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The scientific evidence for cardiac rehabilitation is strong with reductions in total and cardiac mortality of 13% and 26% respectively in randomised controlled trials comparing rehabilitation to usual care.1 However, this evidence largely pre-dates acute revascularisation, initially by thrombolysis and then angioplasty, and the widespread use of cardioprotective medications, also reducing total mortality.2 So RAMIT (Rehabilitation after myocardial infarction trial) asked the seminal question does cardiac rehabilitation, as provided by the NHS, further reduce total mortality and morbidity and improve health related quality of life in the context of cardiology practice in the late 90s?3 It did not (see page 637).
In this multicentre parallel group trial hospitals already running a cardiac rehabilitation programme, fourteen of them, agreed to randomise patients following myocardial infarction to their own programme or to usual care. These programmes reportedly conformed to guidelines issued by the British Association for Cardiac Rehabilitation and comprised exercise training, health education about heart disease, risk factors and treatment, counselling for recovery and advice for long term secondary prevention.4 Exercise training was described as the largest component using equipment in physiotherapy gyms. The primary endpoint was total mortality at 2 years and a sample size of 8000 patients was required to detect a 20% RR reduction compared to usual care. In the event only 1813 patients were randomised between 1997 and 2000, before the money ran out, with 903 allocated to rehabilitation and 910 to usual care. Baseline characteristics were almost identical. With less than a quarter of patients recruited out of the total originally planned the trial was far too weak to assess the primary endpoint. At 2 years the number of deaths in cardiac rehabilitation and usual care were almost identical. So this complete cohort of trial patients was carefully followed up for all cause …