Referral rate and outcomes of cardiac rehabilitation after cardiac catheterization in a large Canadian city

Cardiac Rehabilitation Programs: Content, Effectiveness, Limitations, and Gaps in Knowledge

Cardiac rehabilitation (CR) constitutes a valuable therapeutic approach for patients with a broad spectrum of cardiovascular diseases facilitating the development and maintenance of a desirable level of physical, social, and psychological functioning following the onset of cardiovascular disease. Nowadays, cardiac rehabilitation programs emphasize the use of a multidisciplinary approach. The current review aims at presenting the state-of-the-art knowledge on the indications of patients entering cardiac rehabilitation programs, including their core components, duration, and effectiveness. Following a careful review of the international literature, we conclude that there are significant differences between the most commonly cited international CR guidelines as well as additional limitations and gaps in knowledge. Despite the benefits associated with CR and despite their widespread acceptance, CR referrals and program attendance remains low, while many questions have not been so far addressed through scientific research. Overall, the findings of our study suggest a critical need for the development of robust and evidence-based standardized CR interventions to increase their use and effectiveness throughout the world.

Causal Model Building in the Context of Cardiac Rehabilitation: A Systematic Review

Randomization is an effective design option to prevent bias from confounding in the evaluation of the causal effect of interventions on outcomes. However, in some cases, randomization is not possible, making subsequent adjustment for confounders essential to obtain valid results. Several methods exist to adjust for confounding, with multivariable modeling being among the most widely used. The main challenge is to determine which variables should be included in the causal model and to specify appropriate functional relations for continuous variables in the model. While the statistical literature gives a variety of recommendations on how to build multivariable regression models in practice, this guidance is often unknown to applied researchers. We set out to investigate the current practice of explanatory regression modeling to control confounding in the field of cardiac rehabilitation, for which mainly non-randomized observational studies are available. In particular, we conducted a systematic methods review to identify and compare statistical methodology with respect to statistical model building in the context of the existing recent systematic review CROS-II, which evaluated the prognostic effect of cardiac rehabilitation. CROS-II identified 28 observational studies, which were published between 2004 and 2018. Our methods review revealed that 24 (86%) of the included studies used methods to adjust for confounding. Of these, 11 (46%) mentioned how the variables were selected and two studies (8%) considered functional forms for continuous variables. The use of background knowledge for variable selection was barely reported and data-driven variable selection methods were applied frequently. We conclude that in the majority of studies, the methods used to develop models to investigate the effect of cardiac rehabilitation on outcomes do not meet common criteria for appropriate statistical model building and that reporting often lacks precision.

Exercise Training: The Holistic Approach in Cardiovascular Prevention

Nowadays, there are robust clinical and pathophysiological evidence supporting the beneficial effects of physical activity on cardiovascular (CV) system. Thus, the physical activity is considered a key strategy for CV prevention. In fact, exercise training exerts favourable effects on all risk factors for CV diseases (i.e. essential hypertension, type 2 diabetes mellitus, hypercholesterolemia, obesity, metabolic syndrome, etc…). In addition, all training modalities such as the aerobic (continuous walking, jogging, cycling, etc.) or resistance exercise (weights), as well as the leisure-time physical activity (recreational walking, gardening, etc) prevent the development of the major CV risk factors, or delay the progression of target organ damage improving cardio-metabolic risk. Exercise training is also the core component of all cardiac rehabilitation programs that have demonstrated to improve the quality of life and to reduce morbidity in patients with CV diseases, mostly in patients with coronary artery diseases. Finally, it is still debated whether or not exercise training can influence the occurrence of atrial and ventricular arrhythmias. In this regard, there is some evidence that exercise training is protective predominantly for atrial arrhythmias, reducing the incidence of atrial fibrillation. In conclusion, the salutary effects evoked by physical acitvity are useful in primary and secondary CV prevention.

Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

Exercise-based, multimodal rehabilitation programming similar to that used in the existing models of cardiac or pulmonary rehabilitation or prehabilitation is a holistic potential solution to address the range of physical, psychological, and existential (e.g., as their diagnosis relates to potential death) stressors associated with a cancer diagnosis and subsequent treatment. The purpose of this study was to systematically evaluate the structure and format of any type of exercise-based, multimodal rehabilitation programs used in individuals with cancer and the evidence base for their real-world effectiveness on metrics of physical (e.g., cardiorespiratory fitness, blood pressure) and psychological (e.g., health-related quality of life) health. Very few of the 33 included exercise-based, multimodal rehabilitation programs employed intervention components, education topics, and program support staff that were multi-disciplinary or cancer-specific. In particular, a greater emphasis on nutrition care, and the evaluation and management of psychosocial distress and CVD risk factors, with cancer-specific adaptations, would broaden and maximize the holistic health benefits of exercise-based rehabilitation. Despite these opportunities for improvement, exercise-based, multimodal rehabilitation programs utilized under real-world settings in individuals with cancer produced clinically meaningful and large effect sizes for cardiorespiratory fitness (VO2peak, ±2.9 mL/kg/min, 95% CI = 2.6 to 3.3) and 6-minute walk distance (+47 meters, 95% CI = 23 to 71), and medium effect sizes for various measures of cancer-specific, health-related quality of life. However, there were no changes to blood pressure, body mass index, or lung function. Overall, these findings suggest that exercise-based, multimodal rehabilitation is a real-world therapy that improves physical and psychological health among individuals with cancer, but the holistic health benefits of this intervention would likely be enhanced by addressing nutrition, psychosocial concerns, and risk factor management through education and counselling with consideration of the needs of an individual with cancer.

Impact of cardiac rehabilitation on mortality and morbidity in diabetic versus non-diabetic patients: protocol for a systematic review and meta-analysis

BACKGROUND

Cardiac rehabilitation (CR) decreases the morbidity and mortality risk among patients with cardiac diseases; however, the impact of CR on patients with diabetes remains underexplored. This is a protocol for a systematic review and meta-analysis methodology to explore if the effect of CR on mortality and morbidity is the same in patients with type 2 diabetes compared with patients without diabetes.

METHODS AND ANALYSIS

Interventional and non-interventional studies comparing the effect of CR, for at least 1 month, on all-cause mortality and cardiovascular outcomes including fatal and non-fatal myocardial infarction, revascularisation and rehospitalisation in adults with cardiac diseases will be deemed eligible for inclusion. Studies published between 1990 and 2020 will be searched in PubMed, Embase, Cochrane, CINAHL, Scopus and in registries for randomised controlled trials. Eligible studies will be selected using the Covidence software, and their salient details regarding the design, population, tested interventions and outcomes of interest will be gathered. The quality of studies to be deemed eligible and reviewed will be assessed using the Cochrane Collaboration and National Heart, Lung, and Blood Institute's tools. The appraisal process will be based on the study design (interventional and non-interventional). In the meta-analysis step, the pooled effect of CR on the outcomes will be estimated. All meta-analyses will be done using the random-effects model approach (inverse-variance method). I² and p value of χ² statistics will guide the heterogeneity assessment. Subgroup analyses will also be performed. The small study effect will be investigated by generating the funnel plots. The symmetry of the latter will be tested by performing Egger's test.

ETHICS AND DISSEMINATION

The systematic review will use data from published literature; hence, no ethical approval will be required. Findings of the systematic review and meta-analysis will be published in peer-reviewed international journals and will be disseminated in local and international scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42020148832.

Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration: Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II)

Background

Despite numerous studies and meta-analyses the prognostic effect of cardiac rehabilitation is still under debate. This update of the Cardiac Rehabilitation Outcome Study (CROS II) provides a contemporary and practice focused approach including only cardiac rehabilitation interventions based on published standards and core components to evaluate cardiac rehabilitation delivery and effectiveness in improving patient prognosis.

Design

A systematic review and meta-analysis.

Methods

Randomised controlled trials and retrospective and prospective controlled cohort studies evaluating patients after acute coronary syndrome, coronary artery bypass grafting or mixed populations with coronary artery disease published until September 2018 were included.

