Referral for cardiac rehabilitation after acute myocardial infarction: Insights from nationwide AMIS Plus registry 2005–2017

doi:10.1016/j.ijcard.2018.01.096

International Journal of Cardiology

Volume 261, 15 June 2018, Pages 1-5

https://doi.org/10.1016/j.ijcard.2018.01.096 Get rights and content

Highlights

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Data from 23’222 patients after AMI are included in our analysis
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Patients referred for CR are younger, more male, more obese with more STEMI.
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Hypertension, dyslipidemia and diabetes were less present in CR patients
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In-hospital complications were strong predictors for CR recommendation.
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Patients with pre-existing coronary or cerebrovascular disease as well as the elderly and women should not be distracted from benefits of CR.

Abstract

Background

Referral rates for cardiac rehabilitation (CR) after an acute myocardial infarction (AMI) are low despite a Class I recommendation in the present guidelines. Therefore, we aimed to identify predictors for referral and patient characteristics from the national Swiss AMIS Plus registry.

Design and methods

Data were extracted from the Swiss AMIS Plus registry between 2005 and 2017, which included patients with ST-elevation myocardial infarction (STEMI) and Non-ST-elevation myocardial infarction (NSTEMI). For 32,416 patient (93.2%) data about destination at discharge were available with 10,940 (33.7%) having a recommendation for CR while 12,282 (37.9%) went home. 9194 (28.4%) were transferred to another hospital after index hospitalisation and were excluded.

Results

Patients referred to CR were younger (62.6 vs. 68.2 years) and had a higher prevalence of obesity (22.0% vs. 20.4%). Except for smoking (44.0% vs 34.9%), they had less risk factors such as dyslipidemia (55.0% vs. 60.1%), hypertension (55.6% vs. 65.3%) and diabetes (16.7% vs. 21.5%). Patients with in-hospital complications were more likely being referred for CR. Furthermore, STEMI (OR 1.61; CI 1.52–1.71), performed PCI (OR 2.65; CI 2.42–2.90) and Killip class >2 (OR 1.58; CI 1.36–1.84) favoured referral for CR, while age > 65 years, previous myocardial infarction, cerebrovascular disease or peripheral artery disease had a negative impact on referral for CR.

Conclusions

Our data from 23,222 patients after AMI demonstrate that in Switzerland patients referred for CR are younger, more obese with more STEMI. In-hospital complications were strong predictors for CR recommendation. Unlike anticipated, other risk factors were less present in CR patients.

Section snippets

Background

Cardiac rehabilitation (CR) plays an important role in secondary prevention after acute coronary syndromes and has a Class I recommendation in the recent European STEMI and NSTEMI guidelines [[1], [2], [3]]. Furthermore, CR is recommended in stable CAD patients with or without elective PCI [4]. Cardiac rehabilitation after myocardial infarction and/or myocardial revascularization is associated with lower cardiovascular mortality, re-hospitalisation, coronary revascularization, and

Study design

This analysis was performed using data from the AMIS Plus registry. AMIS Plus is an ongoing nationwide prospective registry of patients admitted with ACS to Swiss hospitals, founded 1997 by the Swiss Societies of Cardiology, Internal Medicine and Intensive Care. Details were previously described [13,14]. From 106 centres treating ACS patients in Switzerland, 83 centres have been collecting temporally or continuously data for the AMIS Plus project. Participating centres range from

Patient characteristics

Between January 2005 and March 2017, 34,789 patients with AMI were enrolled, excluding patients who suffered their MI during a hospitalisation for another disease. 32,416 (93.2%) patients had data on further proceeding at discharge of which 10,940 (33.7%) had a recommendation for inpatient or outpatient cardiac rehabilitation (CR) at discharge. For 12,282 (37.9%) patients it was indicated that they went home after hospitalisation. Patients who were transferred after initial AMI treatment to

