It has been clearly estab- lished that in this high-risk cohort, subsequent cardiovascular morbidity and mortality can be reduced by a comprehensive approach to favorably modifying patients risk profiles.27 Secondary prevention comprises lifestyle changes, risk fac- tor education, medical therapy, and, where appropriate, revas- cularization. These elements are discussed in Section 6.4. Despite the proven utility of secondary prevention, its imple- mentation remains suboptimal, and enhanced application is a major goal in this patient population. See Online Data Supplement 23 for additional information on risk reduction strategies. 6.3.1. Cardiac Rehabilitation and Physical Activity: Recommendation Class I 1. All eligible patients with NSTE-ACS should be re- ferred to a comprehensive cardiovascular rehabilita- tion program either before hospital discharge or dur- ing the first outpatient visit.449 452 (Level of Evidence: B) The US Public Health Service emphasizes comprehensive car- diac rehabilitation programs,449 and the 2011 secondary pre- vention CPG underscores referral to cardiac rehabilitation for survivors of ACS.27 Since 2007, referral to these programs has been designated a quality performance measure.453 455 Barriers to referral can be obviated by discussion with the patient and referral by the patient s primary care clinician and/or cardio- vascular caregiver. These comprehensive programs provide patient education, enhance regular exercise, monitor risk factors, and address lifestyle modification.456 Aerobic exercise training can generally begin 1 to 2 weeks after discharge in patients treated with PCI or CABG.457 Mild-to-moderate resis- tance training can be considered and started 2 to 4 weeks after Unsupervised exercise may target a heart rate range of 60% to 75% of maximum age-predicted heart rate based on the patient s exercise stress test. Supervised training may target a higher heart rate (70% to 85% of age-predicted Additional restrictions apply when residual isch- emia is present. 