What's new?

The benefits of cardiac rehabilitation (CR) programs in the management of risk factors in patients with chronic coronary syndromes is underreported in Poland. This is the first multicenter study to investigate the referral and participation patterns of CR in Poland. We found the rate of referral to CR in Poland was low, particularly in the elderly, unemployed, and in patients after elective percutaneous coronary intervention. There was a significant positive effect of CR on aspects of secondary prevention approximately 1 year after the acute coronary event or elective revascularization: smoking habit, blood glucose level, and quality of life. The observed effects may be limited by the fact that patients only participated in a single course of CR. Therefore, we suggest a single course of CR should be accompanied by a more prolonged schedule to sustain such benefits.

Introduction

Cardiac rehabilitation (CR) is one of the core elements of secondary prevention in patients with ischemic heart disease (IHD), aiming to improve risk factors, reduce hospital readmission, and produce a more favorable survival outcome. Two large meta‑analyses of 34 and 18 randomized controlled trials have shown that CR reduces recurrent cardiovascular events and improves mortality rates in patients with myocardial infarction.^1,2 Moreover, CR has also been shown to improve patients’ quality of life and ability to return to work quickly.¹

International guidelines recommend that all patients who have had a planned revascularization procedure or have acute coronary syndrome (ACS), chronic stable angina, or heart failure should engage in a CR program to reduce subsequent events.^3,4 Moreover, recently revised practice guidelines urge for a “comprehensive rehabilitation” program covering a range of aspects: exercise training aimed at improving clinical profiles (optimization of blood pressure, lipid and glucose levels, and weight), healthy heart education (appropriate diet and smoking cessation), and psychological counseling to reduce stress and improve quality of life.^3,5,6 These comprehensive efforts are intended to foster better cardiovascular risk management than could be achieved by supervised exercise alone.

In Poland, cardiovascular disease is one of the major causes of mortality, accounting for 46% of total deaths in 2010,⁷ with nearly half of these attributable to IHD. To address this serious situation, healthcare experts have been trying to promote a preventive approach through CR and lifestyle changes. In addition, there has been an increase in the efforts to manage care for patients with IHD, including increased access to CR programs.⁸ To our knowledge, there are no multicenter studies to investigate disparities in referral rates and participation in CR and the effectiveness of CR in Poland.

However, referrals for CR programs and the impact of such programs in the real world have been suboptimal⁹ both in Europe¹⁰ and the USA.¹¹ A summary of a large cross‑sectional survey carried out by the pan‑European group, EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events), reported that CR referral rates and hence participation rates in Europe remain low.^12,13 Thus, there is the need for urgent action to increase referral and enrollment rates in CR programs.

This study assessed the effectiveness of CR in a patient population enrolled in a CR program in 14 cardiology centers from 4 different regions of Poland, all of which participated in the EUROASPIRE.

Patients and methods

The POLASPIRE is a parallel program run by Polish centers involved in the EUROASPIRE V. In total, 403 patients chosen from the POLASPIRE survey contributed to the Polish subset of the EUROASPIRE V. The detailed methodology of this survey has been described previously.^14,15 A multicenter cross‑sectional study was conducted between 2016 and 2017 on Polish patients from 4 geographical areas (Kraków, Katowice, Warszawa, Białystok) and from 14 cardiology departments. For each department, medical records were reviewed retrospectively of patients aged between 18 and 80 years who had been hospitalized for 1) coronary artery bypass graft surgery (CABG), 2) elective percutaneous coronary intervention (PCI), 3) acute myocardial infarction (International Classification of Diseases, Tenth Revision codes I21 and I22), or 4) unstable angina. Eligible patients were invited for an interview and follow‑up examination 6 to 18 months after being discharged. In addition to the patients from the EUROASPIRE V database, we also enrolled additional patients from participating centers during the same period, using the same methodology as well as inclusion and exclusion criteria.

All patients provided written informed consent to take part in the study. The study was approved by the local ethics committees in each regional center.

