Cardiac rehabilitation after percutaneous coronary intervention – Evidence and barriers

Naga Venkata K Pothineni; Suhas Gondi; Swathi Kovelamudi

doi:10.4103/hm.hm_10_18

REVIEW ARTICLE

Year : 2018 | Volume : 2 | Issue : 1 | Page : 1-4

Cardiac rehabilitation after percutaneous coronary intervention – Evidence and barriers

Naga Venkata K Pothineni¹, Suhas Gondi², Swathi Kovelamudi³
¹ Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
² Harvard Medical School, Boston, MA, USA
³ Division of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Date of Web Publication

4-Feb-2019

Correspondence Address:
Prof. Naga Venkata K Pothineni
Division of Cardiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #532, Little Rock, AR 72205
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/hm.hm_10_18

Abstract

Cardiac rehabilitation (CR) represents a spectrum of interventions that influence physical, mental, and social well-being of an individual. These interventions can range from dietary counseling to intense physical activity. The role of CR in various cardiac disorders, particularly ischemic heart disease, has been well established across multiple studies. However, real-world utilization of CR still seems to lag behind. As coronary intervention modalities keep evolving with increasing number of patients receiving percutaneous coronary intervention, there is a need for reappraisal of the role of CR in this population. In this review, we discuss data behind the benefit of CR in patients with ischemic heart disease and highlight the barriers encountered in implementing CR in real-world practice.

Keywords: Cardiac rehabilitation, health policy, percutaneous coronary intervention

How to cite this article:
Pothineni NV, Gondi S, Kovelamudi S. Cardiac rehabilitation after percutaneous coronary intervention – Evidence and barriers. Heart Mind 2018;2:1-4

How to cite this URL:
Pothineni NV, Gondi S, Kovelamudi S. Cardiac rehabilitation after percutaneous coronary intervention – Evidence and barriers. Heart Mind [serial online] 2018 [cited 2023 Jun 10];2:1-4. Available from: http://www.heartmindjournal.org/text.asp?2018/2/1/1/251479

Introduction

Coronary heart disease remains a major cause of mortality and morbidity worldwide. Based on the recent heart disease and stroke statistics published by the American Heart Association (AHA), it is estimated that 16.5 million Americans ≥20 years of age have coronary heart disease and approximately 335,000 Americans are expected to have a recurrent event.^[1] As techniques to diagnose and manage coronary disease continue to improve, strategies to decrease the recurrence of disease are increasingly relevant. These strategies are particularly important given the significant burden placed on the healthcare delivery system of managing patients with recurrent acute coronary syndromes and angina symptoms. Cardiac rehabilitation (CR) in patients with a prior history of myocardial infarction (MI) is one intervention that has shown promise in this area as a tertiary prevention strategy. In this review, we discuss the evidence for the benefits of CR in patients who undergo percutaneous coronary intervention (PCI) and explore practical issues pertaining to the implementation of CR in this patient population.

What Does the Evidence Say?

CR is a multidisciplinary program of exercise training, risk factor modification, and psychosocial counseling that reduces mortality and hospitalizations and improves the quality of life in patients with heart disease. Interventions included in CR span a wide spectrum, including simple exercises, intensive supervised exercise training, and dietary monitoring. Early studies of CR in patients with cardiovascular (CV) disease primarily focused on patients with heart failure (HF). More recent studies shed light on the role of CR in other patient populations with ischemic heart disease. Even among those with ischemic heart disease, the bulk of the evidence supporting the use of CR was derived from patients undergoing surgical revascularization. Only a few studies have specifically evaluated the role of CR post-PCI.

