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Receipt of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors --- United States, 2005

Each year, approximately 865,000 persons in the United States have a myocardial infarction (i.e., heart attack) (1). In 2007, direct and indirect costs of heart disease were estimated at approximately $277.1 billion (1). Cardiac rehabilitation, an essential component of recovery care after a heart attack, focuses on cardiovascular risk reduction, promoting healthy behaviors, reducing death and disability, and promoting an active lifestyle for heart attack survivors (2). Current guidelines from the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation emphasize the importance of cardiac rehabilitation (2,3), which reduces morbidity and mortality, improves clinical outcomes, enhances psychological recovery, and decreases the risk for secondary cardiac events (3). To estimate the prevalence of receipt of outpatient cardiac rehabilitation among heart attack survivors in 21 states* and the District of Columbia (DC), data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) were assessed. The results of that assessment indicated that 34.7% of BRFSS respondents who had experienced a heart attack participated in outpatient cardiac rehabilitation. Outpatient cardiac rehabilitation for eligible patients after a heart attack is an essential component of care that should be incorporated into treatment plans. Increasing the number of persons who participate in cardiac rehabilitation services also can reduce health-care costs for recurrent events and reduce the burden on families and caregivers of patients with serious sequelae (5).

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years. Data collected by BRFSS include age, sex, race/ethnicity, marital status, educational level, employment status, household income, health-insurance coverage, assigned metropolitan statistical area (MSA) (i.e., containing a core urban area with a population >50,000), and state of residence. In 2005, a total of 129,416 persons in 21 states and DC responded to questions regarding history of heart attack and receipt of cardiac rehabilitation. Participants were asked, "Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?" If the answer was "yes," the participants were asked, "After you left the hospital following your heart attack, did you go to any kind of outpatient rehabilitation?" Participants who refused to answer the question or who responded "don't know/not sure" were coded as missing. The median response rate (i.e., the percentage of persons who completed interviews among all BRFSS-eligible persons, including those who were not successfully contacted) among the 21 states and DC, based on Council of American Survey and Research Organizations (CASRO) guidelines, was 51.6% (range: 34.6%--66.7%). The median cooperation rate (i.e., the percentage of persons who completed interviews among all BRFSS-eligible persons who were contacted) was 74.3% (range: 63.2%--85.3%). The median response rate among all states in the 2005 BRFSS was 51.1% (range: 34.6%--67.4%).

Aggregate and state-specific prevalence estimates and 95% confidence intervals (CIs) for history of heart attack and receipt of outpatient cardiac rehabilitation among heart attack survivors were determined. Prevalence estimates of outpatient cardiac rehabilitation also were determined for selected characteristics defined by age, sex, race/ethnicity, marital status, education level, employment status, annual household income level, health-insurance coverage, and MSA. Logistic regression was used to assess the odds of receiving cardiac rehabilitation for each of the selected characteristics independently, after adjusting for age. Data were weighted to reflect each state's population, taking into account the probability of selection of a telephone number, the number of adults in a household, the number of telephone numbers in a household, and combinations of age, sex, and race/ethnicity (6). Data for Kansas were based on a split sample (i.e., only a portion of the state sample respondents were asked questions from the optional module), and appropriate weights were used in all calculations. All prevalence estimates have a denominator >50 and a relative standard error <30% to ensure reliability of estimates (7).

Among 129,416 survey respondents in 21 states and DC, 7,230 (4.2%; CI = 4.0%--4.3%) reported ever having had a heart attack (Table 1); prevalence ranged from 2.6% in Utah to 6.9% in West Virginia. Of these, 6,819 responded to the question regarding cardiac rehabilitation receipt; 2,219 (34.7%; CI = 32.8%--36.6%) had received outpatient cardiac rehabilitation services, ranging from 22.6% in DC to 59.1% in Nebraska. The prevalence of cardiac rehabilitation receipt among heart attack survivors aged <50 years was 25.3% and for older age groups ranged from 35.5% to 37.0% (Table 2). The age-adjusted prevalence of receipt of cardiac rehabilitation was higher among men than women (adjusted odds ratio [AOR] = 1.8; CI = 1.5--2.1), and Hispanics had a higher prevalence of cardiac rehabilitation receipt than non-Hispanic whites (AOR = 1.9; CI = 1.1--3.3). Heart attack survivors who were married had a higher prevalence of cardiac rehabilitation receipt than unmarried persons (AOR = 1.3; CI = 1.1--1.5).

