Cardiac Rehabilitation Participation and All-Cause Mortality: A Systematic Review of Real-World Registry Data

Abstract

Introduction: Cardiac rehabilitation (CR) is recommended after myocardial infarction and revascularization, but participation rates are low. Most efficacy data come from trials with selected patients. Real-world registry studies provide generalizable estimates.
Methods: Systematic literature search for observational cohort studies (2000–2023) using national or regional registries reporting all-cause mortality by CR participation (attendance ≥1 session) vs. no CR. Inclusion: post-MI or post-CABG patients. Exclusion: RCTs and single-center studies. Meta-analysis using random-effects.
Results: 19 registry-based studies (n=1.8 million patients) were included. CR participation rate averaged 35% (range 18–58%). Pooled adjusted hazard ratio for all-cause mortality comparing CR vs. no CR was 0.64 (95%CI 0.58–0.71). Benefit was similar for post-MI (HR 0.62) and post-CABG (HR 0.67). Women (HR 0.72) and elderly >75 years (HR 0.80) showed smaller but still significant reductions. Dose-response: each additional session (up to 24) reduced mortality by 3% per session.
Discussion: Real-world effectiveness is slightly lower than trial-based estimates (~30% vs. ~25% mortality reduction). Selection bias (healthier patients more likely to attend) may overestimate benefit, but propensity-adjusted analyses still show robust effects. Barriers include travel distance, cost, and lack of referral.
Conclusions: Cardiac rehabilitation is associated with a 36% lower all-cause mortality in routine clinical practice. Efforts to improve participation, especially in women and elderly, are needed. Home-based CR models may bridge gaps.