Cardiac Rehab: No Impact on Quality of Life for Acute MI Patients?

It may be that cardiac rehab—an intervention well-known to improve cardiovascular outcomes—may not actually improve patients’ quality of life after acute MI, according to an observational study.

But even if that is the case, the proven benefits of cardiac rehab on factors like mortality and need for hospitalization are still enough justification for practitioners to be prescribing it aggressively, Alexis Beatty, MD (VA Puget Sound Health Care System, Seattle, WA), told TCTMD. “If I told my patients that you can have a quality of life where you're 90% happy with your health status for 5 years or 6 years, I think most people would choose do it for 6 years,” she said. “If we look at overall quantity of quality of life and put it in a [quality-adjusted] life-years perspective, cardiac rehab still increases that.”

Yet it is a problem that prior studies have suggested that cardiac rehab indeed improves patient quality of life without providing evidence, said lead author Faraz Kureshi, MD, MSc (Saint Luke’s Mid America Heart Institute, Kansas City, MO), to TCTMD. For their study published online last week in JAMA Cardiology, his team used disease-specific health status measures from the Seattle Angina Questionnaire (SAQ) and the 12-item Short-Form Health Survey (SF-12) and a propensity-matched analysis to show no differences in scores over 1 year among 4,929 between acute MI patients enrolled in the PREMIER and TRIUMPH registries who participated in at least one cardiac rehab session (40.9%) and those who attended none.

Of note, people with a record of cardiac rehab held a slight survival advantage over those who never participated (HR 0.59; 95% CI 0.46-0.75).

Patients “expect” improved quality of life by participating in cardiac rehab, Kureshi said. However, this has been “so understudied” in the setting of acute MI, he added, that even “more work is needed using validated health status measures . . . so we can get patients accurate information, and so we can tell them, ‘You may not necessarily feel better by participating in cardiac rehab—you may feel the same even if you didn't do it—however, there are significant benefits in these other realms.’”

Beatty admitted that she has told patients who are “on the fence” about cardiac rehab about the potential for improvement in health status measures, although she usually begins with the arguments that it will help them “live longer and have fewer hospitalizations.”

“This study is one thing that will make it more difficult for me to tell people that it definitely improves health status,” she stated, with the caveat that the results may have been confounded by including a population with “pretty high” quality of life ratings at the outset. “It’s often harder to make people who are already feeling 100 feel better than 100,” Beatty added.

In an accompanying editorial, Hani Jneid, MD (Michael E. DeBakey VA Medical Center, Houston, TX), writes that “from the clinician’s perspective, the neutral effect on health status outcomes observed in the current article does not refute the established salubrious effects of cardiac rehabilitation.”

The fact that fewer than half of the patients in the study participated in cardiac rehab “highlights significant unmet needs in the field,” Jneid continues. Specifically, he said he would like to see a “definitive contemporary large multicenter randomized clinical trial confirming not only the hard outcome benefits of cardiac rehabilitation but also its effect on validated health status measures, as well as the need for more research to identify suboptimally treated patients and overcome the barriers behind the striking underuse of cardiac rehabilitation.”

This striking underuse is what Beatty said is most important. “The weight of evidence in support of cardiac rehabilitation has yet to convince people that they should be prescribing this evidence-based and effective therapy,” she said. “We need to come up with other approaches for getting more people to participate in cardiac rehab. I’m not sure that more registry-based or observational evidence is going to convince anybody at this point.”

Sources
  • Kureshi F, Kennedy KF, Jones PG, et al. Association between cardiac rehabilitation participation and health status outcomes after acute myocardial infarction. JAMA Cardiol. 2016;Epub ahead of print.

  • Jneid H. Cardiac rehabilitation after myocardial infarction: unmet needs and future directions. JAMA Cardiol. 2016;Epub ahead of print.

Disclosures
  • Kureshi reports receiving support from the National Heart, Lung, and Blood Institute.
  • Jneid and Beatty report no relevant conflicts of interest.

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