Discussion

In our present study we identified important predictors for a referral to for CR in patient after STEMI or NSTEMI in Switzerland. In particular, a performed PCI, Killip class 3 or 4 and complications during hospitalisation such as cardiogenic shock, reinfarction or cerebrovascular events were strong independent predictors. Interestingly, age >65 years and previous known atherosclerotic disease, such as previous myocardial infarction, previous revascularisation, cerebrovascular disease or

Conclusions

Despite given limitations, our present study characterized patients and identified predictors for participation and non-participation in CR programs from the large scale AMIS Plus registry in Switzerland. In particular, disparities exist for age and gender with significantly younger patients and less women being referred. High risk patients with pre-existing coronary or cerebrovascular disease as well as the elderly and women should not be distracted from the benefits of a cardiac

Author contributions

MH, FW and DR: conception, data interpretation and manuscript drafting

FW, DR: acquisition and analysis of data

PE and HR: critical revision of the manuscript draft

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of conflicting interests

The Authors declare that there is no conflict of interest. The authors report no relationships that could be construed as a conflict of interest

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Cited by (22)

Predictors of gain in exercise capacity through cardiac rehabilitation: Sex and age matter
2023, Heart and Lung
Cardiac rehabilitation (CR) is a cornerstone of secondary prevention that improves cardiovascular outcomes. However, the determinants of treatment success are poorly understood.
We investigated the associations of health-related quality of life (HRQoL), sex, age, employment status and housing situation with improvement in exercise capacity throughout CR.
We analyzed data from 392 CR outpatients (81% men and 19% women). Exercise capacity at baseline and upon completion of the program was measured with the 6-minute walk distance (6MWD). HRQoL at CR entry was assessed with the Short Form 36 Health Survey (SF-36).
A multivariable regression analysis revealed that both men and women showed significant improvement in exercise capacity (p < .001). Female sex (B = 18.118, 95% CI 0.341 - 36.035, p = .046) and younger age (B = -0.887, 95% CI -1.463 - -0.312, p = .003) emerged as predictors of greater improvement, while HRQoL, employment status, and housing situation were not associated with significant change in exercise capacity. The final model explained 25% of the variance in exercise capacity change (adjusted R² = 0.25, p < .001).
Our results indicate that women and younger participants benefit from CR by improving their exercise capacity. Employment status, housing situation and HRQoL showed no effects on CR outcome.
Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)
2023, American Journal of Cardiology
Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.
Are patient characteristics and modes of delivery associated with completion of cardiac rehabilitation? A national registry analysis
2022, International Journal of Cardiology
Citation Excerpt :
For this paper, patients were deemed to have completed the program if they were recorded as having completed or had a post-assessment with no other recorded reason for them not to have completed. Based on the literature on completion of CR, a wide collection of patient and service factors were included [18–20]. Patient characteristics, and additional service data, were collected at two time points.
To achieve effectiveness and reduce inequality in everyday cardiac rehabilitation, this study aims to compare individual patient characteristics along with completion rates to traditional and evolving modes of delivery in cardiac rehabilitation.
Patients were included from the UK National Audit of Cardiac Rehabilitation (NACR) database. All patients with coronary heart disease (≥18 years) between the 1st of January 2014 to 31st of December 2019 that started core rehabilitation with a recorded mode of cardiac rehabilitation delivery were eligible. Modes of delivery were divided into: centre-based, home-based, and hybrid. Logistic regression models were used to investigate association between modes of delivery and completion adjusting for patient demographics.
In total 182,722 patients had mode of delivery recorded: 72.8% centre-based, 8.3% home-based and 18.9% hybrid. The home-based mode in comparison to hybrid and centre-based had significantly higher rates of females, single, white, and unemployed patients (p < 0.001). There was a higher proportion of cardiovascular risk factors in home-based than the other modes (p < 0.001). There was a reduced likelihood of completing home-based cardiac rehabilitation compared to centre-based with an odds ratio of 0.66, (95% CI: 0.48 to 0.91) but no significant difference between hybrid and centre-based modes (odds ratio, 1.18; 95% CI 0.92 to 1.51).
