The Association Between a Second Course of Cardiac Rehabilitation and Cardiovascular Outcomes Following Repeat Percutaneous Coronary Intervention Events : Journal of Cardiopulmonary Rehabilitation and Prevention

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The Association Between a Second Course of Cardiac Rehabilitation and Cardiovascular Outcomes Following Repeat Percutaneous Coronary Intervention Events

Zhang, Wenliang MD; Supervia, Marta MD; Dun, Yaoshan MD; Lennon, Ryan J. MS; Ding, Rongjing MD; Sandhu, Gurpreet MD, PhD; Tilbury, Thomas MD; Squires, Ray W. PhD; Vardar, Ufuk MD; Tabatabaei, Niloufar MD; Thomas, Randal J. MD, MS

Author Information

Xiangya Hospital, Central South University, Changsha, China (Drs Zhang and Dun); Department of Physical Medicine and Rehabilitation, Gregorio Marañon General University Hospital, Gregorio Marañon Health Research Institute, Madrid, Spain (Dr Supervia); Departments of Quantitative Health Sciences (Mr Lennon) and Cardiovascular Medicine (Drs Sandhu, Tilbury, Squires, and Thomas), Mayo Clinic, Rochester, Minnesota; Cardiovascular Department, Peking University People's Hospital, Beijing, China (Dr Ding); Department of Cardiology, Olmsted Medical Center, Rochester, Minnesota (Dr Tabatabaei); Halifax Health, Daytona Beach, Florida (Dr Tabatabaei); and Department of Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois (Dr Vardar).

Correspondence: Randal J. Thomas, MD, MS, Department of Cardiovascular Medicine, Mayo Clinic, 200 First Ave, SW, Rochester, MN 55905 ([email protected]).

A small grant was obtained from the Mayo Clinic Department of Cardiovascular Diseases to carry out the statistical analyses for this project.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com).

Journal of Cardiopulmonary Rehabilitation and Prevention 43(2):p 101-108, March 2023. | DOI: 10.1097/HCR.0000000000000717

Worldwide, each year millions of patients experience major adverse cardiovascular (CV) events, including myocardial infarction (MI), coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention (PCI).1 Although substantial reductions in CV mortality have occurred in recent decades, recurrent CV events are still a significant concern.2 Approximately 50% of major adverse CV events, in fact, occur in individuals with a previous MI, and 20% of MI survivors suffer a second major adverse CV event within the first year after their MI.3

Cardiac rehabilitation (CR) is an extensively investigated systematic approach to delivering secondary CV disease prevention interventions to patients with CV disease. Participation in CR by patients recovering from a coronary artery disease event has been associated with lower rates of hospital readmission4 and the risks of cardiac and all-cause mortality,5–7 while improving CV risk factor control,8 exercise capacity,9 and psychological well-being.10 National and international clinical practice guidelines and performance measures strongly encourage CR participation following the occurrence of any of several CV conditions, including MI, PCI, CABG, heart valve surgery, heart transplantation, stable angina, and heart failure with reduced ejection fraction.11,12 Although developments in revascularization techniques,13,14 as well as the use of postrevascularization prevention and CR therapies,15,16 have contributed to improvements in patient outcomes after an acute coronary syndrome, recurrent CV events, including repeat revascularization, are still relatively common.17,18

Participation in CR following a qualifying CV event is considered a standard of care and is covered by most health insurance plans, even if the patient has previously participated in CR after a prior CV event. However, published studies of CR have been limited to the first course of CR after such events. Studies are lacking that have assessed the impact of a second (repeat) course of CR in patients who have had a second CV event. The aim of this study was to assess the association between a second course of CR and CV outcomes in patients who have undergone a second PCI procedure.

