Why do we keep asking, do we still need cardiac rehabilitation?

Cardiac rehabilitation programs have been treating patients for decades. A substantial volume of literature supports patient attendance1 and national guidelines include cardiac rehabilitation as part of optimal treatment for cardiovascular disease (CVD).2 In recent years, however, some scientists and clinicians have conducted meta-analyses and systematic reviews questioning the value of cardiac rehabilitation.3 This was recently the topic of debate at the European Society of Cardiology Congress 2019 in Paris entitled “Is cardiac rehabilitation still a ‘must’ in the 21st century?” The justification for asking this question is based on continued advancement in the medical management of CVD, which could potentially diminish the added value of cardiac rehabilitation. Advancement began with statins, followed by more sophisticated anti-hypertensives and now minimally invasive revascularization procedures. Early cardiac rehabilitation began as predominantly exercise-focused programs. Prior to that, patients following myocardial infarction (MI) were restricted to bed rest for 30 days for fear of overworking the heart. As a result, patients often died in hospital of pulmonary embolism. Only when hospitals got patients up and moving did these outcomes disappear. From there, a number of RCTs were conducted but no single study was large enough to investigate the effect of cardiac rehabilitation on MI and premature mortality alone. However, early meta-analyses indicated a substantial 20% and 22% reduction in all-cause and CVD mortality, respectively,4 a benefit similar to the angiotensin-converting enzyme inhibitor ramipril. The provision of cardiac rehabilitation is also highly cost effective.5 Subsequently, cardiac rehabilitation blossomed to include dietary counseling, optimization of medications, psychosocial support and smoking cessation, as needed.6 As time passed and evidence mounted in support of cardiac rehabilitation, it became a mainstay in guidelines being strongly recommended following MI at the same level as percutaneous coronary intervention (Class 1, Level A).2 As a proven and accepted treatment, conducting a much sought-after randomized controlled trial (RCT) on the efficacy of cardiac rehabilitation is challenging, as ethics committee are reluctant to have a non-intervention comparator group. With the ethical requirement to have comparator groups receive some form of secondary prevention, a RCT would require a large number of patients and long follow-up period that make such a trial unfundable or unfeasible. The RAMIT trial aimed to address this question in the mid-late 1990s, through a pragmatic RCT examining cardiac rehabilitation programs in the UK, but was stopped due to futility in recruitment.7 Originally designed for 8000 patients, only 1813 were randomized, leaving the study severely underpowered. In addition, there were several methodological problems such as lack of control of the intervention, high intervention drop-out rate (20%), absent trial reporting details and a potentially biased sample, making generalization problematic.8 Despite these flaws, many readers interpreted the lack of effect of cardiac rehabilitation on mortality, cardiac events, risk factors, quality of life and physical activity as indication that cardiac rehabilitation is ineffective. Indeed, the RAMIT trial was the largest included in a 2017 meta-analysis of cardiac rehabilitation studies conducted since 2000, which concluded “the current approach to exercise-based cardiac rehabilitation has no effect on all-cause mortality or cardiovascular mortality, when compared with a no-exercise control.”3 However, the comparison groups from these studies generally received optimal secondary prevention, exercise and dietary counseling, along with psychosocial support. Essentially a cardiac rehabilitation program without supervised exercise. We should obviously not skirt our ethical obligations, but it does make it difficult to robustly answer the question and appease critics. As an alternative, it has been suggested we test this hypothesis in low and middle income countries where access to cardiac rehabilitation is poor, and therefore the comparison group can be free of any similar intervention. However, we would argue this is equally unethical and unlikely to answer the question soundly, as standard practices of care in these countries differ from care in high income countries, making extrapolation problematic. Why then does cardiac rehabilitation continue to be singled out? Exercise, which has been a mainstay of cardiac rehabilitation, has proven effective across a range of metrics associated with lower risk for CVD and was touted as a “miracle cure” in a recent editorial.9 Despite four decades having passed since the first cardiac rehabilitation trials, it is unlikely that exercise, along with other cardiac rehabilitation components, is no longer effective. Nor is it likely that the pathology of atherosclerosis has changed in a way which makes exercise ineffective. Conversely, percutaneous coronary intervention, of which a number of trials have indicated is no better than optimal medication and lifestyle management such as in the COURAGE trial10 and more recently in the ISCHEMIA trail,11 does not fall under the same scrutiny. Indeed, an earlier trial found exercise to be more effective at