RAMIT explored the effect of a phase II outpatient-based cardiac
rehabilitation (CR) concept. The authors reported no effect on mortality,
cardiac or psychological morbidity, risk factors, health-related quality
of life or physical activity of a comprehensive CR programme after
myocardial infarction. However, to our opinion these findings cannot be
generalized and merit an in-depth critical analysis. In many European
countries a residential CR programme starts within weeks after myocardial
infarction. After 3-4 weeks of intense residential CR (physical training ~
3-4 hrs/week) patients are offered to participate in an outpatient CR
programme for additional 8-12 weeks. The intensity of the physical
activity is essential for the success of a CR programme. In the RAMIT
trial the minimum CR duration was 10 hours, which included exercise as
well as education and counseling. In fact, the mean CR duration was 20
hours within 6-8 weeks. This comprised approximately 10 hours of exercise
training per patient. According to current recommendations an appropriate
combination of endurance and resistance training seems crucial for
effective CR. Hence, most guidelines recommend a minimum of 30 minutes of
moderate exercise training per day at least five days per week. 1, 2 The
lack of detailed information on resistance/endurance units and the well
known dose-response relation of physical activity on cardiovascular risk
reduction, rises the question whether the negative results of RAMIT may
merely reflect an insufficient amount of physical exercise. 3 4 The
somehow unexpected lower physical activity in the CR patients compared to
the control group questions the motivational effect of physical activity
counseling during CR. The benefit of regular exercise was shown in several
trials and a recent meta-analysis showed a significant reduction in all
cause-mortality.4
Moreover, the all-cause mortality in the RAMIT trial was 6% in the CR and
5.2% in the control arm, which seems rather high for this population
compared to other trials. Myers et al. and Hammil et al. reported an
average annual mortality rate of 2.6% and 2.2% for a comparable CR
population, again with a dose-dependent response/behavior.4,5
Nonparticipants, however, showed similar mortality rates compared to RAMIT
patients. A potential explanation for the high mortality despite CR
participation may reflect a suboptimal medical therapy with lower
adherence to statins or ACE inhibitors as compared to the EUROASPIRE III
registry.6 Finally, the author?s conclusion with such potential clinical
implication should not be based on an underpowered, although well-designed
study, as the initial sample size calculation was 8000 patients with final
inclusion of only 1813 patients in the randomised arm.
References:
1. Smith SC, Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA,
Franklin BA, et al. AHA/ACCF Secondary Prevention and Risk Reduction
Therapy for Patients with Coronary and other Atherosclerotic Vascular
Disease: 2011 update: a guideline from the American Heart Association and
American College of Cardiology Foundation. Circulation 2011;124(22):2458-
73.
2. Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D,
et al. Secondary prevention through cardiac rehabilitation: from knowledge
to implementation. A position paper from the Cardiac Rehabilitation
Section of the European Association of Cardiovascular Prevention and
Rehabilitation. European journal of cardiovascular prevention and
rehabilitation : official journal of the European Society of Cardiology,
Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation
and Exercise Physiology 2010;17(1):1-17.
3. Sattelmair J, Pertman J, Ding EL, Kohl HW, 3rd, Haskell W, Lee IM. Dose
response between physical activity and risk of coronary heart disease: a
meta-analysis. Circulation 2011;124(7):789-95.
4. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE.
Exercise capacity and mortality among men referred for exercise testing.
The New England journal of medicine 2002;346(11):793-801.
5. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between
cardiac rehabilitation and long-term risks of death and myocardial
infarction among elderly Medicare beneficiaries. Circulation
2010;121(1):63-70.
6. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U.
Cardiovascular prevention guidelines in daily practice: a comparison of
EUROASPIRE I, II, and III surveys in eight European countries. Lancet
2009;373(9667):929-40.
Conflict of Interest:
None declared
RAMIT explored the effect of a phase II outpatient-based cardiac rehabilitation (CR) concept. The authors reported no effect on mortality, cardiac or psychological morbidity, risk factors, health-related quality of life or physical activity of a comprehensive CR programme after myocardial infarction. However, to our opinion these findings cannot be generalized and merit an in-depth critical analysis. In many European countries a residential CR programme starts within weeks after myocardial infarction. After 3-4 weeks of intense residential CR (physical training ~ 3-4 hrs/week) patients are offered to participate in an outpatient CR programme for additional 8-12 weeks. The intensity of the physical activity is essential for the success of a CR programme. In the RAMIT trial the minimum CR duration was 10 hours, which included exercise as well as education and counseling. In fact, the mean CR duration was 20 hours within 6-8 weeks. This comprised approximately 10 hours of exercise training per patient. According to current recommendations an appropriate combination of endurance and resistance training seems crucial for effective CR. Hence, most guidelines recommend a minimum of 30 minutes of moderate exercise training per day at least five days per week. 1, 2 The lack of detailed information on resistance/endurance units and the well known dose-response relation of physical activity on cardiovascular risk reduction, rises the question whether the negative results of RAMIT may merely reflect an insufficient amount of physical exercise. 3 4 The somehow unexpected lower physical activity in the CR patients compared to the control group questions the motivational effect of physical activity counseling during CR. The benefit of regular exercise was shown in several trials and a recent meta-analysis showed a significant reduction in all cause-mortality.4 Moreover, the all-cause mortality in the RAMIT trial was 6% in the CR and 5.2% in the control arm, which seems rather high for this population compared to other trials. Myers et al. and Hammil et al. reported an average annual mortality rate of 2.6% and 2.2% for a comparable CR population, again with a dose-dependent response/behavior.4,5 Nonparticipants, however, showed similar mortality rates compared to RAMIT patients. A potential explanation for the high mortality despite CR participation may reflect a suboptimal medical therapy with lower adherence to statins or ACE inhibitors as compared to the EUROASPIRE III registry.6 Finally, the author?s conclusion with such potential clinical implication should not be based on an underpowered, although well-designed study, as the initial sample size calculation was 8000 patients with final inclusion of only 1813 patients in the randomised arm.
References:
1. Smith SC, Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124(22):2458- 73. 2. Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology 2010;17(1):1-17. 3. Sattelmair J, Pertman J, Ding EL, Kohl HW, 3rd, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation 2011;124(7):789-95. 4. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. The New England journal of medicine 2002;346(11):793-801. 5. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010;121(1):63-70. 6. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009;373(9667):929-40.
Conflict of Interest:
None declared