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Data to convince policy makers to (re)consider reimbursement regulations for CV rehabilitation.

comment by Dominique Hansen, EAPC Secondary Prevention and Rehabilitation Section

Cardiovascular Rehabilitation

In 2016 the CROS study has shown that even in the era of statin use and acute revascularisation, multidisciplinary cardiovascular (CV) rehabilitation leads to significant reductions in morbidity and mortality in patients with coronary artery disease (CAD) (1).

As a result, CV rehabilitation is a class 1A intervention in the secondary prevention and should thus be considered as mandatory to every patient with CAD (2).

Although progress is being made is exercise prescription to these patients (3), the impact of the different (especially non-exercise) components of CV rehabilitation remained however to be examined in greater detail (e.g. nutritional counselling, risk factor modification, psychosocial management, patient education). This is important, since a recent meta-analysis demonstrated that CV rehabilitation programs offering more core components achieved greater reductions in all-cause mortality than those offering less (4).

In December 2018, Kabboul and colleagues published a meta-analysis examining the impact of the core components of CV rehabilitation, including nutritional counselling (NC), risk factor modification, psychosocial management (PM), patient education (PE), and exercise training (ET)), on mortality (all-cause and CV) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalisation (all-cause and CV)) (5).

Ultimately, 148 RCTs (including 50,965 participants) were included. Main effects models were best fitting for mortality (for all-cause, specifically PM (hazard ratio (HR) = 0.68) and ET (HR = 0.75), MI (specifically PM (HR = 0.76), ET (HR = 0.75) and PE (HR = 0.68)) and hospitalisation (for all-cause, PM (HR = 0.76). For revascularization (including CABG and PCI), the full interaction model (thus including all components) was best-fitting.

Given that each component, individual or in combination, was associated with lower mortality or morbidity, comprehensive CV rehabilitation should thus offered to every patients with CAD. These data should convince policy makers to (re)consider re-imbursement regulations in CV rehabilitation, and/or support to CAD patients.


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


Dominique Hansen commented on this article:

5. Kabboul NN, Tomlinson G, Francis TA, et al. Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis. J Clin Med. 2018 Dec 4;7(12). pii: E514. doi: 10.3390/jcm7120514.

Additional References:

  1. Rauch B, Davos CH, Doherty P, et al. The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol. 2016;23:1914-1939.
  2. 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: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol. 2014;21:664-81.
  3. Hansen D, Dendale P, Coninx K, et al. The European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool: A digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology. Eur J Prev Cardiol. 2017;24:1017-1031.
  4. Van Halewijn G, Deckers J, Tay HY, et al. Lessons from contemporary trials of cardiovascular prevention and rehabilitation: A systematic review and meta-analysis. Int J Cardiol. 2017;232:294–303.