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Do not miss cardiac rehabilitation for better outcomes

Comment by Maria Simonenko, Secondary Prevention and Rehabilitation Section

Preventive Cardiology
Rehabilitation and Sports Cardiology

Despite progress in prevention and treatment, coronary artery disease (CAD) remains the leading cause of health loss globally [1] and the most common cause of death related to cardiovascular disease (CVD) [2]. For a long time, underrepresentation of migrants, women, and older adults in CVD trials has likely contributed to disparate care and survival. Not only does prevention and on-time diagnosis impact patients’ outcomes, but so does management including rehabilitation. Missing any of these points can be crucial.

N. Gonzalez-Jaramillo et al. suggested that among underrepresented groups undergoing percutaneous coronary intervention (PCI), age, but not migration status nor sex, contributed to disparities in mortality. Migrant status did not result in lower attendance of cardiac rehabilitation (CR). Considering the protective associations of CR on CVD mortality independent of age, sex and migration status, the lower uptake in women and older adults is noteworthy [3]. Despite the specificity of their clinical setting, their results indicate the need to evaluate if inclusive policies at the country and health-system levels may help overcome health disadvantages and exclusions in migrants. By comparing how rates of CR uptake among migrants and nationals change over time, future studies should evaluate the impact of health policies addressing health inequities in the migrant population [3]. However, in most centres, the same as in the analysed cohort of PCI patients by N. Gonzalez-Jaramillo, ambulatory CR is the intervention of choice, whereas stationary CR is preferred after coronary artery by-pass grafting, valve surgery, and percutaneous aortic valve replacement [3].

According to N. Gonzalez-Jaramillo et al., after the first major adverse cardiovascular events (MACE), 11% of patients had a second MACE, 5% died from cardiovascular causes, and 2% died from other causes. Age was associated with a significant risk for non-CVD mortality as a first transition, and CVD mortality in all the transitions, but not with MACE. For each year of increase in age, participants had an 8% increased risk of non-CVD and CVD mortality after PCI in the first transition. [3]

There are different causes of missing cardiac rehabilitation in the underrepresented population. Awareness of ethnicity, the language spoken and the need for an interpreter would then allow providers such as the cardiac rehabilitation team to address issues related to health literacy as evidence suggests that those with greater cardiac knowledge are more likely to attend CR [4]. While the recently published study highlighted the importance and positive outcomes of cardiac rehabilitation in underrepresented groups, it also promotes that every CVD patient should be included in CR programmes. I suggest authors extend their study by comparing described patients with those who underwent open-heart surgery. And the future perspectives are to organize both inpatient and outpatient CR programmes, as well as onsite and virtual.


Maria Simonkeno commented on this article:

3. Nathalia Gonzalez-Jaramillo, et al. Clinical outcomes and cardiac rehabilitation in underrepresented groups after percutaneous coronary intervention: an observational study, EJPC, 2021; 1-11 DOI: 10.1093/eurjpc/zwab204

Other references:

1. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1151–1210.
2. Roth GA, Johnson C, Abajobir A et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol 2017;70:1–25.
4. Umesh Chauhan, Deborah Baker, Helen Lester, Richard Edwards – Exploring uptake of cardiac rehabilitation in a minority ethnic population in England: a qualitative study, European Journal of Cardiovascular Nursing, 2010; 9: 68-74.

Notes to editor

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.