Results

Based on CROS inclusion criteria out of 7096 abstracts six additional studies including 8671 patients were identified (two randomised controlled trials, two retrospective controlled cohort studies, two prospective controlled cohort studies). In total, 31 studies including 228,337 patients were available for this meta-analysis (three randomised controlled trials, nine prospective controlled cohort studies, 19 retrospective controlled cohort studies; 50,653 patients after acute coronary syndrome 14,583, after coronary artery bypass grafting 163,101, mixed coronary artery disease populations; follow-up periods ranging from 9 months to 14 years). Heterogeneity in design, cardiac rehabilitation delivery, biometrical assessment and potential confounders was considerable. Controlled cohort studies showed a significantly reduced total mortality (primary endpoint) after cardiac rehabilitation participation in patients after acute coronary syndrome (prospective controlled cohort studies: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; retrospective controlled cohort studies HR 0.64, 95% CI 0.53–0.76; prospective controlled cohort studies odds ratio 0.20, 95% CI 0.08–0.48), but the single randomised controlled trial fulfilling the CROS inclusion criteria showed neutral results. Cardiac rehabilitation participation was also associated with reduced total mortality in patients after coronary artery bypass grafting (retrospective controlled cohort studies HR 0.62, 95% CI 0.54–0.70, one single randomised controlled trial without fatal events), and in mixed coronary artery disease populations (retrospective controlled cohort studies HR 0.52, 95% CI 0.36–0.77; two out of 10 controlled cohort studies with neutral results).

Conclusion

CROS II confirms the effectiveness of cardiac rehabilitation participation after acute coronary syndrome and after coronary artery bypass grafting in actual clinical practice by reducing total mortality under the conditions of current evidence-based coronary artery disease treatment. The data of CROS II, however, underscore the urgent need to define internationally accepted minimal standards for cardiac rehabilitation delivery as well as for scientific evaluation.

Barriers physicians face when referring patients to cardiac rehabilitation: a narrative review

While cardiac rehabilitation (CR) has been shown to be a beneficial form of secondary prevention for patients with cardiovascular disease, barriers of referral to CR still exist for patients. Barriers that specifically make it difficult for physicians to make the referral could be worthwhile to examine. This narrative review hypothesizes that increasing awareness and education on the various aspects of CR as well as simplifying the referral process could lead to increased referral rates as they target physician-related barriers. This narrative review seeks to further understand the physician-related barriers of low CR awareness and hindering referral processes. A search in Scopus was conducted with preference for articles examining CR referral strategies used by physicians; physicians' awareness of CR programs; physicians' perceptions, beliefs, or knowledge of the benefits of CR; or physicians' experience with or understanding of the selection process of CR programs, including indications for referral. Two systematic reviews and two observational studies were selected for discussion. Three of the selected studies had findings supporting the notion that increasing physicians' awareness of CR could impact referral rates. One of the studies evaluated the perceptions that physicians and CR programs had on various referral strategies. While more study is needed to assess the actual level of knowledge and awareness physicians have regarding CR, this review supports using educational interventions as well as targeting various aspects of the referral process for improving referral rates.

Impact of cardiac rehabilitation and exercise training programs in coronary heart disease

Cardiovascular rehabilitation (CR) is the process of developing and maintaining an optimal level of physical, social, and psychological well-being in order to promote recovery from cardiovascular (CV) illness. It is a multi-disciplinary approach encompassing supervised exercise training, patient counseling, education and nutritional guidance that may also enhance quality of life. Beneficial CV effects may include improving coronary heart disease risk factors; particularly exercise capacity, reversing cardiac remodeling, and favorably modifying metabolism and systemic oxygen transport. We review the historical basis for contemporary CR, the indications and critical components of CR, as well as the potential salutary physiological and clinical effects of exercise-based CR.

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)

Background

The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.

Design

Structured review and meta-analysis.

Methods

Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.

Results

Out of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; rCCS: HR 0.64, 95% CI 0.49–0.84; odds ratio 0.20, 95% CI 0.08–0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54–0.70) and in mixed CAD populations.

Conclusions

CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study

BACKGROUND

Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory.

DESIGN

A prospective cohort study.

METHODS

A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up.

RESULTS

AEE was 1948+/-1450, 1676+/-1290, and 1637+/-1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P=0.012) and education and time (P=0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P=0.033).

