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Effect of early short-term rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on clinical events after 1-year follow-up.

Comments by B. Rauch, EACPR Cardiac Rehabilitation Section

The EACPR Cardiac Rehabilitation Section comments on:


From the prospective Acute COronary Syndromes (ACOS) registry 4,547 consecutive patients after ST-elevation- (STEMI: n = 2,432) or non-ST-elevation myocardial infarction (NSTEMI: n = 2,115), recruited between June 2000 and December 2002, were evaluated for clinical outcomes during 1-year follow-up 1. Cardiac rehabilitation (CR) participation rate was 67.8% (STEMI) and 52.3% (NSTEMI) respectively.

Multivariable analysis adjusting for propensity score shows that CR was independently associated with a significant reduction of all-cause mortality (STEMI: OR 0.41, 95% CI 0.28-0.60; NSTEMI: OR 0.53, 95% CI 0.38-0.76) and Major Adverse Cardiac and Cerebrovascular Events (STEMI: OR 0.66, 95% CI 0.49-0.89; NSTEMI: OR 073, 95% CI 0.55-0.98).

Particularly patients with elevated risk (age above 70 years, diabetes mellitus, left ventricular ejection fraction < 40%) derived advantage from rehabilitation as expressed by the number needed to be exposed.

The major limitation of the study is not to be a prospective randomized trial. Unequal distribution of risk factors relevant for long-term prognosis had to be corrected by multivariable analysis adjusting for propensity score. Despite prospective randomized trials on clinical and social long-term effects of various rehabilitation programs are urgently needed, such studies are not funded in Germany at present.

The recently published GOSPEL study, however, may serve as an example that national prospective multicenter trials evaluating CR are feasible. It therefore is time to think about a multinational trial evaluating the effect of cardiac rehabilitation on prognostic, social and economic measures.