The prevalence of cardiac rehabilitation receipt among heart attack survivors increased with increasing levels of education. For example, compared with heart attack survivors who had less than a high school education, receipt of cardiac rehabilitation was higher among those with some college education (AOR = 1.8; CI = 1.3--2.3) and those with a college education or more (AOR = 2.1; CI = 1.6--2.8). Heart attack survivors with higher levels of annual household income had a higher prevalence of cardiac rehabilitation receipt. For example, compared with persons with an income <$15,000, receipt of cardiac rehabilitation was higher among those with an income of $25,000--$49,000 (AOR = 1.5, CI = 1.2--2.0), an income of $50,000--$74,999 (AOR = 1.6, CI = 1.1--2.3), and an income >$75,000 (AOR = 2.1, CI = 1.4--3.0). Adults living outside of an MSA had a lower prevalence of cardiac rehabilitation receipt than those living in the center city of an MSA (AOR = 0.7; CI = 0.6--0.9). The prevalence of receipt of outpatient cardiac rehabilitation did not vary significantly by employment status or health-insurance coverage.

Reported by: C Ayala, PhD, J Xie, MD, PhD, HF McGruder, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion; AL Valderrama, PhD, EIS Officer, CDC.

Editorial Note:

Heart disease is the leading cause of death among U.S. men and women and is a cause of substantial morbidity and mortality (1). Compared with the general population, survivors of a heart attack have a higher incidence of sudden death and illness, including another heart attack, angina, heart failure, and stroke (1). Cardiac rehabilitation improves patient outcomes and quality of life after a heart attack (3) by providing a multidisciplinary approach to reducing cardiovascular risk and preventing secondary cardiac events and serious sequelae. Cardiac rehabilitation focuses not only on medically supervised exercise but also on other essential elements, including patient evaluation, lifestyle modification, physical activity counseling, nutritional counseling, psychosocial counseling or referral, and risk factor management, including cholesterol level, blood pressure, weight, diabetes, and smoking (2).

The findings in this report indicate that 34.7% of heart attack survivors receive cardiac rehabilitation, which is consistent with previous studies indicating that approximately one third of heart attack survivors receive cardiac rehabilitation services (1,3,4,8). Low rates might be explained by the high overall cost of services and out-of-pocket costs for outpatient services, lack of access to services (e.g., in rural areas), lack of social support (e.g., from spouse or other caregiver), patient anxiety, travel time and time off from work for attending rehabilitation sessions, patients' lack of knowledge regarding the benefits of rehabilitation services, and lack of patient motivation. (This report did not demonstrate any significant differences in cardiac rehabilitation receipt by health-insurance status.) In addition, physicians might not be aware of the importance of cardiac rehabilitation for patients after a heart attack and therefore might not refer patients to rehabilitation services. Although physicians might be able to provide certain services that normally would be provided in cardiac rehabilitation (e.g., counseling and risk factor management), physicians do not routinely provide the supervised exercise training that is a core component of cardiac rehabilitation.

The findings from this study indicate that Hispanics had a higher prevalence of receipt of cardiac rehabilitation services than non-Hispanic whites; however, another study that assessed referrals to cardiac rehabilitation found that Hispanics were less likely to be referred than non-Hispanic whites (9). These disparate findings might be explained by the different focus of each study; the patterns for participation in and referrals to rehabilitation might be different. The finding that adults living in the center city of an MSA had a higher prevalence of cardiac rehabilitation receipt than those living outside an MSA might reflect lack of access to rehabilitation services outside MSA locations. Consistent with a previous study that demonstrated that women are less likely to participate in rehabilitation than men (1), the results of this study indicated that men had a higher prevalence of participation in cardiac rehabilitation services after heart attack than women; the reasons for this difference are unclear.

