Cardiac rehabilitation in the Balearic Islands. Indications, baseline patient characteristics and estimation of the volume of patients with indication for cardiac rehabilitation but not referred
Authors: Torres Marques J , Moranta Ribas ME , Melia Mesquida C , Ruiz Pizarro V , Gamez Martinez JM , Alvarez Rubio J , Serra Creus J , Cremer Luengos D , Magnani Raganato S , Ripoll Vera T , Trias Oliver C , Jardi Rodriguez AM , Ferrer Oliver JA , Gomez Monjo MJ , Robles Amar J 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Objectives
1) To describe the indications and baseline characteristics of patients (p.) referred to the only cardiac rehabilitation (CR) center in Mallorca (Balearic Islands) and 2) Estimate of the volume of patients with indication of CR but not referred to a CR phase II program.

Material and methods
1) Retrospective observational study. We studied the indication, cardiovascular risk factors (CVRF), somatometric data, blood test and hospital anxiety and depression scale (EHAD) of all consecutive patients attended in the only CR center in Mallorca. 2) Estimation based on the recommendations of the ESC guidelines and epidemiological data of CV disease in the Balearic Islands.

Results
Since 2014, 524 patients have attended the CR program. Their mean age was 56.2±10, 18% (95p.) women. The most frequent indication (79.2%, 415 p.) was acute coronary syndrome (ACS, 58% STEACS, 42% NSTEACS). The second most frequent indication was chronic coronary syndrome (7.8%, 41p.). In only 5% (26p.) the indication was heart failure (HF). Other indications were coronary artery bypass grafting (3.8%, 20p,), valve surgery (1.9%, 9p), heart transplantation (0.4%, 2p), congenital heart disease (0.4%, 2p).
Among patients referred with any clinical expression of coronary disease (92.6%, 485p.), their mean age was 56.7±9, and only 15.7% (76) were women. Only 21% were non-smokers (neither smokers nor former smokers). The prevalence of hypertension, diabetes and dyslipidaemia were 56%, 26% and 63% respectively. 44% were overweight and 39% obese. At the beginning of the CR program 57% of patients had LDL cholesterol &gt;70mg/dl and 80% &gt;55mg/dl. 26% of coronary patients had EHAD scores indicative of significant anxiety (case) and 14.5% of patients had significant depression.
Exercise-based CR is recommended by ESC guidelines after an ACS and in HF with depressed LVEF(1). In the Balearic Islands around 400p. are admitted annually with STEACS, 23% of them women(2). It is estimated that around 50% of acute myocardial infarctions are non-ST-elevation (3) so 400 more p. could have an indication for CR. Every year in the Balearic Islands about 2100 p. are admitted for HF (4), and it’s estimated that 50% of them have reduced LVEF(5). With all the reservations generated by this crude estimate, up to 1800 p. could have an indication for CR every year. The only existing CR center in Balearic Islands can treat 80 patients per year. Therefore, around 1700 patients with a possible indication for CR every year (95.6% of p.) have no access to it.

Conclusion
The most frequent indication for CR in the Balearic Islands is ACS, usually with ST elevation. Patients with HF are rarely referred to CR. Women are referred to CR less frequently than expected. We observed high percentages of smokers or former smokers, overweight or obese patients and patients with severe anxiety. The vast majority of patients with an indication for CR has no access to a CR program in Balearic Islands.