METHODS

We carried out a retrospective observational study that included patients from Olmsted County, Minnesota, who underwent PCI at the Mayo Clinic in Rochester, Minnesota, between January 1, 1998, and December 31, 2013. Data were extracted from the Mayo Clinic PCI registry, which has prospectively included medical records for patients who have undergone PCI at the Mayo Clinic coronary catheterization laboratory since 1979.19 Patient medical records include records from all sources of medical care provided at the Mayo Clinic, plus additional indexing and linkage with other sources of medical care in Olmsted County, Minnesota, where the Mayo Clinic is located, using resources from the Rochester Epidemiology Project.20 Patients were included in this study if they met the following criteria: (1) underwent PCI at the Mayo Clinic between January 1, 1998, and December 31, 2013; (2) were a resident of Olmsted County, Minnesota, at the time of PCI; (3) were discharged alive after the PCI procedure; (4) participated in >1 session of CR after a first-time PCI during the study period; (5) had a repeat PCI event after the first CR during the study period, occurring >6 mo after the index PCI; (6) survived >3 mo after repeat PCI; and (7) had given approval to use their medical records for medical research.

Patients were excluded from the study if they met any of the following criteria: (1) PCI was not successful (as judged by the interventional cardiologist who performed the procedure); (2) patient data were incomplete; (3) patient was discharged to a long-term care facility following the second PCI event; and (4) patient had a documented symptomatic or life-threatening comorbid condition at the time of the repeat PCI event (renal disease, lung disease, uncontrolled diabetes mellitus, malignancy, and/or orthopedic injury). We obtained demographic, clinical, angiographic, procedural, and medication data from the PCI registry and medical records. Our study was approved by the Mayo Clinic and Olmsted Medical Center Institutional Review Board.

CARDIAC REHABILITATION

The Mayo Clinic CR program, during the time of this study, was an in-person, multidimensional program started within 1-2 wk after a CV event and included three, 1 hr supervised sessions/wk for a total of 36 sessions. Components of CR included exercise training and counseling, nutritional counseling, CV risk factor modification, medication adherence counseling, and referral of patients for assessment and management of comorbid conditions (eg, depression, musculoskeletal limitations, diabetes, sleep apnea). Attendance was ascertained by use of the Mayo Clinic CR database, which has been described elsewhere.21 We relied on Current Procedural Terminology codes4 (93797, 93798, or 93799) with an associated numeric key specific for CR participation. Manual chart review was used to supplement billing data to ensure accuracy of the data. In accordance with previous studies,7 participation in the first course of CR was defined as attending >1 outpatient CR session within 6 mo of the initial PCI, ascertained using administrative billing data. Participation in the second course of CR was defined as attending >1 outpatient CR session within 6 mo of the repeat PCI. The Mayo Clinic electronic medical record and the Olmsted Medical Center medical records of all the patients who were reported as nonparticipants in our CR database were checked until 6 mo after PCI to verify that there was indeed no record of CR participation after the PCI date. Patients who did not attend CR within 6 mo after the index PCI or after the repeat PCI but attended CR after a subsequent qualifying event were considered nonparticipants.

OUTCOME DATA

The primary end point of our study was all-cause mortality. Secondary end points were cardiac death, MI, coronary revascularization (PCI or CABG), CV hospitalization, and a composite of all secondary end points, all of which were ascertained by a review of patient medical records. Death certificates were used to classify CV and non-CV causes of death. Coronary (target lesion) revascularization was defined as percutaneous or surgical revascularization of the target lesion after the initial percutaneous procedure.

STATISTICAL METHODS

Differences in continuous, categorical, ordinal, and time-to-event variables were analyzed using accepted analytical methods (Student two-sample t test, Pearson χ2 test, Mann-Whitney-Wilcoxon rank sum test, and log-rank test, respectively). For all-cause mortality, Kaplan-Meier methods were used. For nonfatal or cause-specific mortality events, competing risk methods were used to calculate cumulative incidence. Cox proportional hazards models were used to estimate HRs for the effect of a second course of CR.

We used a landmark approach such that patients who died or were lost to follow-up within 3 mo of the PCI were excluded. Conditioning on 3-mo survival allowed all patients in the analysis to have the same opportunity to attend CR and allowed testing of CR participation as a “baseline” factor in the Cox proportional hazards modeling.

