The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS)

Bernhard Rauch, Constantinos H Davos, Patrick Doherty, Daniel Saure, Maria-Inti Metzendorf, Annett Salzwedel, Heinz Völler, Katrin Jensen, Jean-Paul Schmid, ‘Cardiac Rehabilitation Section’, European Association of Preventive Cardiology (EAPC), in cooperation with the Institute of Medical Biometry and Informatics (IMBI), Department of Medical Biometry, University of Heidelberg, and the Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Heinrich-Heine University, Düsseldorf, Germany

Research output: Contribution to journalReview articlepeer-review


BACKGROUND: The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.

DESIGN: Structured review and meta-analysis.

METHODS: Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.

RESULTS: Out of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20-0.69; rCCS: HR 0.64, 95% CI 0.49-0.84; odds ratio 0.20, 95% CI 0.08-0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54-0.70) and in mixed CAD populations.

CONCLUSIONS: CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

Original languageEnglish
Pages (from-to)1914-1939
Number of pages26
JournalEuropean journal of preventive cardiology
Issue number18
Early online date24 Oct 2016
Publication statusPublished - 1 Dec 2016

Bibliographical note

© The European Society of Cardiology 2016. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details


  • Rehabilitation
  • acute coronary syndrome
  • coronary artery disease
  • coronary bypass grafting
  • hospital readmission
  • mortality
  • Cardiac Rehabilitation/methods
  • Myocardial Revascularization/rehabilitation
  • Prognosis
  • Humans
  • Myocardial Ischemia/drug therapy
  • Treatment Outcome
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use

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