Results

We assessed 1012 patients who were interviewed 6 to 18 months after their index event and who had provided complete information on their participation in CR (Table 1). Of these, women accounted for less than 30% of patients. The median age of patients at the time of hospitalization was 65 years, and the majority of the patients had been hospitalized in teaching hospitals (83%). Almost 40% of the patients had been recruited following elective PCI (n = 377). Other common index events were: non–ST‑segment elevation myocardial infarction (NSTEMI) in 217 patients (21.4%), unstable angina in 215 (21.2%), and ST‑segment elevation myocardial infraction (STEMI) in 160 (15.8%) (Table 1). Overall, one‑third of patients had been referred for a CR program (35.6%), and 76.1% of these completed all the recommended sessions.

Physicians were more likely to refer younger than older patients (median [IQR] age, 62 [57–68] years vs 67 [61–72] years, respectively), and employed as compared with unemployed patients (P <⁠0.001) to CR. The rates of CR referral and participation differed considerably between regions (Figure 1). Clinically, the patients referred were more likely to have presented with STEMI (P <⁠0.001), CABG (P <⁠0.001), or hypertension (P <⁠0.001), and were more likely to be taking angiotensin‑converting enzyme (ACE) inhibitors (P <⁠0.001), diuretics (P <⁠0.001), and anticoagulants (P <⁠0.001) at the time of hospital discharge. One‑third of smokers at the time of the index event (35.1%) were referred for CR (P <⁠0.001). Among the patients referred for CR, obese patients were twice as likely to participate in CR (OR, 2.32; 95% CI, 1.07–5) than the nonobese. In addition, a higher level of education was marginally associated with CR participation (OR, 2.05; 95% CI, 0.99–4.27) (Table 2). After PSM, we revealed that patients who participated in CR were 2‑fold more likely to stop smoking (OR, 2.42; 95% CI, 1.33–4.14) and to achieve appropriate glucose control (OR, 1.70; 95% CI, 1.02–2.83) than those who did not participate in CR (Table 3). A marginal improvement was observed in the physical domain of the quality of life score in patients who participated in CR (β coefficient = 0.12; 95% CI, 0.00–0.24). Overall, there were no significant changes in lipid concentrations and systolic blood pressure during follow‑up that were affected by CR (Table 4). We further performed sensitivity analyses to examine the effects of PSM compared to conventional methods, which showed that both produced very similar results.

Discussion

We present several findings of interest regarding CR referrals in Poland. First, the rate of referrals between 2016 and 2017 was relatively low, with only 35.6% of relevant cardiac patients referred for CR. Second, there were significant disparities in CR referral rates between regions, but little or no difference between teaching and nonteaching hospitals. Third, CR was most often recommended for those with acute myocardial infarction (STEMI, 28.9% and NSTEMI, 28.3%). Obesity was a strong predictor of participation in CR. Finally, patients who participated in CR were twice as likely to quit smoking, achieve a favorable glucose concentration, and have an improved quality of life (in the physical domain) than those who did not take part in CR.

The challenge is that, despite growing evidence from meta‑analyses, systematic reviews, and multicenter studies showing that CR improves the prognosis for IHD patients in terms of reduced hospital readmissions, recurrent events, and mortality,^2,20-22 there is still a low acceptance of CR overall in Poland. Our results confirm that there is a huge gap in referrals and enrollments between hospital discharge and participation in CR. Only just over one‑third (35.6%) of study patients were advised to participate in CR after their index cardiovascular event, of whom just under 77% completed full sessions: in other words, fewer than 30% of the study population completed the recommended CR sessions. These Figures on CR participation in Poland are even lower than those in both the EUROASPIRE III and IV reports covering 27 countries in Europe, which similarly showed a low proportion of patients (≤50%) being advised to take part in CR and only around one‑third doing so.^12,13 These differences in participation levels could be due to the patients’ clinical profile, healthcare systems, and the accessibility of CR services in different countries.

