Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II)

Abstract

Background Despite numerous studies and meta-analyses the prognostic effect of cardiac rehabilitation is still under debate. This update of the Cardiac Rehabilitation Outcome Study (CROS II) provides a contemporary and practice focused approach including only cardiac rehabilitation interventions based on published standards and core components to evaluate cardiac rehabilitation delivery and effectiveness in improving patient prognosis. Design A systematic review and meta-analysis. Methods Randomised controlled trials and retrospective and prospective controlled cohort studies evaluating patients after acute coronary syndrome, coronary artery bypass grafting or mixed populations with coronary artery disease published until September 2018 were included. Results Based on CROS inclusion criteria out of 7096 abstracts six additional studies including 8671 patients were identified (two randomised controlled trials, two retrospective controlled cohort studies, two prospective controlled cohort studies). In total, 31 studies including 228,337 patients were available for this meta-analysis (three randomised controlled trials, nine prospective controlled cohort studies, 19 retrospective controlled cohort studies; 50,653 patients after acute coronary syndrome 14,583, after coronary artery bypass grafting 163,101, mixed coronary artery disease populations; follow-up periods ranging from 9 months to 14 years). Heterogeneity in design, cardiac rehabilitation delivery, biometrical assessment and potential confounders was considerable. Controlled cohort studies showed a significantly reduced total mortality (primary endpoint) after cardiac rehabilitation participation in patients after acute coronary syndrome (prospective controlled cohort studies: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; retrospective controlled cohort studies HR 0.64, 95% CI 0.53–0.76; prospective controlled cohort studies odds ratio 0.20, 95% CI 0.08–0.48), but the single randomised controlled trial fulfilling the CROS inclusion criteria showed neutral results. Cardiac rehabilitation participation was also associated with reduced total mortality in patients after coronary artery bypass grafting (retrospective controlled cohort studies HR 0.62, 95% CI 0.54–0.70, one single randomised controlled trial without fatal events), and in mixed coronary artery disease populations (retrospective controlled cohort studies HR 0.52, 95% CI 0.36–0.77; two out of 10 controlled cohort studies with neutral results). Conclusion CROS II confirms the effectiveness of cardiac rehabilitation participation after acute coronary syndrome and after coronary artery bypass grafting in actual clinical practice by reducing total mortality under the conditions of current evidence-based coronary artery disease treatment. The data of CROS II, however, underscore the urgent need to define internationally accepted minimal standards for cardiac rehabilitation delivery as well as for scientific evaluation.

Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC)

“…4 Comprehensive CR should encompass a multidisciplinary intervention, including exercise training, risk factor control, psychosocial counselling, smoking cessation, patient education and vocational reintegration. 4 Previous data, including recent meta-analysis have shown the efficacy of CR 3,[5][6][7] to reduce mortality, myocardial infarction (MI) and improve functional capacity, psychosocial wellbeing and quality of life in coronary artery disease patients. Several benefits extend to patients with heart failure (HF) and patients with devices [8][9][10] or submitted to cardiac surgery, 11 among others.…”

Patient-reported outcomes predict return to work and health-related quality of life six months after cardiac rehabilitation: Results from a German multi-centre registry (OutCaRe)

“…[1] Through this multimodal approach, an improved clinical prognosis, high quality of life and social participation should be achieved. [1] While the positive effect of CR on the clinical course and health-related quality of life (HRQL) has been sufficiently proven, [2][3][4][5][6] the evidence regarding the impact on occupational outcomes and return to work rates remains inconclusive. [7] However, CR programmes based on a multi-modal approach seem to be at an advantage over exercise-based programmes in terms of both clinical and occupational outcomes.…”

Cost-effectiveness of rivaroxaban plus aspirin (dual pathway inhibition) for prevention of ischaemic events in patients with cardiovascular disease: on top optimisation of secondary prevention medication in the context of COVID-19 pandemia

“…On the other hand, the consequent utilisation of well-structured and supervised prevention and rehabilitation programmes will help to enforce prevention strategies and thereby also help to introduce innovative therapies sustainably in clinical all day care. [17][18][19] 'From the top back to baseline' When writing this editorial COVID-19 threatens every country all over the world. At this time neither effective vaccination nor targeted therapeutic options are available, but patients with CVD and/or diabetes are known to be of special risk of dying from Sars-CoV-2 infection.…”