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Rochester, MN - About half of the mortality over three years among patients discharged after a first MI could be attributed to nonparticipation in a formal cardiac rehabilitation program, a population study covering 16 years of data indicates.1 Women and the elderly were consistently less likely to engage in rehab than men and younger patients, respectively, independent of cardiac risk-factor profiles and comorbidities, according to a report in the September 1, 2004 issue of the Journal of the American College of Cardiology.
For patients who participated in cardiac rehab, it was almost as if the heart attack never had happened.
"On average, for patients who participated in cardiac rehab, it was almost as if the heart attack never had happened. They had the same three-year survival as what would be expected from area residents of the same age and sex who had not suffered heart attacks," said Dr Véronique L Roger (Mayo Clinic, Rochester, MN) in a statement for reporters.
Rate of participation in a cardiac rehabilitation program after a first MI|
Group |
Participation rate (%) |
|
Overall (n=1821) | 55 |
|
Men (n=839) | 67 |
|
Women (n=765) | 38 |
|
Age <60 | 81 |
|
Age 60-69 | 66 |
|
Age >70 | 32 |
In an analysis of records from all patients discharged after a first MI from 1982 to 1998 in Olmsted County, Minnesota, Roger and her colleagues found that:
Overall, 55% of patients participated in a cardiac rehabilitation program.
The rate of participation declined steadily with increasing age and was significantly lower among women than among men regardless of age. In either case, the reduced participation was independent of any comorbidities.
Participation rates for the two sexes and within different age groups remained consistent throughout the study period.
Participation was significantly more likely if a cardiologist was involved in caring for the patient at the time of the MI, either as the primary physician or a consultant.
Characteristics correlated with rehab participation included hyperlipidemia, greater body mass index, a family history of heart disease, and being a current smoker.
Patients with a personal history of heart disease, hypertension, or diabetes or other comorbidities were less likely to participate in rehab.
Reduced likelihood of participation in cardiac rehab, multivariate analysis|
Characteristic |
Likelihood of participation: RR (95% CI)* |
|
Age 60-69 (vs <60 y) | 0.60 (0.41-0.88) |
|
Age >70 (vs age <60 y) | 0.23 (0.16-0.33) |
|
Female (vs male) | 0.45 (0.34-0.60) |
Influence of rehab on outcomes
Follow-up data for the patients covered an average of 6.6 years, during which time 27.1% developed reinfarctions and 42.5% died. Participation in rehab was associated with a 56% increase in survival (p<0.001) and 28% reduction in reinfarction risk (p=0.049) as compared with nonparticipation. Both findings were independent of age, sex, and whether the patient was discharged on beta blockers, ACE inhibitors, aspirin, or statins. They were adjusted for a "propensity score" that accounted for various factors (demographic, clinical, and cardiologist involvement in initial care) that influenced whether a patient engaged in a rehab program.
Of all the deaths occurring within three years of discharge, nearly half were attributable to nonparticipation in a rehab program.
Mortality risk attributable to nonparticipation in a cardiac rehabilitation program after a first MI|
Group |
Attributable mortality risk |
95% CI |
|
Overall (n=1821) | 0.48 | 0.43-0.53 |
|
Men (n=839) | 0.55 | 0.47-0.64 |
|
Women (n=765) | 0.39 | 0.33-0.45 |
|
Age <70 | 0.27 | 0.20-0.35 |
|
Age >70 | 0.44 | 0.36-0.52 |
Outcome trends over time
Hopefully this study will encourage physicians to give all of their patients, but especially women, that extra nudge to participate in rehab.
The rehab-related survival benefit increased significantly over the years covered by the data. The relative mortality risk for death among participants as compared with nonparticipants dropped 59% between 1982 and 1990; by 1998, the risk had fallen 72%. Possible reasons, according to the authors, may include concurrent increases in the post-MI population's proportions of high-risk groups, which include women and the elderly.
"Hopefully this study will encourage physicians to give all of their patients, but especially women, that extra nudge to participate in rehab," said Roger. "And for patients, hopefully it will encourage them to follow their doctor's advice."
