Delayed Post CABG Cardiac Rehabilitation Associated With Worse Outcomes

Susan Marzolini, R.Kin, PhD Scientific Associate, TRI-REPS Supervisor Toronto Rehab/UHN Cardiovascular Prevention and Rehabilitation Program

Dr. Marzolini Interview with:
Susan Marzolini, R.Kin, PhD
Scientific Associate, TRI-REPS Supervisor
Toronto Rehab/UHN Cardiovascular Prevention and Rehabilitation Program

Medical Research: What is the background for this study? What are the main findings?

Dr. Marzolini: Coronary artery bypass graft (CABG) surgery is a leading revascularization procedure for treating coronary artery disease. Despite effective revascularization, cardiovascular risk factor control through intensive lifestyle and pharmacological treatment is essential to prevent graft deterioration and progression of atherosclerosis following surgery. Outpatient cardiac rehabilitation (CR) programs offer structured exercise, education, interdisciplinary support, counselling, and risk reduction to promote secondary prevention. These programs have been shown to improve fitness, psychosocial well-being, and significantly reduce morbidity and mortality after CABG surgery.

However, while Canadian and international guidelines endorse “early” referral to CR post-cardiac event, actual practice is variable and delays are common_ENREF_9_ENREF_9_ENREF_7. Delayed entry is of concern, as there is emerging evidence that later referral and initiation of cardiac rehabilitation is associated with negative consequences on cardiovascular fitness, however this has not been examined in the post-CABG population. Therefore, we conducted a retrospective analysis of 6497 consecutively enrolled post CABG participants in a single cardiac rehabilitation program in Toronto, Canada from January 1995 to October 2012. Our objective was to examine the effects of later entry on CR outcomes (i.e., CR use, anthropometrics, and functional capacity) while accounting for demographic, environmental, and physiological correlates of longer wait-time.

We found that longer wait-time to start a cardiac rehabilitation program was associated with poorer outcomes including less improvement in cardiopulmonary fitness and lower program attendance, which have been shown to confer a mortality disadvantage. Longer wait time was also associated with less improvement in body fat percentage as well as poorer completion rates. We identified that bypass patients predisposed to longer wait times, and subsequently poorer participation and outcomes, are women, those who are older, from a lower socioeconomic neighborhood, people with a more complex medical history, who are employed, have a longer drive-time to cardiac rehabilitation, and people with less social support.

Medical Research: What should clinicians and patients take away from your report?

Dr. Marzolini: Policies to initiate cardiac rehabilitation referral from the acute care setting and to begin exercise training within 60 days of hospitalization are recommended to optimize the benefit derived from cardiac rehabilitation. Also, the disparities identified necessitate efforts to expedite initiation of cardiac rehabilitation for socially-vulnerable individuals by both hospital and CR staff. Patients should be informed early of the options available in cardiac rehabilitation programs such as home program (off site) models, evening class options, classes specific for women, social support workshops, transportation alternatives, as well as offering early telephone contact with a CR social worker for financial, transportation, and social support consultation that may help to expedite patient access to cardiac rehabilitation. These options are typically presented later, at the time of the first cardiac rehabilitation visit.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Marzolini: While we cannot generalize the results of this study yet, the results offer a starting point to explore the impact of cardiac rehabilitation delays on a larger scale, find methods to integrate the socially vulnerable earlier, and continue to examine cardiac rehabilitation wait times for other cardiac patient population. Unfortunately, examining the effect of early access clinics may not be efficacious as socially-vulnerable patients would be less likely to attend these for the same reason(s) that delay them starting cardiac rehabilitation.


AHA publication:

Delays in Referral and Enrolment Are Associated With Mitigated Benefits of Cardiac Rehabilitation After Coronary Artery Bypass Surgery
Susan Marzolini, Chris Blanchard, David A. Alter, Sherry L. Grace, and Paul I. Oh

Circ Cardiovasc Qual Outcomes.2015;CIRCOUTCOMES.115.001751published online before print November 10 2015, doi:10.1161/CIRCOUTCOMES.115.001751

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Susan Marzolini, R.Kin, PhD (2015). Delayed Post CABG Cardiac Rehabilitation Associated With Worse Outcomes