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Original Investigation
December 2016

Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction

Author Affiliations
  • 1Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
  • 2School of Medicine, University of Missouri–Kansas City
  • 3Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
  • 4Division of Cardiovascular Diseases, University of Colorado–Denver
  • 5Division of Cardiovascular Diseases, University of Michigan Health System, Ann Arbor
  • 6University of Wisconsin School of Medicine and Public Health, Milwaukee
  • 7Aurora Cardiovascular Services, Milwaukee, Wisconsin
JAMA Cardiol. 2016;1(9):980-988. doi:10.1001/jamacardio.2016.3458
Key Points

Question  What is the association between participation in cardiac rehabilitation and health status outcomes of patients after acute myocardial infarction?

Findings  In this cohort study of 4929 patients enrolled in 2 acute myocardial infarction registries, mean Seattle Angina Questionnaire domain scores were similar at 6 and 12 months after acute myocardial infarction between patients who did and did not participate in cardiac rehabilitation.

Meaning  Increased use of validated health status outcome measures are needed to further examine if and how health status can be maximized for participants in cardiac rehabilitation after acute myocardial infarction.

Abstract

Importance  Cardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients’ health status (eg, quality of life, symptoms, and functional status) is poorly defined.

Objective  To examine the association of participation in CR with health status outcomes after AMI.

Design, Setting, and Participants  A retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015.

Exposures  Participation in at least 1 CR session within 6 months of hospital discharge.

Main Outcomes and Measures  Patient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality.

Results  After successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was –0.76 (95% CI, –2.05 to 0.52) for the SAQ quality of life score, –1.53 (95% CI, –2.57 to –0.49) for the SAQ angina frequency score, 0.38 (95% CI, –0.51 to 1.27) for the SAQ treatment satisfaction score, –0.42 (95% CI, –1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, –0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, –0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was –0.89 (95% CI, –2.20 to 0.43) for the SAQ quality of life score, –1.05 (95% CI, –2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, –0.54 to 1.29) for the SAQ treatment satisfaction score, –0.14 (95% CI, –1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, –0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, –0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75).

Conclusions and Relevance  In a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.

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