Exercise-based cardiac rehabilitation after MI reduces total mortality in men and women

Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: results from the SWEDEHEART registry

Literature - Ekblom Ö, Cider A, Hambraeus K et al. - Eur J Prev Cardiol. 2021 Jun 7;zwab083. doi: 10.1093/eurjpc/zwab083.

Introduction and methods

Previous studies have shown that participation in exercise-based cardiac rehabilitation (exCR) after MI reduces the risk on CVD mortality [1-3]. Moreover, the ESC has given participation in exCR a class 1A recommendation post-MI [4,5]. However, whether exCR post-MI has beneficial effects on total mortality has remained unclear and gender-specific analyses have not been performed in previous studies investigating effects of exCR. This study assessed the association between participation in exCR and total mortality in men and women in the SWEDEHEART registry.

The SWEDEHEART registry is a large, unselected nationwide cohort of patients, which contains continuous information on acute care and secondary prevention for patients with MI in Sweden [6]. The present analysis included a total of 20 895 patients (74% men) aged between 18 and 75 years who were diagnosed with a first MI and with complete data on covariates, explanatory and outcome variables. Of these 20 895 patients, 9647 (46%) participated in exCR, defines as center-based supervised exercise sessions, at least two times per week. The primary outcome was total mortality. Mean follow-up (time between index MI and date of death or end of study) was 4.55 (SD 2.33) years. A total of 1000 deaths occurred during this follow-up time.

Main results

  • Patients participating in exCR had a significantly lower mortality-risk compared to non-participants (fully adjusted HR 0.72, 95%CI 0.62-0.83).
  • Similar results were found when patients with shorter follow-up than 2 years were excluded (HR for exCR participation: 0.70, 95%CI 0.60-0.82).
  • Interaction analysis revealed significant interaction effects of exCR between genders. Women participating in exCR had a significant lower HR than men participating in exCR (Male participants: fully adjusted HR 0.81, 95%CI 0.68–0.96; female participants: fully adjusted HR 0.54, 95%CI 0.41–0.72).
  • Interaction analysis further revealed significant interaction effects of exCR between health-related quality of life (HRQoL) strata. Reduced mortality with participation in exCR was more pronounced in patients with an EQ5D-score below median, compared to patients with an EQ5D-score above median (HRQoL EQ5D ≤0.85 [median]: fully adjusted HR 0.63, 95%CI 0.51–0.77; HRQoL EQ5D >0.85: fully adjusted HR 0.83, 95%CI 0.68–1.03).


This study in an unselected nationwide cohort of patients with MI showed that participation in exCR after MI significantly reduced total mortality. The association between participation in exCR and lower total mortality was more pronounced in women than in men and in patients with low HRQoL compared to those with high HRQoL.

The authors state that: ‘Our results further support the recommendations to participate in exCR, and hence we argue that exCR should be a mandatory part of comprehensive CR programmes, offered to all patients post-MI.’


1. Anderson L, Oldridge N, Thompson DR, Zwisler A-D, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016;67:1–12.

2. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011;7:CD001800.

3. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001;1:CD001800.

4. Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet JP, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-Hesselink J-W, Stuart AG, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M, ESC Scientific Document Group 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2020;42:17–96.

5. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen M-L, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S; ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315–2381.

6. Jernberg T, Attebring MF, Hambraeus K, Ivert T, James S, Jeppsson A, Lagerqvist B, Lindahl B, Stenestrand U, Wallentin L. The Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies (SWEDEHEART). Heart 2010;96:1617–1621.

Find this article online at Eur J Prev Cardiol.

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