安排、有监督、有同伴的运动变成自我管理的独自运动，维持期研究一致显示结业后数月体力活动下降，尤其是缺乏居家常规的患者。
服药依从性：安大略老年人 ACS 两年后只有约 40% 仍服他汀，肌肉症状、疲劳和「没有症状」都有影响，很多停药并未与处方医生沟通。
情绪：约五分之一心梗幸存者符合重度抑郁标准，抑郁独立关联更差预后和更低依从性；康复课程通过规律和同伴提供的非正式情绪支持，随课程结束而消失。
风险：这一切并非发生在中性背景下——约 18% 的心梗幸存者第一年再发主要事件，风险在之后数年仍偏高。
Three patients you have probably already seen
The gap is easier to recognise in individual patients than in statistics. These are composite examples, but most cardiology clinics will know them.
The high achiever. A 54-year-old executive completes all 36 sessions, hits every target and returns to a 60-hour working week. By month five, exercise has shrunk to weekends, sleep to six hours, and the statin is being taken "most days". At the next visit, LDL has crept up and he has no clear explanation.
The quiet struggler. A 67-year-old woman attends rehab faithfully but says little. After discharge she stops walking alone because she's afraid of chest symptoms when nobody is nearby. She doesn't mention it at follow-up because nobody asks, and her PHQ-9, had it been done, would have been in the moderate range.
The language gap. A 71-year-old Mandarin-speaking man understands the exercise but not the education sessions. He stops his statin after muscle aches, assuming they mean harm, and adds three supplements recommended by a relative, one of which interacts with his antiplatelet therapy. None of this is visible in his chart.
In each case, the problem is not a lack of good medicine. It is a lack of visibility between visits, and nobody whose job it is to keep things on track.
您可能早已见过的三位患者： 比起统计数字，空白在具体患者身上更容易辨认（综合案例）。
「高成就者」：54 岁高管完成全部 36 次课、各项达标后回到每周 60 小时工作，五个月后运动缩到周末、睡眠只有六小时、他汀「大多数天」在吃，下次复诊 LDL 回升却说不清原因。
「沉默的挣扎者」：67 岁女性认真上完康复但话不多，出院后怕没人在身边时胸口不适而不再独自散步，复诊没人问她也没提，若做 PHQ-9 会是中度。
「语言鸿沟」：71 岁讲普通话的男士能跟上运动却听不懂宣教，肌肉酸痛后以为有害而停用他汀，又加了亲戚推荐的三种补充剂，其中一种与抗血小板药相互作用，而这些在病历中完全看不到。
每个案例的问题都不是缺少好的医疗，而是复诊之间缺乏可见性，也没有专人负责让事情保持正轨。
What a Phase 4 bridge should include
Terminology varies between programmes: some call supervised community maintenance Phase 3 and long-term self-management Phase 4. Whatever the label, the components that protect gains after session 36 are fairly consistent.
A daily activity structure the patient owns, with a defined minimum and a way to log it.
Adherence support with side-effect triage, so that muscle aches or fatigue trigger a conversation rather than a quiet discontinuation.
Routine mood screening, using a validated tool such as the PHQ-9 at regular intervals, with a clear route back to the care team.
Nutrition matched to the medication list, including attention to predictable drug-nutrient effects such as statins and coenzyme Q10, diuretics and magnesium, and long-term acid suppression and vitamin B12 (see the drug-nutrient debt).
Structured information flowing back to you, so that the next appointment starts with data rather than recall.
None of these requires a clinician's time between visits. All of them require someone to own them.
第四阶段衔接应包括什么： 各项目术语不同：有的把有监督的社区维持称为第三阶段，把长期自我管理称为第四阶段。无论叫什么，保护第 36 次课后获益的要素相当一致：
① 患者自己掌握的每日活动结构，有明确最低量和记录方式；
② 带副作用分诊的依从性支持，让肌肉酸痛或疲劳触发一次沟通，而不是悄悄停药；
③ 定期情绪筛查（如 PHQ-9），并有明确的回转路径；
④ 与用药清单匹配的营养，关注可预测的药物-营养影响，如他汀与辅酶 Q10、利尿剂与镁、长期抑酸与维生素 B12；
⑤ 结构化信息回流给您，让下次复诊从数据而非回忆开始。这些都不需要临床医生在复诊间投入时间，但都需要有人负责。
Where Healos™ fits, and where it doesn't
Healos™ was built for exactly that ownership gap, as complementary support that sits alongside your care rather than competing with it.
What Healos™ does. Patients start with the H-Index, a structured self-assessment across 32 dimensions of recovery, from medical understanding and nutrition to sleep, mood and adherence. It is a pre-visit communication tool, not a diagnostic test, and it produces a summary formatted for the treating clinician. Nutritional programmes run as the 91-Day Protocol (Detox, Replenish and Repair) or ongoing monthly support, use Health Canada NPN-licensed products positioned as complementary support, and are pharmacist-reviewed against the patient's medication list before anything ships, with follow-ups at days 30 and 60 and a blood-test report review at day 90. Materials are available in English and Chinese.
What Healos™ does not do. It does not diagnose, prescribe, adjust medications or replace supervised rehab or community Phase 3 programmes. Any symptom or result that needs clinical attention is routed back to the patient's care team.
For a cardiologist or rehab team, the practical value is simple: patients who stay engaged between visits, and who arrive with structured information about what has happened since you last saw them.