To account for imbalances in covariate distributions between groups, a propensity score was developed using logistic regression, based on the variables listed in Supplemental Digital Content Table 1, available at: https://links.lww.com/JCRP/A406. From this model, weights were developed to be applied to each subject. For CR patients, the weight was the inverse of the estimated probability of being a CR patient. For non-CR patients, the weight was the inverse of the estimated probability of not being a CR patient. This weighting approach allowed us to estimate the average treatment effect of a second course of CR in all PCI patients. Weights were then normalized so that the sum of weights in each group was equal to the number of patients in each group. Balance between groups was inspected by reviewing the standardized difference, with <0.10 considered acceptable balance. All but one variable (number of segments treated) achieved difference <0.10, with the exception being very close at 0.11. Summary tables show both the unadjusted covariate summary statistics and P values for group comparisons, as well as group means and percentages based on weighted observations. We also generated weighted cumulative incidence curves based on the propensity score inverse probability weighting (PS-IPW) approach.

RESULTS

PATIENT POPULATION AND CR PARTICIPATION

Patients in our study group underwent 24 479 PCI procedures between January 1, 1998, and December 31, 2013, for which the patient was discharged alive. Of these patients, 3090 were noted to have participated in CR for the first time, following their PCI. Of these, 675 had a second PCI of >6 mo after their initial PCI, with 384 classified as Olmsted County residents at the time of the second PCI. Fifteen patients were excluded who did not provide consent to use their medical records for research, 119 were excluded because of being duplicate procedures in the same patients, 7 were excluded because of having <3 mo of follow-up, and 3 were excluded who were not eligible for CR due to a life-threatening illness, leaving 240 patients in our study group. Overall, 97 (40%) of the 240 eligible patients participated in a second course of CR after repeat PCI. Patient and clinical characteristics are shown in Tables 1–3. There were no significant differences noted between the CR and no CR groups, when comparing the demographic, medication, clinical, angiographic, or procedural variables. The mean age of patients was approximately 65 yr in both groups, and about 70% of the two groups were male. The median length of time between the first and second patient PCIs was 35.4 (15, 67) and 27.5 (14, 54) mo, respectively, in the CR and non-CR groups.

