Authors (including presenting author) :
Lui WC (1)(5), Chow ESL (1)(5), Chu ACK (1)(5), Lee S (1)(5), Tse PMY (1)(5),
Tam RWL (1)(5), Yick HY (1)(5), Ho PY (1)(5), Ching HWA (2), Wan SS (2), Wong MYC (3), Chau KHR (3), Cheung HMS (3), Mak MYM (2), Wong YY (1)(5), Cheung JTY (3), YL Cheung (5), Ho V (4), Leung C (4)
Affiliation :
(1) Division of Rehabilitation & Extended Rehabilitation Centre (ERC)
(2) Physiotherapy Department
(3) Occupational Therapy Department
(4) Yan Oi Tong
(5) Department of Medicine and Geriatrics & Tuen Mun Hospital Rehabilitation Center, Tuen Mun Hospital
Introduction :
Cardiac rehabilitation (CRP) is nowadays a standard for patients with stable coronary artery diseases (CAD),
after myocardial infarction (MI), and after revascularization. It includes supervised aerobic exercise training, physical activity counselling and various non-exercise based cardiovascular risk factors management, life style modifications and psychosocial management.
Taking into account of the risk associated with exercise training in cardiac patients, traditionally, the participation of non-government organizations (NGO) in cardiac rehabilitation was mainly limited to the lower-risk non-exercise components.
A unique medical social collaboration model (MSC) of cardiac rehabilitation was implemented in 2004 utilizing the NGO public community gymnasium. Patients suitable for cardiac rehabilitation were first recruited into the traditional hospital-based medically-supervised cardiac rehabilitation program (CRP). Instead of finishing the whole cardiac rehab program in the hospital, after the initial sessions for medical management, the establishment of exercise safety, and non-exercise lifestyle educational interventions, suitable patients were invited to continue their remaining CRP supervised training [by trained personnel] in the partner NGO community gymnasium. Afterwards, patients might further choose to continue their unsupervised life-long exercises in the gymnasium as NGO members with minimal fees and much more flexible opening hours. The model evolved with time.
To the understanding of the authors, this was probably one of the earliest medical-social collaboration models of the comprehensive cardiac rehabilitation program in Hong Kong involving exercises training in a public gymnasium during an earlier stage of CRP.
There was a lack of data on the long-term outcomes of the cardiac rehabilitation program in Hong Kong, especially with such a unique medical-social collaboration model.
Objectives :
The study aimed to study the long-term effects of a unique medical-social collaboration (MSC) model of
comprehensive cardiac rehabilitation program (CRP) in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) in a regional rehabilitation center in Hong Kong.
Methodology :
A retrospective review of a cohort of patients recruited from CRP from 2004 to 2010 was compared to a
cohort of usual care patients during the same period. Data of CAD patients attending the comprehensive CRP after PCI during 2004 - 2010 were retrieved from CDARS. The data were compared with a control group of patients with PCI done in the study hospital during the same period but without participating in CRP.
Exclusion criteria included
1. Non-CAD patients
2. Patients planned for further revascularization procedures within three months after the index PCI
3. History of coronary artery bypass grafting (CABG)
4. Revascularization or death occurred before completion of CRP (defined by the post-CRP treadmill date)
Primary outcomes were defined as the all-cause mortality at 3, 5, 10 years and at the end of the study [a median of 12.4 years].
Secondary outcomes included
1. Cardiovascular (CV)-related mortality,
2. Non-fatal myocardial infarction (MI)
3. Need of revascularization (PCI or CABG) by 5 and 10 years
4. Number of hospitalizations and total hospitalization days in the first year and 5th year
5. Survival rate
Result & Outcome :
Among the 200 CRP participants, 183 patients (91.5%) successfully completed the CRP. After the CRP, there was a mean improvement in exercise capacity (VO2 peak) of 1.72 ± 1.27 METS (p< 0.001), or a 36.6% ± 31.1 % improvement from the baseline.
After a median follow-up period of 12.4 years (IQR 9.7 to 14.0), the all-cause mortality of CRP group was 21.9% (Vs 36.1% in the control group, p=0.01). This accounted for a relative risk reduction (RRR) of 39.3% and an absolute risk reduction (ARR) of 14.2% in all-cause mortality in the CRP group. The corresponding 3, 5 and 10 year all-cause mortality of CRP group were 2.7% (Vs 7.1% in control group, p=0.036), 5.5% (Vs 11.7% in control group, p=0.019) and 14.8% (Vs 28.7% in control group, p< 0.001), respectively. Such risk reduction remained statistically significant at all time points, i.e. in 3, 5, 10 years and till the end of the study.
Concerning the CV related death, there were 15 (8.2%) and 63 (17.2%) CV-related deaths in CRP and control group, respectively, which accounted for a RRR of 52.3% (95%CI 18.7% 72.1%) and an ARR of 9.0% (95%CI 3.5% 14.6%) during the entire study period. Similarly, the protective effects of CRP were also found to last throughout the period of follow-up at 3, 5, 10 years and till the end of the study.
CRP completion was significantly associated with a lower risk of death (adjusted hazard ratio (HR) 0.63, 95%CI 0.44 0.91, p=0.014). The use of beta-blocker at baseline was significantly associated with a lower risk of death, while older age at index PCI, history of diabetes mellitus, and the use of diuretics at baseline had a significant association with an increased risk of death
Throughout the study period, there was no statistical difference in the incidences of non-fatal MI, revascularization, or hospitalization in both group.
Regarding the exercise-related adverse events during cardiac rehabilitation, 1 patient in the CRP group suffered from vasovagal attack during exercise training without any sequelae. There was no other major adverse exercise-related CV event reported during the CRP.
Conclusion
This study provided reassuring evidence that a unique medical-social collaboration model of the comprehensive cardiac rehabilitation program in Hong Kong was feasible, safe, and associated with significant long term