In the early days of coronary intervention, before stents were widely used and balloon angioplasty was the primary mode of coronary intervention, there was a considerable interest in CR for secondary and tertiary prevention. The exercise training intervention after coronary angioplasty randomized trial found that exercise training was associated with a decreased 3-year incidence of major adverse CV events including MI, PCI, coronary artery bypass graft (CABG) or death, and hospital admissions after PCI.^[2] This study was published in 2001. Since then, coronary interventions have advanced, with a significant increase in the utilization of stents for PCI. Despite advancements in coronary care, the incremental benefit of CR remained an area of interest, with more recent evidence pointing toward benefits. In an observational study of Medicare patients undergoing PCI, Suaya et al. reported a 30% relative reduction in all-cause mortality with CR compared to standard of care.^[3] However, the rate of use of CR in the entire cohort of Medicare beneficiaries in this study was only 12.2%. Similar findings were reported by Dendale et al. In their study of 223 patients who underwent CR following PCI, a significant reduction was noted in revascularization rates and 15-month incidence of major adverse CV events, including MI, revascularization, recurrent stenosis, recurrent angina, and death, in CR participants compared with patients who did not participate in CR. However, they did not find a reduction in the rate of recurrent MI.^[4] In a large observational study of >2000 participants from Olmsted County, Goel et al. found that CR participation after PCI was associated with a significant reduction in mortality rates. They reported a 45%–47% decrease in all-cause mortality in patients who participated in CR after PCI compared with those who did not participate in CR. This benefit of CR was similar for men and women, for older and younger patients, and for patients undergoing elective or emergent PCI. Interestingly, there was no difference in the rates of subsequent MI or coronary revascularization between the CR and standard of care groups, despite a huge mortality benefit.^[5] Similar results were found in a Cochrane database review published in 2011. In this pooled analysis, exercise-based CR was shown to reduce overall and CV mortality (relative risk [RR] 0.87 [95% confidence interval (CI) 0.75, 0.99] and 0.74 [95% CI 0.63, 0.87], respectively) and hospital admissions (RR 0.69 [95% CI 0.51, 0.93]). However, there was no significant improvement in the rates of recurrent MI or coronary revascularization.^[6] It is important to note that this meta-analysis included patients who underwent both percutaneous and surgical coronary revascularization. In a similar updated meta-analysis of 63 randomized trials of CR in all comers with coronary heart disease, Anderson et al. reported a reduction in pooled CV mortality (10.4%–7.6%; number needed to treat: 37) and hospital admission rate (30.7%–26.1%; number needed to treat: 22) with exercise-based CR compared with no exercise control participants. Again, there was no between-group difference in the risk of fatal or nonfatal MI or subsequent revascularization.^[7] In a recent randomized trial of ST-elevation myocardial infarction (STEMI) patients postemergent PCI, Zhang et al. reported a significant improvement in exercise capacity, quality of life, and even left ventricular ejection fraction in patients randomized to receive CR postdischarge.^[8] However, this was a small trial with only 60 participants in each group to analyze multiple outcomes. Finally, a meta-analysis reported pooled outcomes of CR specifically in patients post-PCI. This study included data from six randomized trials with a total of 682 patients. In this analysis of studies, exercise was not clearly associated with reductions in cardiac death, the recurrence of MI, repeated PCI, CABG, or restenosis. However, exercise was found to improve recurrent angina, total exercise time, angina, and maximum exercise tolerance after PCI.

A review of currently available evidence points toward improved symptoms, quality of life, and exercise capacity with CR in patients postcoronary intervention. There is no evidence pointing toward a reduction in recurrent MI episodes of subsequent revascularization in this patient population. However, CR appears to be associated with an overall reduction in CV mortality in patients with coronary heart disease. This raises an interesting question regarding the mechanism of mortality reduction without significant effect on recurrent infraction.

It appears that the effect of exercise therapy and rehabilitation leads to a healthier state of living that affects overall clinical outcomes in a broader sense than just improvement in specific cardiac endpoints. Patients who participate in CR have been shown to be more careful regarding dietary restrictions, medication compliance, and healthcare follow-ups. This may be a factor leading to improved overall outcomes and quality of life despite a lack of specific effect on the rate of recurrent MI and revascularization. A second major beneficial effect of CR post-PCI is improved symptoms and quality of life.

What Do the Guidelines Say?

Guidelines produced and published jointly by the American College of Cardiology (ACC) Foundation and the AHA consistently recommend CR as part of follow-up care after a MI. In the case of STEMI, the recent updated European Society of Cardiology guidelines recommend exercise-based CR as a Class I recommendation for posthospitalization plan of care (Level of Evidence: A).^[9] Similarly, the ACC/AHA guidelines recommend that all eligible patients with non-ST-elevation acute coronary syndromes should be referred to a comprehensive CV rehabilitation program either before hospital discharge or during the first outpatient visit.^[10] These guidelines are based on cumulative evidence of the benefits of rehabilitation.

