May 16, 2011 (Rochester, Minnesota) — Participation in a cardiac rehabilitation program following PCI is associated with a significant reduction in all-cause mortality, according to the results of a new study [1]. The rehabilitation program, even for low-risk patients undergoing elective PCI, is an integral part of improving outcomes following the placement of a stent or angioplasty, say investigators.
"I think it's important for clinicians, patients, and providers to recognize that PCI is not a cure for coronary artery disease," senior investigator Dr Randal Thomas (Mayo Clinic, Rochester, MN) told heartwire . "There is ample evidence, including from our study, to show that there is much work to do in prevention and improving outcomes. Second, it's important for patients and providers to recognize that not only is rehabilitation important and provides significant benefit, it's also covered by insurance companies."
Thomas said there are standard cardiac rehabilitation programs across the country for patients who have had an acute coronary event, have undergone coronary artery bypass graft (CABG) or valve surgery, or have received a stent. The rehabilitation process includes implementing optimal lifestyle and medical therapy, including psychosocial support and exercise training, and most patients are enrolled within a couple of weeks of their procedure. While cardiac rehabilitation has been shown to be effective post-MI, few studies have looked at the benefits of cardiac rehabilitation following PCI. Until 2006, Medicare and most insurance companies did not cover cardiac rehabilitation for elective angioplasty or PCI, said Thomas.
Includes Elective and Nonelective PCI
The new retrospective analysis, published online May 16, 2011 in Circulation with first author Dr Kashish Goel (Mayo Clinic, Rochester, MN), includes data from a prospectively collected registry of 2395 consecutive patients who underwent PCI between 1994 and 2008. Of these patients, 40% participated in at least one cardiac rehabilitation session during the three months following PCI. Of these 964 patients who participated in rehab, 20% underwent elective PCI, 39% underwent urgent PCI, and 41% received emergent PCI. Approximately one-third of patients were treated with a drug-eluting stent.
The researchers performed three separate analyses--including a propensity-score analysis, a matched-group analysis using propensity scoring, and a landmark analysis that excluded all patients who died, had a coronary event, or underwent revascularization within three months of the index procedure--to assess the relationship between cardiac rehabilitation participation and outcomes. During a median follow-up of 6.3 years, there were 503 deaths, of which 199 were due to cardiovascular causes.
In the propensity-score analysis that excluded individuals with an extreme propensity score, there was a 47% relative reduction in all-cause mortality in patients undergoing cardiac rehabilitation. In the propensity-score analysis of matched pairs of cardiac-rehabilitation participants and nonparticipants, there was a 46% reduction in all-cause mortality in the PCI patients participating in the rehab program. The three-month landmark analysis also showed a significant 45% relative reduction in all-cause mortality.
The investigators report that the findings were similar for men and women and older and younger patients, as well as for patients undergoing elective and nonelective PCI.
"The results were surprising to us, and they will be surprising to most people," Thomas told heartwire . "Since the inception of cardiac rehabilitation in the 1950s, its role has really been to help people who are debilitated and severely affected by coronary disease. Most people have the impression of people undergoing PCI, particularly elective PCI, as not being that sick, so a rehabilitation course would have been expected to have not quite as large a benefit in that population. That we found a robust impact, the extent of the benefit, was surprising to us."
There was a 39% reduction in cardiac mortality in the propensity-scoring analysis applied to the entire cohort, but this was not observed in the matched-pair analysis. However, the researchers note that this finding is likely affected by ascertainment errors regarding the cause of death.
In the 2005 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions updated guidelines, cardiac rehabilitation is recommended following PCI, but according to Thomas and colleagues, just 25% of eligible patients participate in these programs. They note that most insurance companies cover 36 sessions of cardiac rehab after PCI, while Medicare covers approximately 80% of the costs.
The authors report no conflicts of interest.
Heartwire from Medscape © 2011 Medscape, LLC
Cite this: Cardiac Rehabilitation After PCI Lowers Mortality - Medscape - May 17, 2011.
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