Another finding from our study is that CR was most often assigned to patients with acute conditions, particularly those diagnosed with STEMI (65%) or NSTEMI (47%), while the referrals for those who had undergone planned PCI were lower (24.1%). In contrast, a study from the USA using data from the ACTION‑Get registry showed that about 50% of patients were referred for CR overall, with enrollment rates of 84.5% for patients with STEMI, 75.9% for those with NSTEMI, and 60% for those having undergone PCI.²³

In summary, there are significant disparities in the levels of CR referral and participation between the USA, Europe, and specifically Poland. What is not clear is whether these low referral and participation rates are due to low physician awareness of the benefits of CR, limited access to CR facilities, patients declining to participate, or a combination thereof. The fact that CR services after ACS or PCI are covered by the public healthcare system in Poland⁸ makes it all the more surprising that CR has been so underused. One possible explanation is that, as one of the fastest‑aging societies in the EU with 5.9 million people aged 65 years and older,⁷ basic healthcare facilities and hospitals may face problems in managing these large numbers of patients and the costs of treatment involved. As a consequence, hospitals may try to keep the number of admissions and basic health care referrals to a minimum, and prioritize those most in need.⁷ Also, there is evidence that poor uptake of CR may be due to the reluctance of physicians to refer patients, lack of CR facilities, and / or lack of funding.^1,23,24 In Poland, this was the motivation for the introduction of a country‑wide program of managed care after myocardial infarction, including compulsory CR programs.⁵ The hope is that this program will improve communication between physicians and patients, which in turn may improve the uptake of CR as well as optimize secondary prevention.

Further noteworthy observations from our study are that younger, employed, smoking patients, and those on ACE inhibitors were more likely to be advised to take part in CR. Advising patients in employment to participate in CR makes sense since CR can help cardiac patients to improve their condition and quality of life to a point where they can go back to work. Concerning age, physicians are perhaps less inclined to refer the elderly for CR due to frailty and possible difficulties they might face in commuting to the hospital.^5,25 To reduce these age‑related disparities, alternative approaches such as home‑based CR for elderly and frail patients should be considered and ideally included in a country‑wide program.²⁶

Our findings show that more than half of the patients participating in CR were smokers, which is consistent with the results of the EUROASPIRE IV (OR, 1.48; 95% CI, 1.25–1.74). Moreover, those participating in CR were more than twice as likely to give up smoking than nonparticipants. There is previous evidence from landmark trials that smoking may even outweigh the beneficial effects of statins. These studies showed that the risk of mortality observed in nonsmokers not receiving statins was similar to that of smokers on statins.²⁷ Our results and those of others¹³ showing the beneficial impact of CR programs performed in individuals quitting smoking could help boost efforts to encourage more persistent smokers to participate in CR and attend sessions regularly.

Our study confirms positive effects of CR. It showed an approximately 2‑fold reduction of average blood glucose levels (HbA_1c <⁠7%) in those taking part and completing all the sessions. Moreover, patients who participated in CR showed marginal increases in HRQoL in at least 1 domain. This finding is similar to 2 earlier observational studies that reported significant improvements in quality of life at 6‑month²⁸ and 1‑year²⁹ follow‑up. However, neither of these studies adjusted for confounding factors, unlike our study, which applied comprehensive adjustments through the PSM method. Our results therefore provide substantial novel evidence to confirm these findings. However, the observed effects on the attainment of secondary prevention targets are still smaller than expected. We need to search for innovative strategies to improve and sustain the beneficial effects of CR.³⁰

This study is subject to several limitations. The main one is potential recall bias, given that the bulk of data on CR participation and its effects was obtained from patients’ self‑reported questionnaires. Another limitation is that patients volunteered to participate in the study, so individuals more concerned about their health might have been more likely to participate. Finally, since the data was gathered in Poland, the results may not be representative of all countries.

Nonetheless, our findings contribute to the evidence supporting the introduction of the managed healthcare policy for patients with IHD in Poland, which aims to increase CR uptake and participation rates in Poland as well as involving multidisciplinary teams (physicians, nurses, exercise scientists, nutritionists, and psychologists) to improve the prognosis of patients with IHD.^8,21 Our statistical approach, using the PSM method to control confounding variables as well as systematically dealing with missing values using multiple imputations, greatly enhances the statistical power and strength of the study findings, notwithstanding the modest size of the sample groups.