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based on cardiopulmonary exercise testing (CPX) were implemented at a higher rate in RCAP hospitals than non-RCAP hospitals, the implementation rate of OPCR was low in both.3 The authors discuss several reasons for the poor RCAP implementation after AMI in comparison with stroke.3 In Japan, the PCI implementation rate is very high and the OPCR implementation rate is very low, regardless of hospital size, which suggests there may be low awareness of the importance of OPCR and RCAP in post-discharge management and secondary prevention after AMI. Moreover, non-RCAP hospitals are relatively small and staff shortages may reduce the likelihood of RCAP implementation. RCAP is not considered to be necessary when patients are discharged directly home after AMI. Although the benefits of CR have been established, participation rates for eligible patients with CVD are poor (in the USA 14–35% after AMI and 31% after coronary artery bypass graft surgery; 29% after AMI in the UK; 23% after AMI in France).4 In the Japanese survey, the implementation rate of recovery-phase CR was 11.8% overall and only 19.8% even in Japanese Circulation Society training hospitals. The estimated participation rate in outpatient recovery-phase CR was 4–8% in Japan.5 Thus, patient participation in recovery-phase CR is the lowest in Japan (Figure).6 Populations are aging and patients have a larger number of comorbidities. As a super-aged society has come, the number of persons with multimorbidity and multiple disabilities (MMD) and their need for rehabilitation has increased more rapidly than we had expected.7 Medical science basically aims to “adding years to life” by increasing life expectancy. Rehabilitation generally aims to “adding life to years” by helping patients with impairment achieve, and use, their full physical, mental and social potential. However, recent growing evidence suggests that rehabilitation for patients with visceral impairment such as cardiac, renal and pulmonary impairment can not only improve exercise performance and quality of life, but also increases survival.8 Therefore, modern comprehensive rehabilitation for patients with visceral impairment does not aim simply to “adding life to years” but “adding life to years and years to life”, which is a new rehabilitation concept and an ideal medicine.8 In the USA, an estimated 785,000 Americans will have a new coronary attack each year, and 470,000 will have a recurrent attack.9 Of those who have a first MI, the percentage with recurrent MI or fatal CHD within 5 years is 22% of men and ardiac rehabilitation (CR) has been demonstrated to improve not only the physical effects (Table), but also psychological distress and quality of life, and to reduce major morbidity and mortality in patients with cardiovascular disease (CVD).1 A nationwide survey conducted in 2001–2003 in Japan revealed that both exercise-based CR and exercise testing are generally safe, and that formal CR, in which an individual exercise prescription is determined by exercise testing, is particularly safe.2 As the length of stay in acute-phase specialized hospitals for phase I CR and early phase II CR become shorter, late phase II CR programs are provided as ambulatory programs after discharge. As patients with CVD typically visit the clinic biweekly during the first 1–2 months after discharge for follow-up during this period, they should participate in comprehensive CR programs in which outpatient nurses play a central role in educating patients on smoking cessation, diet, and lifestyle interventions. In addition to education, patients should continue exercise training mainly consisting of endurance training, and undergo exercise stress tests at months 1 and 3 and at the end of the program to assess the efficacy of the CR program, predict prognosis, and reissue exercise prescriptions.1

Late Phase II Cardiac Rehabilitation, Which Is Adding Life to Years and Years to Life, Is Still Underused in Japan