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Introduction

Cardiac rehabilitation programs have been treating patients for decades. A substantial volume of literature supports patient attendance1 and national guidelines include cardiac rehabilitation as part of optimal treatment for cardiovascular disease (CVD).2 In recent years, however, some scientists and clinicians have conducted meta-analyses and systematic reviews questioning the value of cardiac rehabilitation.3 This was recently the topic of debate at the European Society of Cardiology Congress 2019 in Paris entitled “Is cardiac rehabilitation still a ‘must’ in the 21st century?”

The justification for asking this question is based on continued advancement in the medical management of CVD, which could potentially diminish the added value of cardiac rehabilitation. Advancement began with statins, followed by more sophisticated anti-hypertensives and now minimally invasive revascularization procedures.

Cardiac rehabilitation through the ages

Early cardiac rehabilitation began as predominantly exercise-focused programs. Prior to that, patients following myocardial infarction (MI) were restricted to bed rest for 30 days for fear of overworking the heart. As a result, patients often died in hospital of pulmonary embolism. Only when hospitals got patients up and moving did these outcomes disappear. From there, a number of RCTs were conducted but no single study was large enough to investigate the effect of cardiac rehabilitation on MI and premature mortality alone. However, early meta-analyses indicated a substantial 20% and 22% reduction in all-cause and CVD mortality, respectively,4 a benefit similar to the angiotensin-converting enzyme inhibitor ramipril. The provision of cardiac rehabilitation is also highly cost effective.5

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