Key result
Foreign-born post-MI status is linked to ~3 percentage points lower cardiac rehabilitation participation.
Why the study?
Although the proportion of foreign-born patients is increasing in Western countries, little was known about their participation in cardiac rehabilitation and achievement of recommended secondary prevention targets after MI.
Does country or region of birth affect cardiac rehabilitation attendance and the attainment of ESC secondary prevention goals during the first year after myocardial infarction in patients in Sweden?
Cohort (n=104,161)
Yes
Does country or region of birth affect cardiac rehabilitation attendance and the attainment of ESC secondary prevention goals during the first year after myocardial infarction in patients in Sweden?
Despite lower cardiac rehabilitation participation rates and higher baseline cardiovascular risk factor prevalence among foreign-born post-MI patients in Sweden, all foreign-born groups except those from Nordic countries achieved secondary prevention targets to a similar or higher extent than native-born patients.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These findings challenge assumptions about migration background and secondary prevention. The main challenge may not be the results achieved once patients enter cardiac rehabilitation, but ensuring equitable access and participation for everyone in cardiac rehab programs.”
Lower participation among foreign-born post-MI patients was not linked to inferior target achievement; hypothesis-generating for equity research in cardiac rehabilitation.
Background Comprehensive cardiac rehabilitation (CR) is central to secondary prevention after myocardial infarction (MI). Although the proportion of foreign-born patients is increasing in Western countries, little is known about their participation in CR and their achievement of recommended secondary prevention targets. Purpose To study CR attendance and attainment of secondary prevention targets after MI in foreign-born compared with native-born (born in Sweden) patients. Methods Patients were identified from the Swedish MI registry SWEDEHEART between 2006 and 2020. The exposure was country or region of birth, categorised into 7 groups, with native-born as the reference group (Figure 1). Outcomes were attainment of secondary prevention targets according to ESC guidelines: 1) systolic blood pressure (BP) <140 mmHg; 2) LDL-cholesterol <2.5 mmol/L between 2006 and 2011 and <1.8 mmol/L between 2012 and 2020; 3) smoking cessation; and 4) completion of centre-based exercise training programme, during the first post-MI year. The association between country of birth and outcomes was assessed using crude and adjusted (age, sex, comorbidities, medication, and socioeconomic variables) logistic regression models presented as odds ratios (OR) with 95% confidence intervals (CI). Results Of 142,927 patients eligible for follow-up at CR-centres after MI, 104,161 patients (74% male, 18% foreign-born) were included (Table 1). CR participation rates were lower in foreign-born patients (70.4%) compared with native-born patients (73.4%), p<0.005. The likelihood of CR participation was lower in all foreign-born groups (Table 1). Foreign-born patients had a higher prevalence of cardiovascular (CV) risk factors, especially diabetes mellitus (Africa-born 36.8% vs native-born 20.1%) and smoking (non-EU European 48.5% vs native-born 26.5%). After adjustment, the attainment of systolic BP (<140 mmHg) was more likely in patients from Asia (OR 1.16, 95% CI 1.04-1.29), Nordic countries (OR 0.83, CI 95% 0.77-0.90), and non-Nordic EU countries (OR 0.86, CI 95% 0.78-0.97) (Figure 1). LDL-cholesterol goal achievement was more likely in patients from Asia (OR 1.28, 95% CI 1.18-1.39) and the Americas (OR 1.23, 95% CI 1.01-1.49), and less likely in patients from Nordic countries (OR 0.92, 95% CI 0.86-98). Only patients born in non-EU European countries had a higher likelihood of smoking cessation (OR 1.30, 95% CI 1.02-1.67). Patients born in Asia (OR 0.88, 95% CI 0.79-0.99) and the Nordic countries (OR 0.84, 95% CI 0.76 – 0.94) were less likely to complete a centre-based exercise training programme. Conclusions The proportion of foreign-born patients participating in CR was generally lower, and they had a higher baseline prevalence of CV risk factors compared with native-born patients. However, all foreign-born patients except those from the Nordic countries achieved secondary prevention goals to a similar or higher extent than native-born patients.
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Zwackman et al. (2026) conducted a cohort in Myocardial infarction (n=104,161). Foreign-born status (categorised into 7 regions/countries of birth) vs. Native-born (born in Sweden) was evaluated on Cardiac rehabilitation participation and attainment of secondary prevention targets (systolic BP <140 mmHg, LDL-C target, smoking cessation, exercise training completion) at 1 year (p=<0.005). Foreign-born post-MI patients had lower cardiac rehabilitation participation than native-born patients (70.4% vs 73.4%, p<0.005), though non-Nordic groups achieved similar or better prevention goals.
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