Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease.

AIMS: Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR. METHODS: We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis. RESULTS: Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < .0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant. CONCLUSIONS: Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.

Cardiometabolic responses to cardiac rehabilitation in people with and without diabetes.

BACKGROUND: Type 2 diabetes and cardiometabolic comorbidities manifesting as the metabolic syndrome (MetS) are highly prevalent in coronary heart disease (CHD) patients attending cardiac rehabilitation (CR). The study aimed to determine the prevalence of cardiometabolic derangements and MetS, and compare post-CR clinical responses in a large cohort of CHD patients with and without diabetes. METHODS: Analyses were conducted on 3953 CHD patients [age: 61.1 ±â€¯10.5 years; 741 (18.7%) with diabetes] that completed a representative 12-week CR program. A propensity model was used to match patients with diabetes (n = 731) to those without diabetes (n = 731) on baseline and clinical characteristics. RESULTS: Diabetic patients experienced smaller improvements in metabolic parameters after completing CR, including abdominal obesity, and lipid profiles (all P ≤ .002), compared to non-diabetic patients. For both groups, there were similar improvement rates in peak metabolic equivalents ([METs]; P < .001); however, peak METs remained lower at 12-weeks in patients with diabetes than without diabetes. At baseline, the combined prevalence of insulin resistance (IR) and diabetes was 57.3%, whereas IR was present in 48.2% of non-diabetic patients, of which rates were reduced to 48.2% and 32.8% after CR, respectively. Accordingly, MetS prevalence decreased from 25.5% to 22.3% in diabetic versus 20.0% to 13.4% in non-diabetic patients (all P ≤ .004). CONCLUSIONS: Completing CR appears to provide comprehensive risk reduction in cardio-metabolic parameters associated with diabetes and MetS; however, CHD patients with diabetes may require additional and more aggressive attention towards all MetS criteria over the course of CR in order to prevent future cardiovascular events.

Cardiac rehabilitation referral, attendance and mortality in women.

BACKGROUND: Cardiac rehabilitation (CR) reduces mortality in women and men with coronary artery disease (CAD). The objective of this study was to examine sex differences in long-term mortality, based on CR referral rates and attendance patterns in a large CAD population. DESIGN: This is a retrospective cohort study. METHODS: The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) and Cardiac Wellness Institute of Calgary (CWIC) databases were used to obtain information on all patients. Rates of referral to and attendance at CR were compared by sex. Logistic regression models were constructed to assess whether sex predicted CR referral or completion. The association between referral, completion, and survival was assessed by sex using Cox proportional hazard models. RESULTS: 25,958 subjects (6374-24.6%-were women) with at least one vessel CAD were included. Females experienced reduced rates of CR referral (31.1% vs 42.2%, p < 0.0001) and completion (50.1 vs 60.4%, p < 0.0001). Adjusting for demographic and clinical characteristics, relative to men, CR referral was significantly lower in women (adjusted odds ratio (OR) 0.74, 95% CI 0.69, 0.79) as was CR completion (adjusted OR 0.73, 95% CI 0.66, 0.81). Women completing CR experienced the greatest reduction in mortality (HR 0.36, 95% CI 0.28, 0.45) with a relative benefit greater than men (HR 0.51, 95% CI 0.46, 0.56). CONCLUSION: This is the first large cohort study to demonstrate that referral to and attendance at CR is associated with a significant mortality reduction in women, comparatively better than that in men.

Patients with diabetes in cardiac rehabilitation: attendance and exercise capacity.

PURPOSE: Diabetes increases mortality after myocardial infarction, but participation in cardiac rehabilitation (CR) reduces this risk. Our objectives were to examine whether attendance at CR and changes in cardiorespiratory fitness differed according to diabetic status and sex. METHODS: Retrospective cohort study of patients referred for CR in Calgary between 1996 and 2010. Cardiorespiratory fitness in metabolic equivalents (METs) was estimated by maximal exercise testing at baseline, at the end of the 12-wk CR program, and 1-yr after CR. RESULTS: Among 7036 nondiabetic and 1546 diabetic patients who started, 84.9% of nondiabetic versus 79.5% of diabetic patients completed CR (P < 0.0001). The difference between diabetic and nondiabetic patients was greater in women (81.7% vs 72.1%, P < 0.0001) than that in men (86.0% vs 82.5%, P = 0.004). Patients without diabetes were more likely to return for the 1-yr assessment (53.7% vs 42.7%, P < 0.0001), and nondiabetic women were more likely than diabetic women to attend the 1-yr follow-up (44.3% vs 31.7%, P < 0.0001). Change in cardiorespiratory fitness from baseline to 12 wk was +1.0 METs in nondiabetic men, +0.9 METS in diabetic men, +0.9 METs in nondiabetic women, and +0.7 METs in diabetic women (within-group change; P = 0.0009). Changes in cardiorespiratory fitness at 1 yr compared with baseline were +0.9, +0.6, +0.9, and +0.5 METS, respectively (within-group change, P = 0.0001). CONCLUSIONS: Patients with diabetes, especially females, were less likely than patients without diabetes to complete CR and attend follow-up. Among patients who attended 1-yr follow-up, changes in cardiorespiratory fitness were not as well maintained in diabetic patients as in nondiabetic patients. Identifying barriers and targeting CR adherence interventions to patients with diabetes may help improve outcomes.