Table 1 - Baseline Patient and Clinical Characteristicsa
Variable Unadjusted Summaries PS-IPW-Adjusted Mean/Percentb
No CR (N = 143) CR (N = 97) P Value No CR CR Absolute Standardized Difference
Age, yr 64.9 ± 12.7 65.5 ± 11.6 .689 65.1 64.8 0.03
Sex, male 96 (67) 72 (74) .239 70 69 0.01
Race, non-White 9 (6) 5 (5) .071 8 7 0.03
Time between PCIs (w/CR), mo 27.5 (13.6, 54.0) 35.4 (15.0, 66.9) 38.5 39.2 0.02
Most recent MIc .059
Comp: superscript
<24 hr 23 (16) 28 (29) 20 19 0.01
1-7 d 6 (4) 4 (4) 5 4 0.01
>7 d 82 (58) 46 (48) 57 57 0.01
Never 31 (22) 18 (19) 19 19 0.01
Pre-procedural shock 2 (1) 4 (4) .180 2 4 0.02
Definite/probable angina 104 (73) 63 (65) .199 70 71 0.01
Unstable angina 97 (68) 60 (62) .339 65 65 <0.01
Canadian Heart Class (III, IV, V) 91 (64) 55 (57) .280 61 61 <0.01
Predominant symptom .662
Chest pain 124 (87) 86 (89) 86 88 0.02
CHF 2 (1) 0 (0) 1 0 0.01
Arrhythmia 1 (1) 1 (1) 1 1 <0.01
Asymptomatic 0 (0) 1 (1) 0 1 0.01
Positive exercise test 10 (7) 5 (5) 8 6 0.01
Other/unknown 6 (4) 4 (4) 4 4 <0.01
CHF statusc .361
Never 109 (78) 75 (82) 78 81 0.03
Previous 13 (9) 11 (12) 11 15 0.04
Current 17 (12) 5 (5) 11 4 0.07
Diabetes mellitus 46 (32) 31 (32) .973 31 30 0.01
Hypertensiond 113 (80) 80 (83) .535 82 82 0.01
Body mass index, kg/m2 30.1 ± 6.2 30.9 ± 6.4 .348 30.4 30.4 0.01
History of cholesterol, ≥240 mg/dL 136 (96) 91 (95) .532 97 95 0.02
Family history of CAD .086
No 46 (32) 37 (38) 35 34 <0.01
Unknown 34 (24) 30 (31) 26 25 0.01
Yes 63 (44) 30 (31) 39 41 0.01
Smoking status .568
Never 42 (30) 31 (32) 29 31 0.02
Former 74 (52) 51 (53) 54 58 0.04
Current 26 (18) 15 (15) 18 11 0.07
History of MI, >7 d 106 (75) 69 (72) .634 77 74 0.04
Prior PCI 143 (100) 97 (100) 100 100
Prior CABG 34 (24) 21 (22) .700 22 27 0.05
Peripheral vascular disease 15 (11) 9 (9) .744 11 12 0.01
CVA/TIA 24 (17) 8 (8) .049 14 9 0.04
Moderate/severe renal disease 4 (3) 1 (1) .347 3 2 0.01
COPD 21 (15) 8 (8) .130 13 14 0.01
Peptic ulcer disease 9 (6) 7 (8) .723 7 8 0.01
Tumor/lymphoma/leukemia 15 (10) 15 (16) .240 12 14 0.02
Metastatic cancer 0 (0) 0 (0) 0 0
Cardiac arrest pre-procedure 0 (0) 0 (0) 0 0
Prophylactic IABP 1 (1) 2 (2) .351 1 2 0.01
LVEF measure .577
>40% 65 (45) 41 (42) 48 47 0.01
NA 67 (47) 47 (48) 46 44 0.03
≤40% 11 (8) 9 (9) 6 10 0.03
Abbreviations: CABG, coronary artery bypass graft surgery; CAD, coronary artery disease; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; CR, cardiac rehabilitation; CVA, cerebrovascular accident; IABP, intra-aortic balloon pump; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NA, not applicable; PCI, percutaneous coronary intervention; PS-IPW, propensity score inverse probability weighting; TIA, transient ischemic attack.
aData presented as mean ± SD, median (IQR), or n (%).
bThe group mean or percent after propensity score inverse probability weights are applied.
cPercentages were calculated using the denominator of those with data available. Data was missing for the following variables (number missing in parentheses): most recent MI (2), pre-procedural shock (1), CHF status (10), hypertension (3), BMI (1), history of cholesterol ≥ 240 (3), smoking status (1), history of MI > 7d (2), peripheral vascular disease (6), COPD (3), peptic ulcer disease (10), tumor/lymphoma/leukemia (1).
dHypertension, blood pressure >140/90 mmHg, or has clinical diagnosis of treated hypertension.

Table 2 - Angiographic Characteristicsa
Unadjusted Summaries PS-IPW–Adjusted Mean/Percentb
Variablec No CR (N = 143) CR (N = 97) P Value No CR CR Absolute Standardized Difference
Diseased vessels (70/50)d .720
0.0 5 (4) 2 (2) 3 2 0.01
0.1 39 (28) 26 (28) 26 31 0.06
0.2 63 (46) 43 (46) 46 45 0.01
0.3 31 (22) 22 (24) 25 22 0.03
Multivessel disease (70/50) 96 (69) 65 (70) .831 72 67 0.05
High risk (C type) lesion 59 (44) 44 (49) .457 47 49 0.03
Thrombus in any lesion 26 (20) 23 (26) .287 24 21 0.03
Bifurcation in any lesion 20 (15) 11 (13) .572 15 11 0.04
Abbreviations: CR, cardiac rehabilitation; PS-IPW, propensity score inverse probability weighting.
aData presented as n (%).
bThe group mean or percent after propensity score inverse probability weights are applied.
cPercentages were calculated using the denominator of those with data available. Data was missing for the following variables (number missing in parentheses): number of diseased vessels (9), multivessel disease (7), high risk (C type) lesion (18), thrombus in any lesion (22), bifurcation in any lesion (23).
dDiseased vessels (70/50) and multivessel disease (70/50): ≥1 vessel with a stenosis of ≥70% and a second or third vessel with ≥ 50% stenosis.

