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Making cardiac rehabilitation more available and affordable
  1. Carl J Lavie,
  2. Sergey Kachur,
  3. Richard V Milani
  1. John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
  1. Correspondence to Dr Carl J Lavie, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA 70121, USA; clavie{at}

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Substantial evidence demonstrates the critical role of cardiac rehabilitation and exercise training (CRET) programmes following major coronary heart disease (CHD) events.1 Although a recent meta-analysis has questioned the impact of CRET on total mortality,2 there is still substantial evidence that this therapy reduces cardiovascular disease (CVD) mortality and improves overall prognosis following major CHD events.1–3 Additionally, this therapy has dramatic effects to improve CHD risk factors, exercise capacity, psychological risk factors associated with higher mortality and overall health-related quality of life (HRQoL).1 3 4

However, as we recently reviewed, the majority of candidates for CRET do not actually attend these programmes,1 4 and greater efforts are needed to make these programmes more available to patients in rural areas, those which transportation or employment issues, as well as efforts to make this therapy even more ‘cost effective’ for our patients.

In their Heart paper, Maddison and colleagues5 from Australia and New Zealand report on a randomised controlled trial of CRET, with telerehabilitation (Remote-CR) and centre-based CRET (Standard-CR) in 162 participants, where exercise capacity or peak oxygen consumption (peak VO2), CHD risk factors, exercise adherence, motivation, HRQoL, and interventions, hospital utilisations and medication costs were all assessed and compared in both groups. After completion of both programmes, most parameters, importantly peak VO2, were similar in both groups, whereas waist and hip circumference was lower in Standard-CR, and Remote-CR patients were less sedentary at 24 weeks. Importantly, per capita programme delivery and medication costs were lower in the Remote-CR patients.

Clearly, the most important parameter would be major CHD events, including CVD, and all-cause mortality, and this study was certainly too small and too short term to assess these major endpoints. However, as we recently reviewed in many studies1 4 and recently demonstrated in over 1100 CR participants,4 improvements in exercise capacity, and specifically peak VO2, corresponded with subsequent prognosis, including all-cause mortality (figure 1). The fact that those in Remote-CR had similar benefits in peak VO2 as did Standard-CR speaks well for the potential of this cost-effective therapy to improve long-term prognosis. However, we have published substantial data that demonstrate the benefits of formal Standard-CR on psychological risk factors, including hostility, anxiety and, especially, depression and total psychological stress, and how this correlates with stress-related reductions in all-cause mortality.1 6 7 Clearly, improvements in peak VO2 strongly predict reductions in depression and depression-related increased mortality rates (figure 2).1 6 7 The fact that Remote-CR produces similar improvements in peak VO2 as did Standard-CR would suggest that similar improvements could occur in psychological risk factors. However, it should be noted that Standard-CR is more than just exercise training; this therapy also includes many educational and teaching sessions, group therapy and social bonding, similar to that performed in many psychiatric therapies.1 6 7 Therefore, although the improvements in psychological risk factors were correlated with improvements in exercise capacity, nevertheless, all patients also received the other non-exercise aspects of Standard-CR. Whether all of the benefits would be similar to Remote-CR was not assessed in the Maddison et al’s5 study, but at least we know HRQoL did at least improve similarly to that with Standard-CR.

Figure 1

Cardiac rehabilitation patients were stratified by absolute improvement in oxygen consumption (VO2) (none, low and high) and adjusted for predictors of mortality show a direct correlation between improvement in VO2 and mortality.4

Regardless of whether Remote-CR is completely equal in all areas to Standard-CR, we already know that so many of our patients in the USA and across the globe are not currently attending and completing formal CRET programmes.1 3 8 Clearly, the current CR model is limited by long commutes, transportation issues, and by infrastructure, capacity and other issues. As we recently reviewed, clearly the ‘one size fits all’ Standard-CR model has limitations and is outdated and will be less effective in the future.3

Figure 2

Prevalence of depression and subsequent mortality based on changes in peak oxygen consumption (VO2) during cardiac rehabilitation and exercise training. *P=0.001 compared with VO2 loss.7 NS, not significant.

Certainly, more comprehensive Remote-CR models, including home, internet and community-based programmes, are needed to provide alternatives to conventional, medically supervised, facility-based Standard-CR.3 The time has come to ‘re-brand and re-invigorate’ CR.1 3 We congratulate Maddison and colleagues5 for providing a good step in the right direction regarding making CRET programmes more available and affordable in the current era.



  • Contributors All authors contributed to the review of the primary paper and literature review and were part of the Original Ochsner studies discussed; this is a Review/Editorial, but all authors reviewed and edited the manuscript and approved the final paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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