Participating in a comprehensive cardiac rehabilitation program enhances both mid- and long-term outcomes for early survivors of an acute coronary syndrome

Background Cardiovascular disease (CVD) continues to be the foremost cause of death in developed nations. Although there have been significant advancements in the acute management of myocardial infarction (MI), the implementation of secondary prevention strategies remains substantially underutilized. Comprehensive cardiac rehabilitation (CCR) is recognized as a critical component in improving outcomes for post-MI patients. This study was designed to rigorously evaluate the impact of CCR participation on survival rates. Methods Hungary has systematically recorded ACS cases since 2014 through the National Myocardial Infarction Register. For this retrospective cohort study, ACS outcomes were examined over a ten-year period, from 2014 to 2024. The study population included all individuals with a documented ACS event, and specific attention was paid to those surviving at least 30 days post-index event to mitigate the influence of early mortality and focus on those eligible for rehabilitation interventions. To ensure comparability between groups, a 1:1 propensity score-matching (PSM) analysis was conducted. Results A total of 158,599 ACS cases were identified during the study period. Of these, only 17.4% of eligible individuals enrolled in a CCR program. The subgroup analysis revealed that patients with non-ST-elevation myocardial infarction (NSTEMI) who did not undergo percutaneous coronary intervention (PCI) exhibited both the lowest rates of CCR participation and the highest mortality rates. Factors independently associated with reduced CCR engagement included advanced age, male sex, NSTEMI diagnosis, and lack of PCI. To address potential confounding, a PSM analysis was conducted using age, sex, diabetes mellitus diagnosis, ACS type, and PCI status as fixed covariates. The procedure established a highly balanced cohort of 27,640 pairs (Mean Bias: 2.6%, Rubin’s B: 7.4%), effectively neutralizing baseline clinical disparities. This rigorous statistical approach demonstrated that CCR participation was associated with a 12.9% reduction in all-cause mortality (ATT = -0.1288; t = -25.84; p < 0.001), compared to non-participants (24.8% vs. 37.7% in the matched groups). These findings were validated using the Rosenbaum-sensitivity test, which confirmed the robustness of the observed effect (p < 0.001) even at a Gamma level of 2.0, indicating the results are insensitive to potential unmeasured confounding. Conclusion The results of this nationwide, retrospective cohort study provide compelling evidence that early survivors of ACS who participate in CCR programs experience significant improvements in survival. Despite the well-documented effectiveness and cost-efficiency of CCR, enrollment rates remain suboptimal at only 17.4%. These findings underscore the urgent need for targeted interventions to increase CCR uptake, particularly among high-risk subgroups such as elderly NSTEMI patients without revascularization.