Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome

Abstract

Purpose: Cardiac rehabilitation after acute coronary syndrome is an important but underused therapeutic intervention. The aim of the French nationwide PREVENIR survey was to improve knowledge on the management of cardiovascular risk factors, especially during cardiac rehabilitation after acute coronary syndrome. The purpose of this study was to specify the characteristics of patients referred to cardiac rehabilitation.

Methods: The survey was performed in 77 of 501 (15.4%) public or private French coronary care units. All French regions were involved. All the patients admitted to the hospital during January 1998 who survived an acute coronary syndrome were included in the survey. Data on rehabilitation practice were collected from patient medical records, either during an outpatient consultation or from the patient and the general practitioner during the 6-month follow-up period.

Results: Of the 1394 patients included in the study (779 with myocardial infarction and 615 with unstable angina), only 310 (22%) underwent cardiac rehabilitation. Significant differences in patient characteristics were found between the cardiac rehabilitation and non-cardiac rehabilitation groups, respectively, in terms of gender (82% male vs 68%; P <.001), age younger than 65 years (56% vs 39%; P <.001), type of acute coronary syndrome (75% myocardial infarction vs 50%; P <.001), left ventricular ejection fraction less than 35% (6% vs 13%; P <.0004), and prevalence of percutaneous intervention (54% vs 46%; P <.02). Two risk factors were more common in the rehabilitated group: dyslipidemia (52% vs 44%; P <.02) and current smoking (51% vs 37%; P <.0001). In the multivariate analysis, female gender (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.44-0.87) and older age (>75 years vs. <65 years; OR, 0.40; 95% CI, 0.3-0.7) predicted decreased cardiac rehabilitation prescription. Conversely, previous history of dyslipidemia (OR,1.4; 95% CI, 1.04-1.8), post-myocardial infarction (OR, 2.8; 95% CI, 2.13-3.89), and a percutaneous intervention (OR,1.9; 95% CI, 1.3-2.7) predicted increased cardiac rehabilitation prescription. Severe left ventricular impairment (< or =35% vs >50%) was not an independent factor for cardiac rehabilitation prescription. At 6-month follow-up assessment, rehabilitation patients had a lower rate of hypertension (18% vs 27%), elevated low-density lipoprotein cholesterol (54% vs 62%), and continued smoking (34% vs 50%).

Conclusions: The results of the PREVENIR survey underscore the low level of cardiac rehabilitation prescription in France, and the relative exclusion of women and elderly people. Among the risk factors, dyslipidemia and current smoking are more frequent among rehabilitated patients. These findings may help to modify the strategy for using cardiac rehabilitation after acute coronary syndrome, although it is an effective intervention for secondary prevention.