Predictors of Early and Late Enrollment in Cardiac Rehabilitation, Among Those Referred, After Acute Myocardial Infarction

Study Questions:

What are the potential barriers to participation, and the prevalence of, and patient-related factors associated with cardiac rehabilitation (CR) participation within 1 and 6 months after an acute myocardial infarction (AMI)?


A total of 2,096 AMI patients were enrolled from 19 US sites in the PREMIER (Prospective Registry Evaluating Outcomes after Myocardial Infarction: Events and Recovery) registry in 2003-2004. Analyses were limited to those patients referred for CR at the time of AMI hospitalization. A multivariable, conditional logistic regression model, stratified by hospital, was used to identify sociodemographic, comorbidity, and clinical factors independently associated with CR participation within 1 and 6 months of AMI hospital discharge.


Mean age was 60 years and 70% were male. Only 29% (419/1,450) and 48.25% (650/1,347) of AMI patients who received referral for CR participated within 1 and 6 months after discharge, respectively. Women (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.44-0.86), uninsured (OR, 0.39; 95% CI, 0.21- 0.71), and patients with hypertension (OR, 0.58; 95% CI, 0.43-0.78) and peripheral arterial disease (OR, 0.43; 95% CI, 0.22-0.85) were less likely to participate at 1 month. At 6 months after AMI, older patients (OR, 0.85 for each 10-year increment; 95% CI, 0.74-0.97), smokers (OR, 0.59; 95% CI, 0.44-0.80), and patients with economic burden (OR, 0.56; 95% CI, 0.38-0.81) were less likely to participate. Caucasians (OR, 1.73; 95% CI, 1.16-2.58) and educated patients (OR, 1.81; 95% CI, 1.42-2.30) were more likely to participate at 6 months. Patients with previous percutaneous interventions were less likely to participate at both 1 and 6 months post-AMI.


Among patients referred for CR post-AMI, participation remains low both at 1 and 6 months after AMI. Because CR is associated with beneficial changes in cardiovascular risk factors and better outcomes after AMI, more aggressive efforts are needed to increase CR participation after referral.


The 20-40% relative risk reduction in mortality associated with CR equals or exceeds that obtained from evidence-based treatments of acute coronary syndrome (ACS) including statins and beta-blockers. The American College of Cardiology/American Heart Association guidelines consider CR a Class I indication after ACS, percutaneous coronary intervention, coronary artery bypass grafting, and stable angina. Despite the endorsement of such guidelines, only 14-30% of eligible US patients recovering from a cardiovascular event participate in CR. While inadequate referral remains a major issue, only about 4 in 10 patients referred participated in this study from 2003-2004. Many health insurers have made CR referral a metric for quality. Improving subsequent participation in CR will be difficult considering the relatively poor compliance with prevention efforts, but this study provides good data to help providers focus on those least likely to participate.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Vascular Medicine, Hypertension, Chronic Angina

Keywords: Odds Ratio, Myocardial Infarction, Acute Coronary Syndrome, Insurance Carriers, Angina, Stable, Hydroxymethylglutaryl-CoA Reductase Inhibitors, European Continental Ancestry Group, Comorbidity, Peripheral Arterial Disease, Risk Factors, Percutaneous Coronary Intervention, Prevalence, Registries, Medically Uninsured, Cardiovascular Diseases, Confidence Intervals, Tobacco Use Disorder, Coronary Artery Bypass, Hypertension, United States, Logistic Models

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