The 2001 BRFSS report on receipt of cardiac rehabilitation services, published in 2003 (8), found that 29.5% of respondents who had experienced a heart attack had received cardiac rehabilitation services; however, that study did not present state-specific prevalence estimates or consider racial/ethnic variations because of low numbers of respondents for the question regarding cardiac rehabilitation receipt. The 2005 BRFSS had more respondents and provided prevalence estimates. The results suggest that states might be more interested in collecting this optional information so that they can better evaluate measures to reduce morbidity associated with heart attacks.

The findings in this report are subject to at least six limitations. First, BRFSS data are based on self-reported information and are subject to recall bias, which might have affected prevalence estimates of participation in cardiac rehabilitation. Second, the BRFSS cardiac rehabilitation question only asks about receipt of outpatient cardiac rehabilitation among those who were treated in a hospital. The results do not provide information on the combined inpatient and outpatient rehabilitation services received by heart attack survivors. Third, BRFSS does not determine whether a respondent was eligible for rehabilitation services; certain respondents who did not participate likely were not eligible to participate. Fourth, BRFSS does not quantify the length of time that a respondent participated in rehabilitation services; the estimates of persons who received cardiac rehabilitation services likely include persons who did not complete the prescribed rehabilitation regimen. Fifth, because only 21 states and DC administered the optional module, the results might not be representative of the entire U.S. population. Finally, although the BRFSS response rate was low (51.6%), BRFSS data have consistently been found to provide valid and reliable estimates when compared with national U.S. household surveys (10).

Rehabilitation facilities should follow the most recently published guidelines and use performance measures to monitor referral and delivery of cardiac rehabilitation services (4). Automatic referral (i.e., providing standing orders for rehabilitation-services referrals for all eligible patients based on current guidelines) is one practice being evaluated by certain facilities, particularly those in Europe, to determine whether this might increase the use of services.

Heart attack survivors who are eligible for rehabilitation should be educated regarding the importance, components, and beneficial effects of cardiac rehabilitation. Many state health departments support AHA's Get with the Guidelines: Coronary Artery Disease, which addresses cardiac rehabilitation referral and physical activity recommendations. In addition, heart disease and stroke prevention programs in three states (Arizona, Montana, and Wisconsin) are initiating newly funded measures (e.g., educating the public about rehabilitation services, increasing rates of physician referral after hospital discharge, and creating a statewide outpatient cardiac rehabilitation registry to collect outcomes on heart attack survivors) to improve statewide cardiac rehabilitation referral systems, quality of care, and patient education.

Programs and policies directed at increasing the number of patients who are referred to and participate in cardiac rehabilitation need to be strengthened. Future research should focus on identifying barriers to cardiac rehabilitation participation and interventions to improve referral and receipt of outpatient rehabilitation services.


The findings in this report are based, in part, on data provided by BRFSS state coordinators.


  1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics---2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007;115:e69--171.
  2. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology, and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675--82.
  3. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005;111:369--76.
  4. Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:1400--33.
  5. Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997;17:222--31.
  6. Anonymous. Overview: BRFSS 2005. Available at
  7. Klein R, Proctor S, Boudreault M, Turczyn K. Healthy People 2010 criteria for data suppression. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2002.
  8. CDC. Receipt of cardiac rehabilitation services among heart attack survivors---19 states and the District of Columbia, 2001. MMWR 2003;52:1072--5.
  9. Cohen MG, Roe MT, Mulgund J, et al. Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE). Am Heart J 2006;152:110--7.
  10. CDC. Public health surveillance for behavioral risk factors in a changing environment: recommendations from the Behavioral Risk Factor Surveillance Team. MMWR 2003;52(No. RR-9):1--11.

* Alabama, Arkansas, Connecticut, Georgia, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Montana, Nebraska, New Jersey, New York, North Dakota, Ohio, Oklahoma, South Carolina, Utah, Virginia, and West Virginia.

Persons with a primary diagnosis of heart attack within the previous year and no absolute contraindications to exercise or other high-risk medical conditions (4). BRFSS does not assess whether patients who answered the question on cardiac rehabilitation were eligible to receive rehabilitation.

Table 1

Table 1
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Table 2

Table 2
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Date last reviewed: 1/30/2008


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