Access to cardiac rehabilitation programs in patients with acute coronary syndrome: can referral be a step towards improvement? Insights from a multicentre national registry

Abstract

Abstract The burden of cardiovascular disease remains on top of society's health problems, and acute coronary syndromes are undoubtedly a major cause. Cardiac rehabilitation programs (CRP) have been demonstrated to be a cost-effective strategy in reducing morbimortality and improving quality of life after an acute event. Despite this evidence and clinical recommendations, CRP are still globally underused. The lack of referral patients to CRP has been appointed as an important impediment to patients' participation. This study aimed to clarify the main features of referred patients to CRP vs non-referred patients after an acute coronary syndrome (ACS). The authors performed a retrospective analysis of adult patients with information about CRP destination, included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and December 2021. Comparison tests for parametric and non-parametric variables were performed. Logistic regression was applied for multivariate analysis. A p-value less than 0.05 was considered statistically significant. A total of 28809 patients admitted for ACS were analysed, 22896 (79.5%) not referred for CRP (group 1) and 5913 (20.5%) were referred or even had a planned CRP. Table 1 shows the most important baseline characteristics and differences between groups. Table 2 demonstrate the group differences regarding admission diagnosis, complementary study results and in-hospital complications. Multivariate analysis established the following variables as independent factors for non-referral for CRP: age greater than 75 years (OR 0.80, 95% CI [0.72, 0.89]), history of valvular disease (OR 0.76, 95% CI [0.59, 0.97]), history of kidney disease (OR 0.65, 95% CI [0.54, 0.79]), admission diagnosis of unstable angina (UA) (OR 0.37, 95% CI [0.27, 0.50]), multivessel disease (OR 0.73, 95% CI [0.67, 0.80]), left ventricular ejection fraction less than 50% (OR 0.76, 95% CI [0.68, 0.84]), mechanical complication of myocardial infarction (OR 0.26, 95% CI [0.10, 0.67]) and acute heart failure during hospitalization (OR 0.67, 95% CI [0.58, 0.77]). In conclusion, contrary to international results, women and patients with non-ST-segment elevation myocardial infarction were not negative predictors for referral to CRP. However, we observed that in our country, older patients, those with UA as an admission diagnosis, comorbidities and/or reduced systolic function are less referred to CRP by physicians. Paradoxically, these patients often have greater disease management complexity and poor outcomes. Besides that, the beneficial effects of cardiac rehabilitation in these groups have been demonstrated. Thus, it is extremely important to understand the limitations of referral in our country and implement strategies to overcome them. Funding Acknowledgement Type of funding sources: None.