Barriers to Cardiac Rehabilitation in Practice

In spite of these guidelines, referral and participation rates for CR programs are consistently lower than the number of patients whom the literature suggests would benefit. A 2007 analysis of Medicare claims data concluded that CR use is relatively low among Medicare beneficiaries, finding that CR was used in 13.9% of patients hospitalized for acute MI and 31.0% of patients who underwent CABG surgery, with significant state-to-state variation.^[11] Other studies have found similarly low participation rates.^{[12],[13],[14],[15]}

Factors contributing to these low participation rates include lack of accessibility to program sites, low patient referral rate, and cost.^[16],[17] Demographic features such as age and race also appear to influence referral rates to CR. One study found that some populations are significantly less likely to use CR, including older individuals, women, nonwhites, and patients with comorbidities including congestive HF, previous stroke, diabetes mellitus, or cancer.^[14] These disparities need to be probed further, but may be due to differences in referral rates, geographic distribution, and insurance coverage. A more important factor affecting referral to CR post-PCI is hospital characteristics. In a recent analysis using PCI and CABG databases from the state of Washington, Beatty et al. reported that referral to CR at discharge was higher after cardiac surgery than after PCI and that the strongest predictor of referral to CR at discharge was the hospital in which the procedure was performed.^[18] This finding speaks to the importance of variations in referral practices among physicians and in systems of care for the management of post-MI patients. The availability of appropriate referral facilities may also play a critical role in these disparities. From a practical standpoint, the availability of a designated CR facility and ease of referrals is a critical factor determining the rate of referrals for CR. This presents an opportunity to improve CR referral rates by designing systems where the referral process is streamlined and less burdensome on providers to improve CR referral rates.

Lack of insurance coverage has in the past been cited as a reason why many patients who could benefit from CR after a PCI do not get it.^[16] However, Medicare decided to cover CR as part of the Part B benefit in 2006, and many commercial insurers likely followed suit.^[19] Currently, Medicare policy is to cover comprehensive CR programs administered in hospital outpatient settings or a physician's office that include exercise, education, and counseling, as well as what Center for Medicare Services defines as intensive CR programs that are more rigorous or more intense than regular CR programs. Importantly, Part B coverage is contingent upon one of the following: a heart attack in the last 12 months, CABG, current stable angina pectoris, a heart valve repair or replacement, a coronary angioplasty or coronary stent, a heart or heart–lung transplant, or stable chronic HF. While Medicare coverage increases the affordability of CR, it does not remove financial barriers since patients are still liable for 20% co-pay and their Part B deductible applies. Private payers generally also cover CR; however, data are sparse for coverage specifically post-PCI. In the case of HF, though, 83% of insurance companies reported that they cover CR for patients with any type of HF.^[20] According to the AHA, most insurers cover CR post-MI.

Recent reporting from a Kaiser Health News investigation into the availability and affordability of CR sheds light on some of the ongoing barriers to the expansion of CR to more patients.^[21] Barriers highlighted in their 2016 report include insurance coverage, high co-pays, not being referred to CR, not being aware of CR, paucity of facilities in local area, transportation, not being able to attend during work hours, and reluctance to exercise. For those patients enrolled in traditional Medicare, the co-pay is approximately $20 per se ssion, with sessions often occurring 2–3 times per week. For those enrolled in Medicare Advantage plans and privately insured, the co-pay can be up to $60 per visit. The move toward high-deductible plans and increased cost sharing with enrollees likely further increases the financial burden borne directly by patients.

The lack of accessible facilities for CR in many geographic areas is another key barrier. A 2014 study determined that, while national CR utilization in 2012 was 28% of eligible patients, even with modest expansion of all existing programs operating at capacity, a maximum of 47% of qualifying patients nationwide could participate in existing CR programs.^[22] The authors pointed to facility restraints and staffing shortages as key reasons why there is insufficient capacity to meet our national needs. Patients who live far from facilities face greater barriers with respect to time and transportation costs, potentially explaining a fraction of the underutilization of CR.

Conclusion

CR is an important therapeutic intervention in post-MI and post-PCI patients. There is ample evidence pointing toward a benefit regarding the quality of life, symptom improvement, exercise capacity, overall well-being, and even mortality. There is no evidence thus far that CR leads to a reduction in the rates of recurrent MI or coronary revascularization. Despite proven benefit and strong guideline recommendations regarding CR, referral rates for CR overall have been disappointing. A myriad of practical issues, some patient related and others system related, are responsible for this. Healthcare provider education and streamlining referral processes across various health systems are pivotal in improving the utilization of CR postcoronary interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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