Inpatient rehabilitation improves implementation of therapeutic guidelines for secondary prevention in patients with coronary heart disease

Abstract

In Germany, measures for secondary prevention in patients with coronary artery disease are poorly utilized. We therefore investigated whether a cardiac in-hospital rehabilitation and education program may enhance the implementation of respective guidelines in patients with severe coronary artery disease (CAD). Specifically, we developed a case-control design in siblings with severe CAD in order to achieve optimal matching for patients with or without participation in the rehabilitation program. By the screening of more than 200,000 patient charts in 15 cardiac rehabilitation clinics, we identified 1500 families in which at least two siblings suffered from severe coronary artery disease. In 268 such sibling pairs, siblings were discordant with respect to participation in a 3-4 week cardiac in-hospital rehabilitation program. The coronary risk profile was studied, first, retrospectively at the time of hospitalization for acute MI or revascularization procedures and, secondly, prospectively at the time of follow-up (on average 5.2 years later). At the time of the acute cardiac event, both groups showed an equal risk factor distribution suggesting appropriate matching. However, at follow-up the number of individuals taking antihypertensive medication and displaying effective antihypertensive treatment (< or = 140/90 mmHg) was significantly higher in the rehabilitation group (92.2 vs. 82.1%, p < 0.01; 59.7 vs. 37.2%). Accordingly, rehabilitation siblings presented with significantly lower systolic (137 +/- 1 vs. 145 +/- 1 mmHg; p < 0.01) and diastolic blood pressure (82 +/- 1 vs. 85 +/- 1 mmHg; p < 0.01). The utilization of CSE inhibitors was also significantly higher in siblings participating in the rehabilitation program (57.5 vs. 43.1%; p < 0.01), leading to significantly lower blood lipid levels in these siblings (total cholesterol 225 +/- 3 vs. 236 +/- 3 mg/dL, p < 0.01; LDL cholesterol 148 +/- 3 vs. 158 +/- 3 mg/dL, p < 0.01). Moreover, participation in the cardiac rehabilitation stimulated markedly more smokers to quit (80.8 vs. 57.6%, p < 0.01). Additionally, there was a strong temporal trend from 1997 until 2000 towards improved control of arterial hypertension in rehabilitation siblings. In parallel, the utilization of CSE inhibitors increased over time and LDL cholesterol decreased. These favorable temporal trends were also observed in siblings not participating in the rehabilitation program, however, to a lesser extent. Taken together, in the last four years, the implementation of secondary preventive strategies in patients with cardiac disease improved. Siblings who participated in a rehabilitation program displayed a better control of cardiovascular risk factors as compared to those not participating in such a program. Thus, an in-hospital cardiac rehabilitation program may successfully encourage the implementation of measures for secondary prevention and enhance the treatment of coronary risk factors.