CONCLUSIONS

Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

The effect of cardiac rehabilitation on recovery of heart rate over one minute after exercise in patients with coronary artery bypass graft surgery

Objective: To evaluate the effects of cardiac rehabilitation on the recovery of heart rate over 1 min after peak exercise of patients who received coronary artery bypass graft (CABG) surgery.

Design: Thirty subjects who received CABG surgery were randomly assigned to enter or not enter a cardiac rehabilitation exercise programme (cardiac rehabilitation n=15; control group n=15).

Setting: Outpatient cardiac rehabilitation centre in a national medical hospital.

Interventions: Patients assigned to the cardiac rehabilitation group received 36 sessions of the exercise programme, three times a week, with the intensity designed to achieve an individual 60-85% peak heart rate in cardiopulmonary exercise test. Patients assigned to the control group did not get further advice about a specific exercise programme.

Main outcome measures: Resting heart rate and recovery of heart rate over 1 min after a peak exercise test at discharge and three months later were collected. The heart rates were analysed with computer-recorded electrocardiogram.

Results: At follow-up, the 15 patients in the cardiac rehabilitation group had a significantly lower resting heart rate (77.469± 9.49 versus 92.319± 10.18 bpm; p B± 0.001) and a significantly higher recovery of heart rate over 1 min (16.389± 6.32 versus 11.389± 4.81 bpm; p ± 0.03) compared with the control group. There were also significant reductions in resting heart rates (cardiac rehabilitation p ± 0.001; control p=0.05) and improvements in recovery on heart rate over 1 min (cardiac rehabilitation p ± 0.001; control p= 0.001) compared with baseline measurements in both the cardiac rehabilitation and control groups.

Conclusion: Cardiac rehabilitation had a positive effect on the improvement of recovery on heart rate over 1 min in patients with coronary artery disease who received CABG surgery.

Drop-out predictors in cardiac rehabilitation programmes and the impact of sex differences among coronary heart disease patients in an Iranian sample: a cohort study

Objective : To determine whether patients who subsequently drop out of a structured cardiac rehabilitation programme could be prospectively distinguished from those who remain in the programme based upon their initial baseline characteristics.

Design : A cohort study.

Setting : A referral rehabilitation department in a cardiovascular research and training institute.

Subjects : One thousand one hundred and fifteen coronary heart disease patients including patients with ischaemic heart disease, and those undergoing bypass surgery or percutaneous coronary interventions.

Interventions : Demographic characteristics, coronary heart disease risk factors, ejection fraction, functional capacity and laboratory tests were considered at baseline.

Main measures : Patients who completed all 24 sessions of the cardiac rehabilitation programme were compared with drop-out cases who did not.

Results : Four hundred and ninety-nine patients (44.8%) completed the whole cardiac rehabilitation programme. Women (adjusted odds ratio (AOR) 1.817, P < 0.001), older patients (AOR 1.015, P = 0.047), patients with lower risk of coronary heart disease (AOR 1.573, P = 0.008) or lower body mass index (BMI) (AOR 0.945, P = 0.001) and higher waist-to-hip ratio (AOR 12.871, P = 0.009) and those who were non-smokers (AOR 1.779, P = 0.001) were significantly more likely to complete cardiac rehabilitation.

Conclusions : Developing interventions to address special needs of young, obese, smoker male patients who have a lower waist-to-hip ratio and higher clinical risk may be important, especially in attempts to retain this high-risk group in cardiac rehabilitation therapy.

Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularization in Ontario

OBJECTIVES

Describe rates of, and examine factors affecting, referral to cardiac rehabilitation (CR) following revascularization in Ontario.

BACKGROUND

CR reduces mortality following cardiac revascularization, but is largely underutilized, partly due to poor referral rates.

METHODS

In this retrospective study, the sample consisted of all CR-indicated patients who underwent revascularization at the Cardiac Care Network of Ontario hospitals between October 2011 through March 2012. Referral rates were described, and multivariate analyses performed to identify disparities.

RESULTS

Of the 3739 patients included, 51.8% were referred to CR. Patients aged ≥85 or requiring a translator, and patients with hyperlipidemia, heart failure, or comorbid pulmonary, renal or peripheral vascular disease, were significantly less likely to be referred. Patients with a history of smoking or myocardial infarction, or who underwent coronary artery bypass graft surgery, were significantly more likely.

