Abstract

Background Chronic total occlusions (CTOs) are a common manifestation of coronary artery disease (CAD) and are associated with increased long-term mortality. While successful CTO revascularization improves symptoms and quality of life, a consistent mortality benefit has not been demonstrated in randomized trials. Outpatient cardiac rehabilitation (CR) has proven benefits in improving functional status, exercise capacity, and quality of life in patients with CAD, yet its impact on CTO patients has not been well studied.

Objective To evaluate the association between CR and long-term outcomes in CTO patients.

Methods Using the TriNetX Research Network, we analyzed de-identified patient data from 75 healthcare organizations using ICD codes. The study population included patients with CTO who started CR within 3 months of diagnosis vs patients with CTO who did not engage in CR. A secondary analysis was also conducted, which excluded patients with other indications for CR, including prior coronary artery bypass grafting (CABG) and prior or concurrent percutaneous coronary interventions (PCI).

Results Of 167,176 CTO patients, 10,021 enrolled in CR, including 1,608 without another CR indication. Patients were propensity-matched for independent risk factors for mortality. After 5 years, CR participation was associated with a significant reduction in mortality (HR 0.68; 95% CI, 0.61–0.75; p < 0.0001). This benefit was preserved even after excluding prior revascularization (HR 0.81; 95% CI, 0.67–0.99; p < 0.036).

Conclusion This study demonstrates that cardiac rehabilitation is associated with improved long-term survival in patients with CTOs.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

There was no external funding for this study

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The University of Iowa Health Care IRB Chair or Chair Designee has determined that this project does not meet the regulatory definition of human subject research and does not require review by the IRB, because this activity is based on evaluation of de-identified outcome data using TriNetX.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Footnotes

Ethical Approval: The University of Iowa Health Care IRB Chair or Chair Designee has determined that this project does not meet the regulatory definition of human subject research and does not require review by the IRB, because this activity is based on evaluation of de-identified outcome data using TriNetX.

Data Availability

The data that support the findings of this study are available from TriNetX but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are available from the authors upon reasonable request and with permission of TriNetX

Non-standard Abbreviations and AcronymsCABGCoronary Artery Bypass GraftCADCoronary Artery DiseaseCRCardiac RehabilitationCTOChronic Total OcclusionsMACEMajor Adverse Cardiac EventsMIMyocardial InfarctionPCIPercutatenous Coronary InterventionICDInternational Classification of Disease, Tenth Edition