Cardiac rehabilitation and socioeconomic disparity

Cardiovascular conditions increase in prevalence with ageing, and yet older persons are often under-represented in research and in treatment programmes like cardiac rehabilitation (CR). The EU-CaRE observational study is seeking to improve knowledge of CR in patients 65 years and older with coronary heart disease or heart valve surgery. For this sub-study, eight CR sites in seven European countries provided data on 1,621 older patients of the immediate (baseline, end of CR) and long-term (one year follow-up) effects of CR on key quality parameters across socio-economic strata. Socio-economic status was determined based on educational attainment: basic (primary school, no higher education); intermediate (high school, trade/craft education, higher education <3 years); and high (university >3 years higher education).

At baseline, those with a basic education were older, more likely to be female, had more comorbidities, more symptoms of anxiety and depression, lower quality of life and lower exercise capacity than those at higher education levels. The gap in risk factors, symptoms and exercise capacity persisted despite no difference in evidence-based medications and generally high participation in exercise sessions (median attendance: 93% basic education, 100% intermediate and high). At follow-up the time x education interaction was significant for less improvement in exercise capacity, poorer risk factor control and higher symptoms of depression and anxiety.

Lower educational attainment/socioeconomic status are associated with lower health literacy and poorer lifestyle-related risk factors, some of the factors that could and should be addressed in CR. Crucially, this paper highlights the importance of taking a broad biopsychosocial view in individualising CR programmes for patients. We can’t assume that patients understand the content presented if they don’t ask questions, or that their personal circumstances provide them with the motivation, environment and economic means to live a healthier lifestyle. We need to find ways to meet the needs and deliver effective CR to all patients regardless of age, education and socioeconomic status.