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To the Editor we read with interest, but also great concern, the paper by West, et al1 on their multi-centre randomised cardiac rehabilitation study, suggesting negligible results. This study was covered in the Belgian press and already led to questions about further reimbursement of such multi- disciplinary programs.
We agree that re-evaluation of cardiac rehabilitation in the era of early revascularisation and thoroughly changed secondary prevention, is timely.
However, this study does not involve a standard exercise training component. Patients only trained once a week or biweekly; this is nowhere near the general recommendations for physical activity in primary or secondary prevention. Intensity, modality and duration of training sessions are not described, and exercise testing pre and post rehabilitation to assess treatment effect is lacking. Also, significantly fewer patients were exercising after 1 year, suggesting exercise underdosage.
We disagree with their presumption that improved secondary prevention precludes multi-disciplinary rehabilitation programs. The recently published EUROASPIRE III showed that cardiovascular prevention is still poorly implemented in daily practice. West et al themselves reported a suboptimal preventive approach; only 54–62% of patients were taking a statin or beta-blocker at follow-up.
The authors also failed to mention two recent studies demonstrating that cardiac rehabilitation led to a 45% reduction in long-term mortality in a registry of 2395 post-PCI patients.2 In a registry of 18 809 patients with acute coronary syndrome, failure to comply with lifestyle and exercise recommendations was associated with an early almost fourfold increased risk of adverse cardiovascular events.3 These patients were extremely well treated in terms of pharmacological prevention. The authors also concluded that cardiac rehabilitation had no effect on psychological morbidity or quality of life, but generic measures, such as the SF36, may have lacked sensitivity to detect actual changes in patient-reported outcomes. Previous work has shown that cardiac rehabilitation has a significant beneficial effect on psychological morbidity.4
To our opinion, the most important conclusion from this study is incorporated in the last line of the abstract; maybe it is time to re- think cardiac rehabilitation in the UK.
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