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The CROS trial: a new piece of evidence in support of cardiac rehabilitation

Comment by Dr. Ines Frederix, Prof. Dominique Hansen, and Prof. Paul Dendale

Despite better coronary revascularization techniques and optimization of medication prescription in current cardiovascular medicine, multidisciplinary cardiac rehabilitation remains of paramount importance to reduce mortality after acute coronary events.
Findings from a recent meta-analysis entitled ‘The prognostic effect of cardiac rehabilitation in the era of acute revascularization and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies – The Cardiac Rehabilitation Outcome Study (CROS)’- By Rauch B, Davos CH, Doherty P, et al. Eur J Prev Cardiol. 2016 Oct 24. pii: 2047487316671181

Cardiovascular Rehabilitation
Risk Factors and Prevention

The prognostic effect of multidisciplinary cardiac rehabilitation within the contemporary era of improved acute coronary revascularization and optimized pharmacological treatment



The ESC guidelines recommend cardiac rehabilitation for ischemic heart disease patients (Class I for ST-elevation myocardial infarction patients, Class IIa for Non-ST-elevation myocardial infarction patients and Class I for stable coronary artery disease patients) [1-3]. Despite these strong recommendations, cardiac rehabilitation uptake rates remain poor. As evidenced by the EUROASPIRE IV survey, < 50% of eligible patients currently participate in cardiac rehabilitation programs [4].


The CROS trial: a new piece of evidence in support of cardiac rehabilitation

The Cardiac Rehabilitation Outcome Study (CROS) study group evaluated the prognostic effect of multi-component cardiac rehabilitation in patients with an acute coronary syndrome or previous coronary artery bypass graft and/or in mixed coronary artery disease patients [5]. Twenty five studies were included in this systematic review and meta-analysis. Eventually, 219.702 ischemic heart disease patients from nine different countries worldwide were assessed. CROS was the first review of the prognostic effect of multi-component cardiac rehabilitation, in the current era of improved acute coronary revascularization and optimized pharmacological treatment (including statin therapy). The predominant finding of this review was that, despite these advances in cardiovascular medicine, multi-component cardiac rehabilitation was still associated with significantly reduced total mortality after a coronary artery bypass graft (HR 0.62) and an acute coronary syndrome (HR 0.37). The authors concluded that cardiac rehabilitation remains an effective therapeutic intervention to reduce the risk of premature death in ischemic heart disease patients. Innovations in cardiovascular medicine do not seem to replace the need for lifestyle changes after acute coronary syndromes/revascularization.

Despite the reported heterogeneity of the included studies in terms of study design, cardiac rehabilitation duration, intensity and/or volume and statistical methods applied, the CROS study adds very important and solid evidence in favor of cardiac rehabilitation in ischemic heart disease. It responds well to the EAPC, ACCA and CCNAP’s call for action to address the challenges in secondary prevention after an acute myocardial infarction, because this study is key in increasing awareness about the benefits of cardiac rehabilitation [6]. Of note, the CROS study included studies assessing multi-component cardiac rehabilitation. This was defined as structured physical exercise training in combination with at least one other core component (information, motivational counseling, education, psychological, social and/or vocational support). It underscores that cardiac rehabilitation uses a comprehensive strategy including multiple core components; rather than solely focusing physical exercise training. The addition of nutritional counselling, risk factor control, psychosocial management, vocational support, therapy compliance and patient education is key to assure program success


Note: 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