Cardiac Rehab Linked to Survival Benefit After Valve Surgery

Cardiac rehabilitation is associated with fewer deaths and hospital readmissions in the year after open heart valve surgery, although stark differences in uptake exist along racial and geographic lines, a large Medicare study shows.

Cardiac rehab was associated with a relative 34% lower risk of hospitalization and 61% lower risk of mortality at 1 year. The absolute reduction in mortality was 4.2%.

Results also show that cardiac rehab was associated with improved outcomes for aortic, mitral, and tricuspid valve surgery.

Contrary to smaller studies that failed to find a survival advantage for cardiac rehab in patients undergoing isolated valve surgery, the magnitude of the associations with mortality and hospitalizations were similar among patients attending cardiac rehab after valve surgery alone or with concomitant coronary bypass graft (CABG) surgery.

"These findings suggest that CR [cardiac rehab] is beneficial in all patients undergoing valve surgery, as opposed to just those with ischemic heart disease," write first author Devin K. Patel, MD, Vanderbilt University Medical Center, Nashville, Tennessee, and colleagues.

The study was published online October 23 in JAMA Cardiology.

The results are consistent with work in other patient groups, according to senior author Justin Bachmann, MD, MPH, also with Vanderbilt.

"It really is a no-brainer," he told theheart.org | Medscape Cardiology. "Cardiac rehabilitation has a very strong level of evidence and recommendations by the American Heart Association and American College of Cardiology and all of us have been trying to improve enrollment rates for years."

Disparities in Enrollment

The study included 41,369 fee-for-service Medicare beneficiaries (median age, 73 years; 40.9% women) who underwent heart valve surgery in 2014 and survived for more than 30 days after discharge. Two thirds had undergone aortic valve procedures, 12.3% mitral valve replacement, and 1.2% tricuspid valve surgery.

Despite guideline recommendations for cardiac rehab after heart valve surgery and Medicare coverage for this indication since 2006, cardiac rehab enrollment was 43.2%.

How that finding may be interpreted could depend upon your vantage point, suggests Bachmann. "If you ask someone generally involved in cardiac care, they would say that seems pretty low, less than half are going. But if you ask someone who's a cardiac rehabilitation professional, they'd say that's actually pretty good compared with other patient populations."

For example, enrollment rates are about 46% following heart transplant but only 35% to 40% after CABG and less than 10% for one of the most recently approved indications, stable systolic heart failure.

One of the most interesting components of the study, however, was the observed disparities in enrollment, which "appear to be more pronounced in this population than we see actually in some other populations," Bachmann said.

Asian patients (17.9%; odds ratio [OR], 0.36; 95% confidence interval [CI], 0.28 - 0.47), black patients (23.7%; OR, 0.60; 95% CI, 0.54 - 0.67), and Hispanic patients (17.9%; OR, 0.36; 95% CI, 0.28 - 0.46) were much less likely to attend cardiac rehab than whites (45%).

Patients undergoing surgery in the Midwest were twice as likely to attend cardiac rehab programs (57.7%; OR, 2.40; 95% CI, 2.28 - 2.54) than those in the South (36.5%).

Patients from disadvantaged populations are more vulnerable to barriers to cardiac rehab, such as cost, transportation, and time off work or from caring for others, Bachmann explained. Removing insurance co-pays and implementing flexible scheduling may help increase participation.

"I think it's important we're just culturally sensitive as well in cardiac rehab programs and are mindful of other considerations and patient factors," he said. "For example, cardiac rehabilitation always has a group component and for some there's anxiety about exercising in a group; so we just need to be mindful of that and make sure that patients feel welcome."

Self-efficacy for exercise can also be lower in disadvantaged populations, suggesting it's important to stress that cardiac rehab is something they can easily learn and do, he said.

The study did not have information on the proportion of patients who were referred, only that they showed up, Bachmann observed. "So it raises the question, are there maybe disparities in referral along racial/ethnic categories?"

If You Enroll, They Will Come

In the study, the median time between discharge and the first rehabilitation session was 44 days and patients attended a median of 32 sessions — just shy of the generally recommended target of 36 sessions.

"These data indicate that programs designed to increase CR use in this population are best directed toward enrollment, as opposed to attendance, since patients who had had CVS and were enrolling in CR programs tend to attend similar numbers of sessions," the authors say.

This pattern may be specific to older populations, although prior studies have shown that the number of sessions attended appears to be relatively similar across different strata of race/ethnicity or eligibility diagnosis, Bachmann said.

"Once they go, they're likely to keep going," he said. "It's always important to maximize attendance at cardiac rehab because there is a dose-dependent relationship between the number of sessions they attend and the outcomes, but where we'll get more bang for our buck is focusing on actually getting people to show up."

"These findings are remarkable and novel for several reasons," Randal Thomas, MD, MS, and LaPrincess Brewer, MD, MPH, both with the Mayo Clinic in Rochester, Minnesota, write in a related commentary.

Although prior studies have linked cardiac rehab with improvements in readmissions and survival after myocardial infarction, percutaneous coronary intervention, and CABG, this is the first large-scale study to do so after cardiac valve surgery, they say.

In contrast to prior work, benefits were also observed across all types of valve surgery and for valve surgery without concomitant CABG.

Although the study lacks data on rehab referral and interventions and patients younger than 65 years, it "adds vital and solid evidence" of the benefits of cardiac rehab in patients recovering from heart valve surgery, they write.

"As CR delivery methods, quality improvement practices, and coverage policies continue to evolve, health care practitioners and policymakers must implement more effective and innovative strategies to improve delivery of CR services to all eligible patients, including those patients undergoing heart valve surgery," Thomas and Brewer conclude.

The study was supported by a Vanderbilt Clinical Trial and Translational Science grant and a grant from the Agency for Healthcare Research and Quality. Patel, Bachmann, Thomas, and Brewer have disclosed no relevant financial relationships.

JAMA Cardiol. Published online October 23, 2019. Abstract, Commentary

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