CONCLUSIONS

A national policy statement recommends 85% referral of indicated patients to CR, a target currently missed by almost 35%.

Cardiac rehabilitation: beginning at the bedside

PURPOSE

Despite well-documented positive benefits, cardiac rehabilitation (CR) is an underutilized resource for patients following a cardiac event or intervention. Bias in the CR referral process has led to programs designed to ensure that all eligible patients receive a referral. The purpose of the current investigation was to describe the implementation of a nurse-delivered automatic bedside referral process and to examine the effectiveness on referral and intake rates for CR.

METHODS

In 2007, an automatic CR referral system was implemented at the University of Ottawa Heart Institute. A nurse-delivered automatic bedside referral process was implemented in 2008. A CR nurse screened all inpatient charts, discussed CR benefits and program options with patients, triaged the patient to the appropriate program, and facilitated booking of the CR intake appointment. Data were analyzed to determine the effectiveness of this approach.

RESULTS

Only 15.5% to 19.7% of eligible patients participated in CR program prior to 2006. Implementation of an automatic referral process increased participation to 26.7%. The nurse-delivered bedside automatic referral process increased participation to 32.6%. The proportion of patients receiving CR referrals almost tripled following the implementation of the nurse-delivered referral process from 26.7% in 2003 to 79.0% in 2008.

CONCLUSIONS

A nurse-delivered automatic bedside referral process had a positive impact on both referral and intake to CR. Future challenges for CR programs will be to ensure optimal participation in programs, while managing the growth associated with increased rates of involvement.

Ambulatory surveillance of patients referred for cardiac rehabilitation following cardiac hospitalization: a feasibility study

BACKGROUND

Our purpose was to examine the feasibility of implementing an ambulatory surveillance system for monitoring patients referred to cardiac rehabilitation following cardiac hospitalizations.

METHODS

This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance at cardiac rehabilitation, waiting times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse.

RESULTS

Among the 1208 consecutive patients referred, only 44.7% attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 18.9% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths), with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program, 114 (25.9%) had adverse clinical events while in the queue; 46 of these events required cardiac hospitalization and 8 patients died.

CONCLUSIONS

Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs, underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.

The Canadian Heart Health Strategy and Action Plan: Cardiac rehabilitation as an exemplar of chronic disease management

BACKGROUND

In October 2006, federal funding was announced for the development of a national strategy to fight cardiovascular disease (CVD) in Canada. The comprehensive, independent, stakeholder-driven Canadian Heart Health Strategy and Action Plan (CHHS-AP) was delivered to the Minister of Health on February 24, 2009.

OBJECTIVES

The mandate of CHHS-AP Theme Working Group (TWG) 6 was to identify the optimal chronic disease management model that incorporated timely access to rehabilitation services and end-of-life planning and care. The purpose of the present paper was to provide an overview of worldwide approaches to CVD and cardiac rehabilitation (CR) strategies and recommendations for CR care in Canada, within the context of the well-known Chronic Care Model (CCM). A separate paper will address end-of-life issues in CVD.

METHODS

TWG 6 was composed of content representatives, primary care representatives and patients. Input in the area of Aboriginal and indigenous cardiovascular health was obtained through individual expert consultation. Information germane to the present paper was gathered from international literature and best practice guidelines. The CCM principles were discussed and agreed on by all. Prioritization of recommendations and overall messaging was discussed and decided on within the entire TWG. The full TWG report was presented to the CHHS-AP Steering Committee and was used to inform the recommendations of the CHHS-AP.

RESULTS

Specific actionable recommendations for CR are made in accordance with the key principles of the CCM.

CONCLUSIONS

The present CR blueprint, as part of the CHHS-AP, will be a first step toward reducing the health care burden of CVD in Canada.

Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system

BACKGROUND

The magnitude and mechanisms of survival benefit associated with cardiac rehabilitation services among real-world populations within a universal health care system remain unclear.

