Temporal Trends and Referral Factors for Cardiac Rehabilitation Post-Acute Coronary Syndrome in Ontario: Insights From the Canadian Global Registry of Acute Coronary Events

Background: Despite the beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS), CR referral rates have been lower than recommended. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined the temporal trends of CR referral rates in Ontario and its associated factors. Methods: From the main Canadian GRACE, we retrospectively analyzed data from 11 Ontario hospitals. CR referral rates were analyzed over time. Using multivariate logistic regression, we examined patient characteristics, in-hospital diagnosis, clinical events, and investigations associated with CR referral. Results: From 2000 to 2007, 3338 ACS patients (median age, 64 years; 32% women) were assessed. CR referral rate increased from 2.7% in 2000 to 51.2% in 2007 (P < 0.0001 for trend). Multivariate analysis identified increasing age per decade (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.14-1.29), presentation Killip class >= 2 (OR, 1.42; 95% CI, 1.09-1.84), non-ST-elevation ACS (OR, 1.60; 95% CI, 1.35-1.89), no left ventricular function assessment (OR, 1.33; 95% CI, 1.11-1.59), heart failure during hospital admission (OR, 1.48; 95% CI, 1.10-2.00), and in-patient cardiac revascularization (OR, 1.70; 95% CI, 1.38-2.09) as independently associated with lack of CR referral. Conclusions: CR referral rate after ACS in Ontario continues to be lower than recommended, although there has been a steady increase over time. Factors independently associated with lack of CR referral include advanced age, higher Killip class, noneST-elevation ACS, lack of left ventricular function assessment, in-hospital heart failure, and revascularization. Targeting nonreferred populations might improve quality of care and close care gaps in secondary prevention.