Healos™ 的定位：做什么，不做什么： Healos™ 正是为这个「无人负责」的空白而建，作为与您的诊疗并行的辅助支持，而非竞争。
Healos™ 做什么：患者先完成 H-Index——覆盖 32 个恢复维度（从医疗认知、营养到睡眠、情绪和依从性）的结构化自评，它是就诊前沟通工具而非诊断工具，生成为主治医生格式化的摘要；营养方案以 91 天方案（排毒、补给、修复）或按月持续支持进行，使用获 Health Canada NPN 许可、定位为辅助支持的产品，发货前由药剂师按患者用药清单审核，并在第 30、60 天跟进、第 90 天解读验血报告；提供中英文材料。
Healos™ 不做什么：不诊断、不开药、不调整药物，不替代有监督的康复或社区第三阶段项目；任何需要临床关注的症状或结果都转回患者的医疗团队。对心脏科医生或康复团队，实际价值很简单：复诊之间保持参与的患者，以及带着结构化信息来复诊的患者。
How referral works, and what you receive
Referral is deliberately light. A clinic can share the free H-Index link or QR code with patients at discharge from rehab or at any follow-up visit, with no forms required. Patients who choose to continue into a structured programme do so directly with Healos™.
What comes back to you is designed to fit a 15-minute appointment: a one-page pre-visit summary showing how the patient rates their recovery across the 32 dimensions, trends since their last assessment, the medication and supplement list they reported, and any items flagged for clinical attention, such as a possible drug-supplement interaction or a mood score that warrants screening. It is information to support your judgement, never a recommendation to change therapy.
For rehab programmes and group practices, a partner briefing covers the sample report, the compliance framework behind Healos™ products and how patient data is handled.
如何转介，您会收到什么： 转介刻意做得很轻：诊所可在康复结业或任何复诊时，把免费 H-Index 链接或二维码交给患者，无需填表；选择继续结构化方案的患者直接与 Healos™ 对接。
回传给您的内容为 15 分钟门诊设计：一页就诊前摘要，显示患者在 32 个维度的自评、与上次评估相比的趋势、患者报告的药物和补充剂清单，以及需要临床关注的标记项（如可能的药物-补充剂相互作用、需进一步筛查的情绪分数）。这是支持您判断的信息，绝不是更改治疗的建议。
对康复项目和团体诊所，合作简报涵盖报告样本、Healos™ 产品背后的合规框架以及患者数据的处理方式。
The bottom line
Session 36 is a discharge, not a destination. Cardiac rehab builds the foundation; the years that follow decide whether it holds. A modest amount of structure between visits, owned by someone other than an already overloaded clinic, can protect a great deal of what rehab achieved.
结论： 第 36 次课是出院，不是终点。心脏康复打下基础，之后的岁月决定它能否稳固。复诊之间适度的结构——由已超负荷的诊所之外的人负责——能保住康复所取得的大部分成果。
Frequently asked questions
What happens after cardiac rehab ends? Most patients return to routine follow-up every few months without structured support between visits. Physical activity, medication adherence and mood commonly decline in the following months, while cardiovascular risk remains elevated, so maintenance structure matters.
What is phase 4 cardiac rehabilitation? Terminology varies, but Phase 4 usually refers to long-term, largely self-directed maintenance after supervised outpatient rehab and any community programme. It focuses on sustaining exercise, adherence, risk factor control and wellbeing for life.
What percentage of eligible patients attend cardiac rehab? Participation is low. Among eligible US Medicare beneficiaries, only about 24% took part in cardiac rehabilitation, with lower rates among women, older adults, rural patients and people facing language barriers.
How can patients maintain the benefits of cardiac rehab? Key elements are a daily activity routine with a defined minimum, support for medication adherence and side effects, regular mood screening, nutrition matched to their medications, and structured information shared with their care team.
Does Healos™ replace cardiac rehabilitation? No. Healos™ is complementary support. It does not diagnose, prescribe or replace supervised rehab or community programmes; it helps patients stay engaged between visits and provides structured pre-visit summaries to their clinicians.
常见问题：
心脏康复结束后会怎样？多数患者回到每隔数月的常规随访，复诊间无结构化支持；之后数月活动、依从性和情绪常下滑，而风险仍偏高。
什么是第四阶段心脏康复？术语不一，通常指有监督门诊康复及社区项目之后的长期、以自我管理为主的维持期。
心脏康复参与率多少？美国符合条件的 Medicare 患者约 24%，女性、老年、农村和有语言障碍者更低。
如何维持康复获益？每日活动常规、依从性与副作用支持、定期情绪筛查、与用药匹配的营养、与医疗团队共享结构化信息。
Healos™ 替代心脏康复吗？不。Healos™ 是辅助支持，不诊断、不开药、不替代康复项目，只帮助患者在复诊间保持参与，并向医生提供结构化就诊前摘要。
References
Dibben G, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews. 2021;11:CD001800.
Ritchey MD, et al. Tracking cardiac rehabilitation participation and completion among Medicare beneficiaries to inform the efforts of a national initiative. Circulation: Cardiovascular Quality and Outcomes. 2020;13(1):e005902.
Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288(4):462–467.
Jernberg T, et al. Cardiovascular risk in post-myocardial infarction patients. European Heart Journal. 2015;36(19):1163–1170.
Thombs BD, et al. Prevalence of depression in survivors of acute myocardial infarction. Journal of General Internal Medicine. 2006;21(1):30–38.
Lichtman JH, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment. Circulation. 2008;118(17):1768–1775.
