Cardiac Rehabilitation

Abstract

ardiac rehabilitation (CR) is a multidisciplinary, secondary prevention treatment modality 1 that reduces mortality and morbidity among patients with coronary heart disease and improves symptoms, functional capacity, metabolic status, depression, and health-related quality of life. 2,3 A recent analysis suggested that CR contributed significantly to the reduction in coronary heart disease mortality observed in the United States between 1980 and 2000 and that the risk reduction attributable to CR was comparable to reductions attributed to postevent aspirin, ␤-blocker, angiotensinconverting enzyme inhibitor, statin, and warfarin therapy as well as to risk reductions attributed to acute thrombolysis and revascularization. 4 CR is considered a Class I indication after acute coronary syndrome, coronary revascularization, and for stable angina, but remains underutilized with low referral, low enrollment, and low completion rates and considerable disparities in access. 5,6 Article see p 677Many of the benefits of CR were demonstrated in clinical trials that predate contemporary treatments for coronary heart disease, in patient populations cared for in tertiary care settings, or in large administrative data sets which lack granularity regarding patients' clinical characteristics, disease severity, and concomitant therapy. 3,7,8 In this issue of Circulation, Martin et al 9 assessed mortality rates, hospitalizations, cardiac hospitalizations, and emergency department visits among 5886 individuals who had undergone cardiac catheterization, had detailed data collected at the time of the index event, and were referred to a single, centralized, communitybased CR program within 1 year of the index event. Median follow-up was 5.37 years. More than 40% of eligible patients who were referred chose not to attend, and an additional 9% enrolled but did not complete the program. Compared to CR completers, those who did not enroll or did not complete were older and sicker, more likely to be women, and more likely to be economically disadvantaged. CR completers had the lowest mortality rate, lowest hospitalization rates, and fewest emergency room visits. The relationship between CR completion and lower mortality rate was robust across unadjusted, adjusted, and propensity-matched analyses with hazard ratios between 0.57 and 0.67 for completers versus noncompleters. A similarly robust effect was seen for hospitalization rates, while there was no significant benefit of CR completion in relation to emergency room visits after adjustment for important covariates. Of note, individuals who enrolled in CR, but did not complete, had the highest rates of hospitalization and emergency room use and had mortality rates similar to those who chose not to attend. This study's major strength is the availability of detailed demographic and clinical information before CR enrollment and complete ascertainment of mortality and important health care utilization measures after enrollment achieved by linking several large databases. Through propensity-matchi...

Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long‐Term Mortality

“…Meta‐analyses suggested that CR participation can reduce all‐cause mortality by 15% to 28% for patients with MI4, 37, 38, 39 and 45% to 47% for patients with percutaneous coronary intervention 40. The effect was estimated to be comparable to improvements associated with aspirin, β‐blocker, angiotensin‐converting enzyme inhibitor, statin, and anticoagulant therapy 5, 41, 42, 43. However, the generalizability of these results was limited because the majority of trial participants were highly selected low‐risk white males, with few females, minorities, or elderly patients, and with short duration of follow‐up 4.…”

“…Observational studies with long‐term mortality were sparse and mainly focused on CR participation. Prior studies lack detailed clinical and treatment information, data on severity of medical conditions, and information about other quality of care/risk interventions that patients received, which serve as important factors for CR referral and participation 4, 22, 41, 44. Most prior studies were based on claims databases that do not contain information on CR referral.…”

“…The GWTG‐CAD database has detailed and rich information on CR referral, as well as other lifestyle intervention recommendations. By linking the GWTG‐CAD with an outpatient database, we were afforded a unique opportunity to examine the association between CR referral with long‐term cardiovascular mortality above and beyond quality of care received 41, 45. The American College of Cardiology and the American Heart Association have issued a Class I recommendation that certain cardiovascular patients (acute MI, percutaneous coronary intervention, coronary artery bypass grafting, heart valve repair/replacement, heart transplant, coronary artery disease, and angina) should be referred to a CR program before hospital discharge.…”