Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands
Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands
复制标题
DOI：
10.1001/jamanetworkopen.2020.11686
复制
发表时间：
2020-07-27
影响因子：
13.8
通讯作者：
Hopman, Maria T. E.
中科院分区：
文献类型：
--
作者：
Eijsvogels, Thijs M. H.;Maessen, Martijn F. H.;Hopman, Maria T. E.
本队列研究探讨了性别、年龄、社会经济地位、心血管疾病（CVD）诊断、心胸外科手术和合并症对心脏康复参与和全因死亡率之间关系的影响。重要性心脏康复（CR）是改善临床结局的有效策略，但在心血管疾病（CVD）患者的某些亚组中仍未充分使用。目的探讨性别、年龄、社会经济状况、CVD诊断、心胸外科手术和合并症对CR参与率和全因死亡率之间关系的影响。设计、设置和参与者观察性队列研究，患者入组时间为2012年7月1日至2017年12月31日，随访至2020年3月19日。分析日期为二零二零年三月至五月。本研究在患有CVD的荷兰患者中进行，这些患者具有多学科门诊CR计划适应症，并在荷兰最大的健康保险公司之一Cooperperstaff Volksgezondheidszorg投保。在410万受益者中，通过住院诊断代码确定了伴有急性冠状动脉事件（心肌梗死或不稳定型心绞痛）、稳定型心绞痛、慢性心力衰竭或心胸外科手术（冠状动脉旁路移植术、瓣膜置换术或经皮冠状动脉介入治疗）的CVD患者，并将其纳入研究。主要结局和测量考克斯比例风险模型用于评价CR参与率和全因死亡率之间的相关性。使用稳定的反向倾向评分加权来解释与CR参与相关的患者和疾病特征。结果在83687例符合条件的CVD患者中（平均[SD]年龄，67 [12]岁; 60.4% [n = 50512]男性），仅31.3%（n = 26171）参与CR，不同亚组间差异较大（范围，5.1%-73.0%）。在平均（SD）4.7（1.8）年的随访期间，1966名CR参与者（7.5%）和13443名CR非参与者（23.4%）死亡。多变量校正后，与未参与相比，CR参与与全因死亡风险降低32%相关（校正风险比，0.68; 95%CI，0.65-0.71）。性别、年龄、社会经济状况和合并症并没有改变CR参与后的风险降低，但在CVD诊断和心胸外科手术的类别中发现了统计学显著的相互作用。在STEMI患者参与CR治疗后，发现全因死亡率的风险估计值有较大降低（校正HR，0.59; 95% CI，0.52-0.68 vs 0.72; 95% CI，0.65-0.79; P <0.001），NSTEMI（校正HR，0.64; 95% CI，0.58-0.70 vs 0.72; 95% CI，0.65-0.79; P <0.001），AP稳定（校正HR，0.69; 95%CI，0.63-0.76 vs 0.72; 95%CI，0.65-0.79; P <0.001），而不稳定AP的风险降低较小。（调整后的HR，0.75; 95% CI，0.67-0.85 vs 0.72; 95% CI，0.65-0.79; P <0.001）。结论和相关性在这项队列研究中，CR参与与全因死亡率风险降低32%相关，并且这种益处与性别，年龄，社会经济地位和合并症无关。这些研究结果加强了CR参与二级预防的重要性，并强调了CR应更广泛地适用于CVD弱势患者的可能性，如患有慢性疾病或多发病的老年人。问题是什么样的患者特异性，疾病特异性和共病特异性心脏康复参与与全因死亡率的关联？结果在这项队列研究中，31%的83687符合条件的心血管疾病患者参加了多学科门诊心脏康复计划。与未参与相比，参与心脏康复与全因死亡风险降低32%相关，这与患者相关和合并症相关特征无关。与不参与相比，心脏康复参与与较低的死亡风险相关;然而，心脏康复仍然未得到充分利用，特别是在患有慢性疾病或多发性硬化症的老年人中。
This cohort study investigates the implications of sex, age, socioeconomic status, cardiovascular disease (CVD) diagnosis, cardiothoracic surgery, and comorbidity for the association between cardiac rehabilitation participation and all-cause mortality.Importance Cardiac rehabilitation (CR) is an effective strategy to improve clinical outcomes, but it remains underused in some subgroups of patients with cardiovascular disease (CVD). Objective To investigate the implications of sex, age, socioeconomic status, CVD diagnosis, cardiothoracic surgery, and comorbidity for the association between CR participation and all-cause mortality. Design, Setting, and Participants Observational cohort study with patient enrollment between July 1, 2012, and December 31, 2017, and a follow-up to March 19, 2020. The dates of analysis were March to May 2020. This study was performed among Dutch patients with CVD with a multidisciplinary outpatient CR program indication and who were insured at Cooperatie Volksgezondheidszorg, one of the largest health insurance companies in the Netherlands. Among 4.1 million beneficiaries, patients with CVD with an acute coronary event (myocardial infarction or unstable angina pectoris), stable angina pectoris, chronic heart