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Rehabilitation: start early to gain more...

Comment by Marc Lambelin, Heilig Hart Ziekenhuis, Lier, Belgium and Paul Dendale, EACPR Secretary


Cardiac rehabilitation (CR) is known as an effective secondary prevention intervention, proven to reduce premature cardiovascular mortality (-26%) and hospitalizations (-18%) and improve quality of life. (1)

In this multicenter, observational study Fell et al aim to determine if there is a relationship between the timing of exercise-based cardiac rehabilitation and patients response. (2)  This real life study  in the United Kingdom, demonstrates that an “early” start of cardiac rehabilitation has a significant impact on both the patient-reported physical activity level as quality of life and it increases the incremental shuttle-walk test (ISWT).

In this study, initiation of CR was considered soon if < 28 days after referral, which is actually less stringent than current guidelines that state that cardiac rehabilitation should be initiated on admission and should be continued after hospital discharge within one to three weeks. (3) The mean wait time with CR referral and CR start was 40 days, with 63% classified as late starters.  The strength of this observational analysis, is to provide supplementary evidence that an early start of CR is beneficial. For every 1-day increase in CR wait time, patients were 1% less likely to improve across all fitness-related measures. These results fit recent studies, showing that delayed CR enrollment compromises patient outcomes such as exercise capacity, weight reduction and smoking cessation. (4) (5)  It draws a clear picture of the current CR landscape with too long waiting times (and low recruitment) in all patients and particularly in post-myocardial infarction (MI) patients (both primary percutaneous coronary intervention [PCI] of medically treated patients), in patients with one or more comorbidities, in females and in older patients.

To conclude, this study confirms that continuous efforts should be made to include patients early in CR to increase its beneficial effects.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


1. Anderson L, Thompson DR, Oldridge N et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016 Jan 5;1
2. Fell J, Dale V, Doherty P.  Does the timing of cardiac rehabilitation impact fitness outcomes? An observational analysis. Open Heart. 2016 Feb 8;3(1)
3. Piepoli MF, Corrà U, Adamopoulos S et al.  Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery. Eur J Prev Cardiol. 2014 Jun;21(6):664-81.
4. Johnson DA, Sacrinty MT, Gomadam PS et al. Effect of early enrollment on outcomes in cardiac rehabilitation. Am J Cardiol. 2014 Dec 15;114(12)
5. Chow CK, Jolly S, Rao-Melacini P et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010 Feb 16;121(6):750-8.

Notes to editor

Dr Marc Lambelin, Heilig Hart Ziekenhuis, Lier, Belgium

Prof Paul Dendale, FESC, Heart Centre Hasselt, Belgium