reducing atherosclerosis than percutaneous coronary intervention.12 Part of the issue may be funding models. Unlike devices and medications, there is no common funding mechanism for cardiac rehabilitation. Programs are often funded by third party insurance, others from excess overhead that hospitals make from procedures or through a public health system. Sometimes it is a combination of these sources. In addition, it is a human health resource intense endeavor. We would also add three more probable reasons, which are not commonly mentioned but equally as likely. First, cardiac rehabilitation, as with any secondary prevention modality, is a slow intervention. Compared with revascularization, the benefits to long-term hard events are not immediately realized. As such, the risk–benefit to health systems may be perceived as being low. For example, if patients die in hospital because they did not have access to bypass surgery this becomes front page news and a liability to the hospital. In contrast, if a patient dies because they did not receive cardiac rehabilitation two years earlier, no one is really the wiser. However, if a hospital is going to offer revascularization procedures, it should be committed to the long term care trajectory as well; that is, providing their patients with secondary prevention and the life skills needed to decrease the likelihood of future cardiac events and hospital admissions and increase their quality of life. Second, cardiac rehabilitation is not lucrative for the hospital or cardiologist. Compared with invasive procedures such as catheterization and electrophysiology studies, the fee for service is much lower. In fee for service models, successful cardiac rehabilitation can actually undermine hospital income by reducing the number of cardiac procedures and hospitalizations. Due to the lower fees paid, few cardiologists are attracted to work in cardiac rehabilitation and those that are often have a weaker voice than their higher paid colleagues. This becomes problematic as cardiologists have a disproportionately strong say in designing the recommendations which many health care systems adopt. Finally, and often overlooked in the discussion, are the numerous other benefits to health and well-being that cardiac rehabilitation offers and that outweigh any detriments (Figure 1). Patient reported outcomes such as increased quality of life, decreased symptoms and disability are increasingly recognized as important to measure. While traditional trials focused on mortality and readmission rates, increased attention should be given to patient reported outcomes and experiences, in which cardiac rehabilitation has a big role to play. Additionally, exercise, a cornerstone of cardiac rehabilitation, has been proven to reduce falls in patients with mobility issues, as a treatment for depression, and has promise in treating cancer,13 among other conditions, many of which are common co-morbidities for patients with CVD. Beyond exercise, cardiac rehabilitation patients receive leading edge dietary advice, smoking cessation, psychosocial support and guidance on medication adherence. In contrast, medical therapies used in CVD medicine are singular in their effect; basically one-trick ponies. Unlike clinical trials, in which the experimental medication is taken for years during their study, cardiac rehabilitation interventions are typically limited to 6–12 weeks yet the benefit persists many years beyond that. Were cardiac rehabilitation interventions as long as those in clinical trials, the benefit may be far greater than currently reported. Indeed, a long-term, yet small RCT reported that 10 years of supervised exercise in patients with heart failure resulted in a 32% reduction in mortality compared with a non-exercise group.14 The beneficial outcomes of cardiac rehabilitation outweigh any perceived barriers to its implementation. At a time when other disciplines are recommending their own form of cardiac rehabilitation for treatments of cancer13 and stroke,15 we should not be turning away from cardiac rehabilitation. Patients deserve to be offered all tools in the toolbox for treating CVD, which includes cardiac rehabilitation, and for some patients cardiac rehabilitation may result in no longer needing other medical therapies. Rather than asking “do we still need cardiac rehabilitation?” why are we not asking other essential questions on how we can improve cardiac rehabilitation so more patients can access and benefit from it? Future work must focus on securing adequate funding, increasing the flexibility and individualization of programs, providing patient-centered care, providing long term follow-up and testing new modes of delivery. SAL contributed to the conception and design of the manuscript, and drafted the manuscript. SC contributed to the conception and design of the manuscript and critically revised the manuscript. Both give approval and agree to be accountable for all aspects of the work ensuring integrity and accuracy. The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SAL acts as a consultant for PHAS3 health. SC – none. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: SAL holds the Pfizer/Heart and Stroke Foundation Chair in Cardiovascular Prevention Research at St. Paul’s Hospital. SC holds a Deakin University Dean’s Postdoctoral Research Fellowship.

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