Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors — 20 States and the District of Columbia, 2013 and Four States, 2015

Jing Fang, MD; Carma Ayala, PhD; Cecily Luncheon, MD, DrPh; Matthew Ritchey, DPT; Fleetwood Loustalot, PhD


Morbidity and Mortality Weekly Report. 2017;66(33):869-873. 

In This Article

Abstract and Introduction


Heart disease is the leading cause of death in the United States.[1] Each year, approximately 790,000 adults have a myocardial infarction (heart attack), including 210,000 that are recurrent heart attacks.[2] Cardiac rehabilitation (rehab) includes exercise counseling and training, education for heart-healthy living, and counseling to reduce stress. Cardiac rehab provides patients with education regarding the causes of heart attacks and tools to initiate positive behavior change, and extends patients' medical management after a heart attack to prevent future negative sequelae.[3] A systematic review has shown that after a heart attack, patients using cardiac rehab were 53% (95% confidence interval [CI] = 41%–62%) less likely to die from any cause and 57% (95% CI = 21%–77%) less likely to experience cardiac-related mortality than were those who did not use cardiac rehab.[3] However, even with long-standing national recommendations encouraging use of cardiac rehab,[4] the intervention has been underutilized. An analysis of 2005 Behavioral Risk Factor Surveillance System (BRFSS) data found that only 34.7% of adults who reported a history of a heart attack also reported subsequent use of cardiac rehab.[5] To update these estimates, CDC used the most recent BRFSS data from 2013 and 2015 to assess the use of cardiac rehab among adults following a heart attack. Overall use of cardiac rehab was 33.7% in 20 states and the District of Columbia (DC) in 2013 and 35.5% in four states in 2015. Cardiac rehab use was underutilized overall and differences were evident by sex, age, race/ethnicity, level of education, cardiovascular risk status, and by state. Increasing use of cardiac rehab after a heart attack should be encouraged by health systems and supported by the public health community.

The BRFSS is a telephone survey, conducted annually by all U.S states, with guidance and support from CDC ( The survey includes a core component and optional modules. Participants with history of a heart attack are identified by an affirmative response to the question, "Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?" In 2013, 20 states* and DC, and in 2015, four states included the cardiovascular health module, which contained questions about using cardiac rehab after a heart attack. The median response rates for the BRFSS were 46.4% and 47.2% for 2013 and 2015, respectively.

Participants identified as heart attack survivors were asked: "After you left the hospital following your heart attack, did you go to any kind of outpatient rehabilitation?" Demographic characteristics included age, sex, race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, or Hispanic), highest level of education achieved (less than high school, high school graduate, some college, or college graduate) and having any kind of health insurance. Selected self-reported cardiovascular disease (CVD) risk factors included hypertension, high blood cholesterol, diabetes, obesity, and current smoking.§ Each respondent was categorized based on their number of CVD risk factors (0, 1, 2, 3, 4, or 5). Among heart attack survivors, the crude and adjusted percentage of cardiac rehab use was assessed overall and by state of residence in 2013 and 2015, as well as by demographic characteristics and CVD risk in 2013. P-values were obtained by Wald F test and p<0.05 were used to identify statistically significant differences among subgroups. The BRFSS's complex sample design was accounted for using statistical software with BRFSS respondent sampling weights and design variables.

In 2013, a total of 166,913 participants who completed the cardiovascular health module from 20 states and DC, among whom, 4.8% (95% CI = 4.6–5.0) were heart attack survivors. In 2015, a total of 20,776 participants from four states completed the module, 4.3% (3.9–4.7) of whom were heart attack survivors. Overall, 33.7% (95% CI = 31.8–35.6) of heart attack survivors in 2013 and 35.5% (95% CI = 31.0–40.3) in 2015 reported use of cardiac rehab after leaving the hospital following their heart attack.

In 2013, among 9,490 heart attack survivors, older adults, men, non-Hispanic whites, persons with college or higher education, and those with two, three, or four (of five) CVD risk factors were more likely to receive cardiac rehab than were younger persons, women, non-Hispanic blacks, Hispanics, persons with less than a college education, and persons with fewer than two or with five out of five CVD risk factors (relative to those with two, three of four; p<0.05) (Table 1).

In 2013, the adjusted percentage of cardiac rehab use ranged from 20.7% in Hawaii to 58.6% in Minnesota (Table 2). Among the four states that used the cardiac rehab module in 2015, both the crude and adjusted percentages of cardiac rehab use were lowest in Georgia and highest in Iowa. Among the four states that used the module in both 2013 and 2015, the overall adjusted percentage of cardiac rehab use was 35.6% (95% CI = 32.1–39.3) in 2013 and 35.5% (95% CI = 31.0–40.3) in 2015 (p = 0.8075).

*Arizona, Arkansas, Florida, Georgia, Hawaii, Iowa, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, Tennessee, Washington, and Wisconsin.
Georgia, Iowa, Maine, and Oregon.
§Hypertension was defined by answering "yes" to the question, "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?" (persons who answered yes only during pregnancy were not included); high blood cholesterol was defined by answering "yes" to the question, "Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?"; diabetes was defined by answering "yes" to the question, "Have you ever been told by a doctor that you have diabetes?"; obesity was ascertained by asking, "About how much do you weigh without shoes?" and "About how tall are you without shoes?," and based on the answers, calculating body mass index (kg/m2); obesity was defined as body mass index ≥30; current smoking was defined by answering "every day" or "some days" to the question, "Do you now smoke cigarettes every day, some days, or not at all?"