Table 3 - Procedural Characteristics and Outcomesa
Variablec Unadjusted Summaries PS-IPW–Adjusted Mean/Percentb
No CR (N = 143) CR (N = 97) P Value No CR CR Absolute Standardized Difference
Urgency of PCI .463
Elective 36 (25) 25 (26) 27 29 0.02
Urgent 84 (59) 50 (52) 54 54 <0.01
Emergency 22 (15) 22 (23) 19 17 0.02
Number of segments treated 1.4 ± 0.7 1.3 ± 0.5 .141 1.4 1.3 0.11
Total vessels treated .797
1 121 (87) 79 (86) 89 85 0.04
2 18 (13) 13 (14) 11 15 0.04
Total stents placed 1.2 ± 0.8 1.1 ± 0.7 .130 1.2 1.1 0.05
Use of drug-eluting stents 83 (60) 54 (59) .878 58 53 0.05
Glycoprotein IIb/IIIa use 75 (52) 56 (58) .420 53 52 <0.01
PCI in native LAD 56 (40) 36 (39) .860 39 41 0.01
PCI in native LM 2 (1) 1 (1) .817 1 1 <0.01
PCI in native RCA 45 (32) 36 (39) .292 34 39 0.05
PCI in native LCX 37 (27) 25 (27) .926 25 25 0.01
Vein graft intervention 16 (12) 8 (9) .492 11 11 <0.01
TIMI = 3 post-procedure, in all lesions 124 (97) 82 (94) .346 98 96 0.01
TIMI = 2, 3 post-procedure in all lesions 126 (98) 85 (98) .695 99 99 <0.01
Inhospital death 0 (0) 0 (0) 0 0
Inhospital any MI 1 (1) 1 (1) .782 1 1 <0.01
Inhospital Q-wave MI 0 (0) 0 (0) 0 0
Inhospital CABG 1 (1) 0 (0) .409 1 0 <0.01
Abbreviations: CABG, coronary artery bypass graft surgery; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LM, left main coronary artery; MI, myocardial infarction; PCI, percutaneous coronary intervention; PS-IPW, propensity score inverse probability weighting; RCA, right coronary artery; TIMI, thrombolysis in myocardial infarction.
aData presented as n (%) or mean ± SD.
bThe group mean or percent after propensity score inverse probability weights are applied.
cPercentages were calculated using the denominator of those with data available. Data was missing for the following variables (number missing in parentheses): urgency of PCI (1), number of segments treated (9), total vessels treated (9), total stents placed (9), use of drug-eluting stents (9), PCI in native LAD (9), PCI in native LM (9), PCI in native RCA (9), PCI in native LCX (9), vein graft intervention (9), TIMI = 3 post-procedure in all lesions (25), TIMI = 2, 3 post-procedure in all lesions (25).

The Figure shows cumulative incidence graphs for the landmark analysis with both unadjusted and propensity score–based IPW-adjusted estimates. In both the unadjusted and adjusted analyses, the primary end point (total mortality) did not differ between the CR and no CR groups (Table 4). However, the secondary end points of the composite end point (CV death/MI/revascularization) and CV hospitalization were significantly lower in CR participants than in nonparticipants (P < .05). In the propensity score–based IPW analysis, the adjusted risks of revascularization, composite end point of death/MI/revascularization, and CV hospitalization were significantly lower in CR participants than in nonparticipants (P < .05).

