The correct answer is: D. Patients after acute coronary syndrome (ACS) should be referred to CR.

ACS is a Class 1A indication for CR and is included in the American Heart Association and American College of Cardiology guidelines¹ as a validated secondary prevention method for CVD. There have been multiple studies that have shown improved outcomes when patients undergo CR. Answer A is incorrect because there are limited data in patients post-transcatheter aortic valve replacement. Conceivably, this may be a population that would benefit from CR, but this has yet to be proven. Answer B is incorrect because although CR is underused in general, it is more underused among women than men. Answer C is incorrect because although the nature of the CR facility is important, patient factors play a key role in the success of CR. Patient involvement and motivation are key factors contributing to the success of CR. Answer E is incorrect because heart failure with preserved ejection fraction is not a Class I indication for CR. Again, patients with heart failure with preserved ejection fraction may experience benefit from CR, but this has yet to be studied in large clinical trials and is currently not an approved indication for CR.

Thus, our case is that of a young Vietnamese female with aggressive, early-onset CVD who was enrolled in CR but, despite this, continued to have uncontrolled hypertension, uncontrolled diabetes, and recurrent coronary lesions requiring PCI. Our patient met criteria for enrollment in CR and was appropriately enrolled after her first cardiovascular event. Despite data suggesting lack of adherence and underutilization in minority females, our patient was adherent with CR yet derived little benefit from it. Her diabetes and hypertension remained poorly controlled despite efforts to implement healthy lifestyle into her routine.

This case illustrates the limitations of CR and the importance of patient engagement and motivation in successfully reaching improvement endpoints. Aggressive risk factor modification is possible in many patients with CR, but there is a subset of patients that may derive little benefit. Cultural barriers when treating patients of different ethnicities must also be considered. For example, the Vietnamese diet is different from that recommended by CR, and there remains room for CR to tailor differing cultural needs. Additionally, in some patients, longer duration or more frequent implementation of CR may be necessary due to varying patient factors including differences in patient engagement and patient health literacy.

References

1. Smith SJ Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124:2458-73.