METHODS

This retrospective matched cohort study compared the long-term survival of 2042 cardiac rehabilitation participants with 2042 matched controls after an index acute cardiac hospitalization between 1999 and 2003, in Ontario, Canada. Each patient survived at least 1 year without recurrent admissions after discharge from the index hospitalization, and was followed for a mean of 5.25 years. Additional matching criteria included the type of sentinel cardiac events, age, sex, socioeconomic status, geography, previous cardiac and noncardiac hospitalizations. A Cox proportional hazards model further adjusted for baseline cardiovascular risk factors and process factors, cardiovascular risk-factor progression, downstream coronary procedure and evidence-based pharmacotherapy utilization.

RESULTS

Cardiac rehabilitation participation was associated with a 50% lower mortality rate (2.6 vs. 5.1%, P<0.001) as compared with population-matched controls. Statistically significant mortality benefits were observed among high-risk patients, and there was no significant interaction among age, cardiac rehabilitation participation, and survival (P=0.22). Associated survival advantages were not meaningfully altered after adjustment for cardiovascular risk-factor progression or the downstream utilization rates of cardiac procedures and evidence-based cardiovascular therapies; survival benefits predominantly applied to those patients that were most compliant with the program.

CONCLUSION

Cardiac rehabilitation is associated with significant long-term survival advantages after index cardiovascular hospitalizations. Despite universal access to medical care, such survival advantages seem to be mediated by compliant behaviors more so than by ancillary health service or evidence-based pharmacotherapy utilization.

Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation

The Canadian Cardiovascular Society formed an Access to Care Working Group ('Working Group') in the spring of 2004. The mandate of the group was to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The present commentary presents the rationale for benchmarks for cardiac rehabilitation (CR) services. The Working Group's search for evidence included: a full literature review of the efficacy of CR, and the factors affecting access and referral to CR; a review of existing guidelines for access to CR; and a national survey of 14 CR programs across Canada undertaken in May 2005 to solicit information on referral to, and wait times for, CR. The Working Group also reviewed the results of The Ontario Cardiac Rehabilitation Pilot Project (2002) undertaken by the Cardiac Care Network of Ontario, which reported the average and median wait times for CR. Some international agencies have formulated their own guidelines relating to the optimal wait time for the onset of CR. However, due to the limited amount of supporting literature, these guidelines have generally been formed as consensus statements. The Canadian national survey showed that few programs had guidelines for individual programs. The Cardiac Care Network of Ontario pilot project reported that the average and median times from a cardiac event to the intake into CR were 99 and 70 days, respectively. The national survey of sampled CR programs also revealed quite remarkable differences across programs in terms of the length of time between first contact to first attendance and to commencement of exercise. Programs that required a stress test before program initiation had the longest wait for exercise initiation. Some patients need to be seen within a very short time frame to prevent a marked deterioration in their medical or psychological state. In some cases, early intervention and advocacy may reduce the risk of loss of employment. Or, there may be profound disturbances in the patient's family as a result of the cardiac event. For other patient groups, preferable wait times vary from one to 30 days, and acceptable wait times vary from seven to 60 days. All cardiovascular disease patients require core aspects of CR services. Patients who would derive benefit from formal CR programs should be provided the opportunity, given the proven efficacy and cost effectiveness of CR.

Depression symptoms have a greater impact on the 1-year health-related quality of life outcomes of women post-myocardial infarction compared to men

OBJECTIVE

Several studies report that women with CAD have a poorer prognosis than men and suggest that depressive symptoms may be a contributing factor. The purpose of this study was to examine gender differences in depressive symptoms, as they relate to health-related quality of life outcomes following an AMI.

METHODS

Patients with documented AMI completed a questionnaire including the Short Form 36 physical (PCS), and mental component summary (MCS) scores, and Beck Depression Inventory at baseline and at 1 year after AMI admission.

RESULTS

486 (82%) patients completed the follow-up questionnaire. Females had significantly worse PCS and MCS scores at baseline and 1-year follow-up compared to males The mean 1-year Beck scores were significantly higher (p=0.01) for females (10.02+/-8.23) compared to males (7.78+/-8.01) indicating more reported depressive symptomatology. Multivariate analyses showed significant gender-related differences in the PCS scores at 1 year, but no gender-related differences in the 1-year MCS scores.

CONCLUSIONS

These results suggest that gender differences in mental health at 1 year relate to gender-related differences at 1-year depression levels. The higher level of depression in women may be a consequence of gender differences in recovery patterns from an AMI and requires further investigation.