F1
Figure.:
Cumulative incidence curves showing the association between cardiac rehabilitation (CR) participation and outcomes. Outcomes include target lesion revascularization, a composite end point of CV death/myocardial infarction/revascularization (PCI and/or coronary artery bypass graft surgery [CABG]), and CV-related hospitalization. (A) Cumulative incidence curves from the unadjusted landmark study analysis, and (B) cumulative incidence curves from the propensity score–based inverse probability weighting (IPW) analysis. The yellow line represents CR participants; the blue line represents nonparticipants. The propensity score was based on age, sex, time between qualifying PCIs, recent myocardial infarction, angina, diabetes mellitus, hypertension, body mass index, family history of coronary artery disease, history of stroke or transient ischemic attack, chronic obstructive pulmonary disease, tumor, urgency of procedure, drug-eluting stent use, and number of stents placed. Abbreviations: CV, cardiovascular; PCI, percutaneous coronary intervention; TLR, target lesion revascularization (PCI and/or CABG). This figure is available in color online (www.jcrpjournal.com).
Table 4 - Unadjusted and Adjusted Associations Between Cardiac Rehabilitation Participation and Clinical Outcomes With 3-mo Landmark Analysis
Unadjusted Estimates Propensity Scorea–Based IPW Estimates
HR (95% CI) P HR (95% CI) P
All-cause mortality 0.96 (0.57-1.62) .89 0.83 (0.49-1.40) .49
MI 0.68 (0.33-1.38) .28 0.67 (0.34-1.33) .25
TLR 0.57 (0.32-1.01) .055 0.47 (0.26-0.86) .014
CV death 0.59 (0.26-1.34) .21 0.56 (0.26-1.22) .14
CV death/MI 0.64 (0.36-1.12) .12 0.57 (0.33-1.01) .054
CV death/MI/TLR 0.64 (0.41-0.99) .046 0.57 (0.36-0.89) .014
CV hospitalization 0.62 (0.44-0.86) .005 0.60 (0.43-0.84) .003
Abbreviations: CV, cardiovascular; MI, myocardial infarction; IPW, inverse probability weighting; TLR, target lesion/coronary revascularization (percutaneous coronary intervention and/or coronary artery bypass graft surgery).
aThe propensity score was based on age, sex, time between qualifying percutaneous coronary interventions, recent myocardial infarction, angina, diabetes mellitus, hypertension, body mass index, family history of coronary artery disease, history of stroke or transient ischemic attack, chronic obstructive pulmonary disease, tumor, urgency of procedure, drug-eluting stent use, and number of stents placed.

Cardiovascular-related mortality was not significantly different in CR participants than in nonparticipants in both the unadjusted analysis (HR = 0.59; 95% CI, 0.26-1.34) and the propensity score–based IPW analysis (HR = 0.56; 95% CI, 0.26-1.22). There were no significant differences in MI or CV death or CV death/MI/revascularization rates among the CR participants and nonparticipants with or without adjustment. However, after propensity score–based IPW adjustment, there was a significant 53% reduction in revascularization rates in CR participants (HR = 0.47; 95% CI, 0.26-0.86; see Table 4).

The composite end point of death/MI/revascularization and CV hospitalization was significantly lower in CR participants than in nonparticipants in both unadjusted and adjusted analyses (see Table 4). Unadjusted analyses showed a 36% relative reduction in the risk of the composite outcome (HR = 0.64; 95% CI, 0.41-0.99) and 38% relative reduction in CV hospitalization (HR = 0.62; 95% CI, 0.44-0.86). Propensity score–based IPW-adjusted analysis showed a 43% reduction in the composite end point (HR = 0.57; 95% CI, 0.36-0.89) and a 40% (HR = 0.60; 95% CI, 0.43-0.84) relative reduction in CV hospitalization in CR participants compared with “standard care.”