From large real-world data, home-based modes of delivery appear to have significantly lower levels of completion than centre-based modes. Cardiac rehabilitation programs offering home-based and hybrid delivery modes need to be structured to ensure adequacy of completion.
The effect of cardiac rehabilitation on left and right ventricular function in post primary PCI patients
2022, Annals of Medicine and Surgery
Citation Excerpt :
Cardiac rehabilitation programs are needed to limit the physical and psychological effects of cardiovascular disease, reduce the risk of sudden death or recurrence, control the symptoms of atherosclerosis, and stabilize and reverse the process of atherosclerosis and improve psychosocial status [15,16]. According to clinical studies, cardiac rehabilitation is a useful method for correcting cardiac risk factors such as hypertension, hyperlipidemia, diabetes, obesity, smoking and reducing anxiety and depression after heart surgery [17,18]. Cardiac rehabilitation is classified into three stages, which include the following: The diagnosis of the disease from the time of hospitalization and includes care, education to the patient and family and coronary therapies.
Acute myocardial infarction is the most severe manifestation of coronary artery disease. Cardiac rehabilitation programs following percutaneous coronary intervention (PCI) assist patients to get back to their daily routine and can improve their cardiovascular health. The aim of this study was to evaluate the effect of cardiac rehabilitation in patients after primary PCI on the left and right ventricular function.
In this cross-sectional study, patient who underwent primary PCI following myocardial infarction were included. Month after the PCI procedure, 5 sessions of cardiac rehabilitation program were performed based on the patient's symptoms and according to the diagnosis by cardiologist. The duration of each rehabilitation session started from 20 min in the first session and reached 60 min in the last session. Exercises included walking on a treadmill and pedaling a stationary bike with limbs. Ventricular function was assessed after primary PCI and after the rehabilitation program. Patients were followed up by telephone after one year of the rehabilitation program.
30 patients were enrolled in the study, 23 of whom were male (76.7%). Right ventricular function did not change after the cardiac rehabilitation program compared to before (p = 1.00). Left ventricular function significantly increased after rehabilitation (p = 0.003). Increased left ventricular function was significant only in males (p < 0.001). Cardiac rehabilitation program in people over 60 years did not change left ventricular function (p < 0.05). One year after the cardiac rehabilitation program, 3 patients (10%) died.
The findings of our study showed that the implementation of an exercise-based cardiac rehabilitation program improves left ventricular function in patients with myocardial infarction after primary PCI but does not affect right ventricular function. The findings also showed that cardiac rehabilitation program may be associated with the gender and the age of the patients.
To what extent are comorbidity profiles associated with referral and uptake to cardiac rehabilitation
2021, International Journal of Cardiology
Citation Excerpt :
Unfortunately, uptake rates to CR are less impressive ranging from 30% to 50% across the United Kingdom (UK) and Europe of all eligible patients with CHD [4,5]. Reasons for not taking part in CR are many and can be related to the individual patients' characteristics [6–8] and service, work or other social concerns [4,8]. Tailoring of CR services toward patients' profile, needs and preferences is crucial in order to increase uptake [9–11].
Given the high proportion of comorbidities in patients with coronary heart disease (CHD) and low participation rates in cardiac rehabilitation (CR), a better understanding of how comorbidity interacts with the CR pathway is needed. We investigated associations between comorbidity profiles and referral and uptake in everyday clinical CR across UK.
Patients (≥18 years) diagnosed with a CHD between 1st of January 2014 and 31st of December 2019 registered in the National Audit of Cardiac Rehabilitation (NACR) database were eligible. Self-reported comorbidities from 15 disease categories were conceptualized into similar or dissimilar based on overall related pathophysiologic profile and care management as CHD. Regression models were conducted with four comorbidity profiles; similar conditions, dissimilar conditions, similar and dissimilar and no comorbidity.
