Dose of Cardiac Rehabilitation to Reduce Mortality and Morbidity: A Population‐Based Study

Abstract

Background There is wide variability in cardiac rehabilitation (CR) dose (ie, number of sessions) delivered, and no evidence‐based recommendations regarding what dose to prescribe. We aimed to test what CR dose impacts major adverse cardiovascular events (MACEs). Methods and Results This is an historical cohort study of all patients who had coronary artery disease and who initiated supervised CR between 2002 and 2012 from a single major CR center. CR dose was defined as number of visits including exercise and patient education. Follow‐up was performed using record linkage from the Rochester Epidemiology Project. MACEs included acute myocardial infarction, unstable angina, ventricular arrhythmias, stroke, revascularization, or all‐cause mortality. Dose was analyzed in several ways, including tertiles, categories, and as a continuous variable. Cox models were adjusted for factors associated with dose and MACE. The cohort consisted of 2345 patients, who attended a mean of 12.5±11.1 of 36 prescribed sessions. After a mean follow‐up of 6 years, 695 (29.65%) patients had a MACE, including 231 who died. CR dose was inversely associated with MACE (hazard ratio, 0.66 [95% CI]; 0.55–0.91) in those completing ≥20 sessions, when compared with those not exposed to formal exercise sessions (≤1 session; log‐rank P =0.007). We did not find evidence of nonlinearity ( P ≥0.050), suggesting no minimal threshold nor ceiling. Each additional session was associated with a lower rate of MACE (fully adjusted hazard ratio, 0.98 [95% CI, 0.97–0.99]). Greater session frequency was also associated with lower MACE risk (fully adjusted hazard ratio, 0.74 [95% CI, 0.58–0.94]). Conclusions CR reduces MACEs, but the benefit appears to be linear, with greater risk reduction with higher doses, and no upper threshold.

Sex Differences in Cardiac Rehabilitation Outcomes

“…31 Importantly, a dose response relationship exists between the number of CR sessions attended and the associated reduction in mortality and major adverse cardiac and cerebrovascular event rates. 16,17,20,21,23,32 Despite the low CR participation rates in females, CR has been shown to elicit similar or greater mortality benefit in females compared with males. 13,14,16,19,22,33 Sex differences in the temporal trends in CR participation are unclear.…”

“…Importantly, CR participation is also associated with reductions in hospital readmissions and mortality. [13][14][15][16][17][18][19][20][21][22][23] Despite these advantageous clinical outcomes, sex disparities are present in outpatient phase II CR programming (ie, from referral to clinical management). In this review, we have focused on sex differences in CR programming (and subsequent outcomes) where we discuss potential contributing biological, environmental, and social factors.…”

Validity and Reliability of the Cardiac Rehabilitation Barriers Scale in the Czech Republic (CRBS-CZE): Determination of Key Barriers in East-Central Europe

“…Despite robust evidence of the benefits of CR, even of each additional session attended [ 25 ], utilization remains low [ 9 ]. Patient’s barriers to CR utilization should be evaluated, hence the emergence of the CRBS and its 15 translations [ 18 , 26 , 27 , 28 , 29 , 30 , 31 ].…”

The Impact of the SARS-CoV-2 Virus (COVID-19) Pandemic and the Rapid Adoption of Telehealth for Cardiac Rehabilitation and Secondary Prevention Programs in Rural and Remote Australia: A Multi-Method Study

“…Since engagement and dose of participation in CR are directly related to clinical outcomes [ 40 ], we would expect lower participation during COVID-19 to be associated with worse outcomes. However, we did not find any association of the time of referral to CR (pre vs during COVID-19) with the composite outcome of hospitalisations and cardiovascular death.…”