Cardiac Rehabilitation and Survival in Older Coronary Patients

Objectives This study assessed the effects of cardiac rehabilitation (CR) on survival in a large cohort of older coronary patients. Background Randomized controlled trials and meta-analyses have shown that CR improves survival. However, trial participants have been predominantly middle-aged, low-or moderate-risk, white men. Methods The population consisted of 601,099 U. S. Medicare beneficiaries who were hospitalized for coronary conditions or cardiac revascularization procedures. One-to 5-year mortality rates were examined in CR users and nonusers using Medicare claims and 3 analytic techniques: propensity-based matching, regression modeling, and instrumental variables. The first method used 70,040 matched pairs, and the other 2 techniques used the entire cohort. Results Only 12.2% of the cohort used CR, and those users averaged 24 sessions. Each technique showed significantly lower (p < 0.001) 1- to 5-year mortality rates in CR users than nonusers. Five-year mortality relative reductions were 34% in propensity-based matching, 26% from regression modeling, and 21% with instrumental variables. Mortality reductions extended to all demographic and clinical subgroups including patients with acute myocardial infarctions, those receiving revascularization procedures, and those with congestive heart failure. The CR users with 25 or more sessions were 19% relatively less likely to die over 5 years than matched CR users with 24 or fewer sessions (p < 0.001). Conclusions Mortality rates were 21% to 34% lower in CR users than nonusers in this socioeconomically and clinically diverse, older population after extensive analyses to control for potential confounding. These results are of similar magnitude to those observed in published randomized controlled trials and meta-analyses in younger, more selected populations. (J Am Coll Cardiol 2009; 54: 25-33) (C) 2009 by the American College of Cardiology Foundation