Don’t underestimate the benefits of cardiac rehabilitation for patients with CVD

By Katie Robinson | Fact-checked by Barbara Bekiesz
Published April 3, 2024

Key Takeaways

  • Cardiac rehabilitation (CR) is endorsed for the secondary prevention of coronary artery disease. It can substantially reduce death or hospital readmission in patients with cardiovascular disease, regardless of age, sex, or race.

  • The rate of CR participation, however, is low—below 10%.

  • Initiatives such as automated patient referrals and the use of digital technologies may increase CR participation.

Duke University researchers, reporting in the Journal of Cardiopulmonary Rehabilitation and Prevention, found that, regardless of age, sex, or race, patients with cardiovascular (CVD) who participated in cardiac rehabilitation (CR) had a 43% reduction in death or hospital readmission compared with those who did not participate in CR.[]

Despite this benefit, however, only 8% of the patients who were eligible for CR participated in the program. 

In a news release from Duke on the findings, lead author Brian Duscha said, “Our study shows that no matter who your patient is, what clinical characteristics they have, what type of intervention they have to clear blockages—if you send them to cardiac rehab, the benefit is far greater than what previous studies have shown.”[]

Effects on secondary prevention

CR is comprised of exercise, stress reduction, and lifestyle counseling, and is an endorsed strategy for the secondary prevention of coronary artery disease. 

Still, research on its impact has produced mixed findings. Some studies have accounted for patient demographics and clinical characteristics, but they may have excluded factors affecting an individual’s ability to participate in CR. Moreover, many studies looking at cardiac patients’ outcomes have failed to consider the importance of participation in CR.[]

The Duke investigation was a single-center cohort study among patients with occlusive CVD who were discharged from July 1, 2010, to June 30, 2012. The patients had been diagnosed with acute myocardial infarction (AMI) and/or blockages requiring percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. The researchers assessed the effects of CR on all-cause readmission and mortality at 180 days after the referring cardiovascular event.

Patients were excluded if they had valve repair/replacement, heart transplant, or angina. Those living more than 50 miles from the CR center or residing in a nursing facility were also excluded. The researchers accounted for clinical characteristics, comorbidities, medications, and demographics in their analysis. “Not controlling for all these factors may explain the inconsistent findings from other studies assessing cardiac rehab’s impact on clinical outcomes,” Duscha explained in the news release.

Low participation rate despite benefit

Of the 2,641 patients (averaging 65% male, 60 years old and above) considered able to undergo CR, 214 (8.1%) attended at least one session and represented the CR group.

The discharge criteria differed between groups—in the CR group, CABG only and AMI plus PCI were more common, whereas PCI only was more common in the non-CR group.

During 180 days of follow-up, 12.1% of the CR and 18.7% of the non-CR patients were readmitted to the hospital. The respective mortality rates were 0.5% and 4.0%. CR resulted in a significant 42.7% reduction in readmission or mortality risk (HR = 0.57: 95% CI, 0.33-0.98; P = 0.043), after adjusting for age, sex, race, dyslipidemia, hypertension, obesity, smoking, type 2 diabetes, depression, anxiety, and discharge criteria.

Only 42% of patients started CR within the recommended 30 days. Patients attended 25 sessions, on average, with 93% completing at least five sessions. 

Notably, attending even five sessions reduced the risk of death or readmission by 10%.

In the Duke news release, senior author William Kraus, MD, noted that the risk of death or readmission dropped by 2% for every CR session attended. “Bottom line—cardiac rehabilitation is effective. It keeps people out of the hospital, saving both money and lives,” he concluded.

Interventions to increase participation

Rates of CR participation fall below optimum levels, despite CR’s class 1A recommendation from the American Heart Association (AHA) and the American College of Cardiology.

Contributing factors relate to the referral process and the geographic location of the CR program. A patient’s psychosocial status also plays a part, with suboptimal participation by women, minorities, and those of lower socio-economic status.

A 2022 review, published in Progress in Cardiovascular Diseases, examined the impact of interventions to increase CR participation.[] “The single biggest impact toward improving attendance at currently available CR programs would be for hospitals to universally adopt automated referral of patients to CR as part of the hospital discharge process,” the authors wrote.

With the limited capacity of currently available CR programs, the presence of CR "deserts," and various obstacles to attendance, it is likely that the future of CR will need to expand home and hybrid programs and create “secondary prevention programs for those who cannot, or will not, attend CR,” the authors added.

AHA advisory on digital CR tech

The AHA released a 2023 advisory, published in Circulation, to help develop and implement digital CR interventions for the clinic.[]

According to the advisory, many of the challenges of traditional center-based CR can be addressed when CR is delivered via telemedicine, telehealth, and digital technologies, such as wearable devices and mobile applications.

Moreover, digital monitoring can provide insights into patients’ lifestyle behaviors, particularly those that could be used to optimize cardiovascular health.

“For digital technologies to transform the paradigm of CR care, however, several methodological gaps must first be addressed along the continuum from development to implementation with a focus throughout on digital health equity,” the Circulation authors concluded.

What this means for you

CR provides a definitive benefit for your patients with CVD, but it is underused. Automated CR referrals for patients on discharge and the use of digital technologies may help address this issue.

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