399,348 (61.8%) patients were eligible for referral from 198 programmes. The majority were males (70%), mean age of 67 (±12 SD) years. A non-significant association was found between comorbidity profiles and referral. Odds ratios (OR) for CR uptake were higher in patients with dissimilar (OR = 1.38 (95% CI 1.26–1.54)) and dissimilar and similar comorbidities profiles (OR = 1.35 (95% CI 1.21–1.43)) compared to patients with similar comorbidities. No significant differences in uptake were found between patients with similar comorbidities and those without comorbidities (OR = 0.985 (95% CI 0.854–1.125).
Using routine practice data, comorbidity profiles were not significantly associated with CR referral suggesting equality in referral. Dissimilar comorbidity profiles were associated with uptake. To increase the likelihood of starting CR, services should consider developing tailored participation strategies that include comorbidity profiles.
Rapid access rehabilitation after exacerbations of COPD – A qualitative study
2021, Respiratory Medicine
Citation Excerpt :
For example, the first phase of cardiac rehabilitation is an early post-discharge phase that includes well-defined participation criteria [33] to facilitate referral within hospital units and between hospitals and specialized centers [34]. Following this structure, referral and uptake of rehabilitation after a cardiac event is around 38–47% [35–37], significantly higher compared to the referral rate (<30%) and uptake (<10%) of PR after discharge for AECOPD [11,12]. Future research is needed to understand how strategies used in other rehabilitation areas could be effectively applied to the RAR and conventional PR programs.
Rehabilitation after acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is beneficial, but its feasibility is questionable. Feasibility is potentiated by stakeholder involvement during program development. We aimed to explore the perspectives of various stakeholders towards an innovative rapid access rehabilitation (RAR) program for patients immediately following hospitalization for an AECOPD.
Semi-structured interviews were conducted with patients recently hospitalized for AECOPD, healthcare professionals (HCP) and policymakers providing care for such patients. Thematic analysis was performed.
Three patients (1 female; 62–89 years; GOLD D), ten HCP (3 females, 31–71 years) and three policymakers (3 females, 38–55 years) participated. Patients, HCP and policymakers shared similar visions for the development of a RAR program. Five main themes and ten subthemes were identified. They comprised: Pre-RAR aspects (Management properties, Eligibility), RAR program (Outcomes, Structure, Components), RAR optimization (Referral, Uptake), Partnership (Collaboration, Dedicated Coordinator) and COVID-19 (Adaptations). Essential elements included: identifying clear eligibility criteria, addressing patients’ needs at the time of hospital discharge, having a structured education and self-management program and modifying to respond to unexpected events (e.g., COVID). Suggestions to optimize referrals included a clear referral pathway, improving program awareness, assigning dedicated care coordinators to provide patient support throughout the program and establishing strong partnerships among different care settings and providers.
Identifying the essential program elements and approaches to optimize referrals, were considered to be key design approaches for success in establishing RAR.

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View full text

Referral for cardiac rehabilitation after acute myocardial infarction: Insights from nationwide AMIS Plus registry 2005–2017

Highlights

Abstract

Background

Design and methods

Results

Conclusions

Section snippets

Background

Study design

Patient characteristics

Discussion

Conclusions

Author contributions

Funding

Declaration of conflicting interests

ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

Eur. Heart J.

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)

Eur. Heart J.

Eur. J. Prev. Cardiol.

Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

Eur. Heart J.

Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States

J. Am. Coll. Cardiol.

Exercise-based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta-analysis

J. Am. Coll. Cardiol.

Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey

Eur. J. Cardiovasc. Prev. Rehabil.

EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries

Eur. J. Prev. Cardiol.

Predictors of enrollment in cardiac rehabilitation programs in Spain

J. Cardiopulm. Rehabil. Prev.

Effect of referral strategies on access to cardiac rehabilitation among women

Eur. J. Prev. Cardiol.

Effects of cardiac rehabilitation referral strategies on referral and enrollment rates

Nat. Rev. Cardiol.