To the Editor We, members of the council of the British Association for Cardiovascular Prevention and Rehabilitation, representing over 800 health professionals, strive to ensure that our guidance for cardiac rehabilitation (CR) programmes is based on best evidence. While, the topic of the RAMIT study1 is a welcome one, we have significant concerns about this study and feel the authors have made judgements that we do not believe can be supported. Our concerns are outlined within this letter.

First, in the opinion of West et al the evidence for the effect of CR on mortality is out of date. However, the authors did not include the systematic review published last year by the Cochrane Heart Group.2 The Cochrane review,2 which included 47 studies with over 10 000 patients, clearly continues to demonstrate that CR reduces death from any cause by 13% and cardiac deaths by 26%. (The West et al study does not report effect on cardiac deaths).

Second, there are substantial omissions from the paper in terms of the study population. The paper purports to follow CONSORT guidelines3 but it does not. We do not know how many programmes were approached to participate, thus we have no idea how representative the study sample was of CR programmes at that time. Additionally, there are no details about the numbers of participants who were approached and the numbers who refused (rather than did not meet the inclusion criteria). The numbers of people recruited per programme were small; 1813 people from 14 centres approximates to 130 people per hospital, over 32 months, so very small numbers per year, only half of which would receive CR. Therefore, we have no real idea of uptake of CR within the hospitals in the study, nor of numbers of people who refused to participate. If large numbers (of programmes and patients) refused to participate then this would mean that the study may not reflect the people who usually attended CR. We also have no idea of how many people in the study completed their full CR programme. Despite numerous requests to the primary author listed for access to the final full report we are yet to receive further details.

Third, it should be noted that the study was carried out over 10 years ago and presents a very traditional viewpoint of CR, during an era associated with gross under-funding of CR in the UK4 and one which preceded the publication of the first BACR Minimum Standards and Core Components (2007).5 These extended the remit of CR beyond ‘exercise, education and relaxation’ and presented modern CR programmes that encompass smoking cessation, diet and weight management, medical risk factor management, cardioprotective therapies and much more. The recently published second edition of the BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation6 sets out the seven core standards that patients, health care professionals and commissioners should expect from a high quality modern cardiac rehabilitation programme. This publication does not adequately describe these programmes in any detail so we have no real idea of either their standard or their homogeneity.

Lastly, there are significant discrepancies in the study results when compared to the findings of the National Audit for Cardiac Rehabilitation. In the West et al study, the people who attended CR were exercising less at 12 months than they had been at the start of the programme, but year on year the National Audit for Cardiac Rehabilitation consistently reports that patients are doing significantly more exercise 12 months after being referred to CR.7

In the conclusion to the abstract, West et al state “The value of cardiac rehabilitation as practised in the UK is open to question.” It is of course entirely possible that this statement is true but only in reference to practice of CR at that time in those particular centres. Of course all evidence is open to question but these (very dated) study results about which we have considerable reservations should not be used as a basis for decision making regarding the contemporaneous worth of cardiac rehabilitation in the UK.