failure, or cardiothoracic surgery (coronary artery bypass grafting, valve replacement, or percutaneous coronary intervention) were identified by inpatient diagnosis codes and included in the study. Main Outcomes and Measures Cox proportional hazards models were used to evaluate the association between CR participation and all-cause mortality. Stabilized inverse propensity score weighting was used to account for patient and disease characteristics associated with CR participation. Results Among 83687 eligible patients with CVD (mean [SD] age, 67 [12] years; 60.4% [n = 50 512] men), only 31.3% (n = 26171) participated in CR, with large variation across different subgroups (range, 5.1%-73.0%). During a mean (SD) of 4.7 (1.8) years of follow-up, 1966 CR participants (7.5%) and 13443 CR nonparticipants (23.4%) died. After multivariable adjustment, CR participation was associated with a 32% lower risk of all-cause mortality (adjusted hazard ratio, 0.68; 95% CI, 0.65-0.71) compared with nonparticipation. Sex, age, socioeconomic status, and comorbidity did not alter risk reduction after CR participation, but a statistically significant interaction association was found across categories of CVD diagnosis and cardiothoracic surgery. Larger reductions in risk estimates for all-cause mortality were found after CR participation for STEMI (adjusted HR, 0.59; 95% CI, 0.52-0.68 vs 0.72; 95% CI, 0.65-0.79; P < .001), NSTEMI (adjusted HR, 0.64; 95% CI, 0.58-0.70 vs 0.72; 95% CI, 0.65-0.79; P < .001), and stable AP (adjusted HR, 0.69; 95% CI, 0.63-0.76 vs 0.72; 95% CI, 0.65-0.79; P < .001) compared with patients with chronic heart failure, whereas unstable AP had a smaller risk reduction (adjusted HR, 0.75; 95% CI, 0.67-0.85 vs 0.72; 95% CI, 0.65-0.79; P < .001). Conclusions and Relevance In this cohort study, CR participation was associated with a 32% risk reduction in all-cause mortality, and this benefit was independent of sex, age, socioeconomic status, and comorbidity. These findings reinforce the importance of CR participation in secondary prevention and highlight the possibility that CR should be prescribed more widely to vulnerable patients with CVD, such as older adults with chronic diseases or multimorbidity.Question What is the patient-specific, disease-specific, and comorbidity-specific association of cardiac rehabilitation participation with all-cause mortality? Findings In this cohort study, 31% of 83687 eligible patients with cardiovascular disease participated in a multidisciplinary outpatient cardiac rehabilitation program. Cardiac rehabilitation participation was associated with a 32% lower risk of all-cause mortality compared with nonparticipation, which was independent of patient-related and comorbidity-related characteristics. Meaning Cardiac rehabilitation participation is associated with a lower mortality risk compared with nonparticipation; however, cardiac rehabilitation remains underused, especially in older adults with chronic diseases or multimorbidity.