DISCUSSION

We and others have previously reported that CR is associated with improved clinical outcomes in patients recovering from PCI,6,15,16,22 but this report is the first published study, to our knowledge, to analyze the impact on clinical outcomes of a second (repeat) course of CR following a second PCI. We found that only 40% of patients with a repeat PCI, who had participated in CR after their first PCI, participated in a second course of CR following their repeat PCI. This level is consistent with underuse of CR following PCI in previous reports,6,16,22–24 but our findings are notable in that all patients in this study cohort had previously participated in CR after their first PCI. We found that participation in a second (repeat) course of CR after second PCI was associated with lower rates of revascularization; lower rates of a combined end point of CV death, MI, and revascularization; and lower rates of CV hospitalizations. These findings provide support for a second (repeat) course of CR in patients with a second PCI, a practice that is commonly followed by clinicians and covered by insurance plans, although such a practice is not clearly specified in current clinical practice guidelines. In addition, the results of this study raise the question of whether or not the current traditional 12-wk model should be altered or lengthened to better optimize longer-term CV health.25

Reasons for the benefits of a second course of CR that we observed in our study are likely similar to those underlying reasons for the benefits of a first course of CR—improvements in patient cardiorespiratory fitness,26 lifestyle habits,27 CV disease risk factor control,28 patient adherence to appropriate guideline–directed medication therapy,29 and psychological health.10 Although a first course of CR helps improve these factors, there is evidence that lifestyle habits and medication adherence decline over time,30 although that decline may be less among individuals who have participated in CR.31 Still, it follows that patients who have a recurrent CV event are likely to have room for improvement in secondary prevention efforts and would therefore stand to benefit from a second course of CR.

The time period following an acute CV event—whether the first or a recurrent event—is an important window of opportunity to identify, treat, and reduce sources of increased CV risk.32 Individuals who have survived an acute CV event, in fact, are at relatively high risk for recurrence, particularly individuals who do not receive appropriate secondary prevention therapies.33 For example, in a retrospective longitudinal observational study by Rockberg et al,34 a lack of statin therapy was associated with higher mortality rates among patients with a history of CV disease compared with those who were receiving statin therapy. Risk of recurrent events is generally greatest during the first 6-12 mo after an acute CV event, but that risk remains relatively high even beyond the first year after the index event.35–37 A systematic approach to secondary CV disease prevention, namely CR, is a key step at a critically important crossroad that can help improve the prescription of appropriate secondary prevention therapies and the receipt of associated benefits.8,38

LIMITATIONS AND STRENGTHS

Some limitations should be considered when interpreting these results. Our results are from one county in the upper Midwest of the United States and may not reflect the experience in other areas of the world with different patient and health care characteristics. Our use of landmark analysis potentially limits the generalizability of our results to patients who survive the first 3 mo after PCI. Since our data are observational, it is possible that our results may be at least partially explained by sources of bias in our study population that may have persisted even after our best efforts to carry out statistical adjustments for potential sources of bias. In addition, we lacked information on income, education, transportation access, and so forth, which may have influenced participation. Despite these potential limitations, our study has several unique strengths, including the use of countywide data with detailed, longer-term information on CR participation, patient characteristics, and patient outcomes.

CONCLUSIONS

In a community sample of patients who experienced a second (repeat) PCI, only 40% participated in a second course of CR. Although previous studies have shown the beneficial effects of one “dose” of CR after an initial CV event, our study also suggests a possible beneficial “booster” effect of a second (repeat) course of CR in individuals who have experienced a second CV event. Participation in a second (repeat) course of CR was associated with lower hospital readmissions, subsequent revascularization procedures, and a combined end point of CV death, MI, and revascularization. These findings support the current standard of practice to refer all patients with a qualifying CV diagnosis, including those with a second (repeat) PCI who have previously participated in CR.

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Keywords:

cardiac rehabilitation; mortality; percutaneous coronary intervention

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