Effects of an expanded rehabilitation programme in patients with ischemic heart disease

Abstract

The effects of expanded cardiac rehabilitation (ECR) after coronary artery by-pass surgery or myocardial infarction (MI) on medical risk markers, cardiovascular (CV) morbidity and hospitalizations due to symptoms of CV disease, were evaluated in a prospective randomized trial. The project was performed at the Department of Cardiology, Danderyd Hospital, between 1999-2001.

In total, 828 patients were screened and 224 patients <75 years were randomized to ECR or usual care (UC). The UC group was offered physical training, education and heart school with information/counselling on risk factor intervention. The patients met with a cardiac nurse on one or two occasions after the event and a cardiologist on one occasion, 6-8 weeks after the event. Patients who were randomized to ECR participated in all activities of the UC rehabilitation programme. In addition they spent one week at the patient hotel after discharge from the hospital. They also participated in a stress management programme in groups during one year, and in cooking sessions and diet counselling. All smokers in both treatment groups were offered a smoking cessation programme.

In paper I, the effects of ECR on metabolic and inflammatory markers and other CV risk markers, as well as exercise performance, were evaluated after one year. Several biochemical risk markers such as total cholesterol and LDL cholesterol, fibrinogen and CRP improved similarly in both the ECR and the UC group. Both groups improved in exercise performance significantly over time. In summary, there was no further improvement in the ECR group in addition to what was observed in the UC group.

In paper II, a five year follow-up was carried out using data from the National Board of Health and Welfare register. The primary composite endpoint was time to first cardiac event defined as CV death, MI or readmission due to CV disease. There was a significant reduction in the primary composite endpoint among those in the ECR as compared to UC group (47.7% vs. 60.2%; hazard ratio 0.69; 95% CI 0.48-0.99; p=0.049). This was mainly due to a reduction in MI in the ECR group (10.8% vs. 20.3%; hazard ratio 0.47; 95% CI 0.21-0.97; p=0.047). Readmission to hospital and days in hospital for CV reasons were significantly reduced in patients who received ECR as compared to UC (p<0.01 and p=0.02, respectively).

In conclusion, our results show that ECR, despite the absence of an incremental effect on risk markers, reduced the incidence of MI and reduced health care consumption due to CV causes in a longterm follow-up.