Health care advances in the field of acute coronary syndrome (ACS) have substantially changed its prognosis.1 However, atherosclerotic cardiovascular disease remains the leading cause of death in western countries.2 After a first myocardial infarction, the risk of new cardiovascular events remains high because of additional risk factors, among other aspects.3

In this setting, adequate secondary prevention measures are essential to reduce the social, personal, and economic burden of cardiovascular disease. Of note, many coronary patients are young and have an active professional life.4

Cardiac rehabilitation programs (CRP) have been shown to have a positive effect on cardiovascular risk factors and quality of life, leading to a lowered risk of recurrence after an infarction.5,6

Unfortunately, only a low percentage of coronary patients follow a CRP.7,8 In fact, recent data from the EUROASPIRE V survey show that in Europe only 31.8% of patients with coronary heart disease and indications for CRP are enrolled in these programs. It is clear that the implementation of the CRP must be improved in our setting.9

Although the duration of standard CRPs is 8 to 12 weeks’ duration, the optimal duration and type of CRP for obtaining the long-term benefits of healthy lifestyle patterns and the impact of these programs on cardiovascular outcomes remain unknown.10–12

Shorter protocols have been proposed that would allow CRPs to be attended by some patients, who otherwise would find it difficult to do so due to time restrictions, work, and family responsibilities. Similarly, such protocols would allow health centers to perform individualized CRP, which otherwise could be hindered by logistical difficulties, space issues, care burden, and so on. In this line, the results of some studies on 2-week CRPs only found improvements in exercise capacity and substitute variables, such as oxidative stress and inflammatory markers; however, these studies did not directly compare their results with those of standard programs of longer duration.13–15

Consequently, the primary objective of this study was to analyze whether an intensive CRP (2 weeks with booster sessions) could improve adherence to physical activity, the Mediterranean diet, smoking cessation, and the use of medical treatments as recommended in the guidelines as a standard CRP (8 weeks). The secondary objective was to analyze its impact on quality of life, psychological state (anxiety and depression), and cardiovascular results at 1 year.

The study initially included 509 patients with ST-segment or non–ST-segment elevation ACS. However, 12 patients were excluded from the study because they did not complete the CRP: 7 were initially assigned to the standard arm and 5 to the intensive arm. Thus, a total of 497 patients were finally assessed (262 in the intensive group and 235 in the standard group) (figure 1).

Figure 1.

Diagram of MxM (Más por Menos) Trial.

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table 1 shows the baseline clinical characteristics of the patients. The mean age of the participants was 58 years, and most were men (87.3%). In total, 50% of the participants had ST-segment elevation ACS. Mean LVEF was 56%. A high percentage of participants had cardiovascular risk factors, with dyslipidemia (65.2%) and hypertension (48.5%) being the most common. There were no statistically significant differences between groups in their baseline demographic characteristics and risk profiles.

There were also no significant differences between the 2 groups in their biochemical parameters, the EQ-5D-5L quality of life questionnaire, Mediterranean diet, Beck Depression Inventory and STAI scores at the beginning of the study, or in cardiac therapies, antiplatelet agents, beta-blockers, lipid-lowering drugs, and the different groups of cardiac drug therapies, which were prescribed in similar numbers between the 2 groups (table 1).

After a mean follow-up of 11.8 ± 2.9 months, both CRPs improved adherence to most of the predefined secondary prevention measures (table 2). Regarding physical activity, at 12 months, the results of stress testing improved by at least 1 MET in 129 patients (94.2%) in the intensive group and 120 (93.0%) in the standard group (P=.80). There were no significant differences between groups in the other parameters (eg, diet, quitting smoking, weight, abdominal circumference, quality of life, depression, and anxiety). During the study period, there were similar changes in medication in both groups. At 12 months, 39.3% of patients in the intensive group and 38.7% of those in the standard group were taking 4 groups of cardiac medications (P2Y12 inhibitors were discontinued at the end of the study in 49.2% and 50.2% of the patients, respectively).

Table 2 shows the study variables by group.

During follow-up, 48 patients (9.7%) had a new cardiovascular event: 9.9% in the intensive group and 9.4% in the standard group (P=.879). Cardiovascular death and all-cause mortality occurred in 0.6% and 1.0% of patients, respectively, with no significant differences between groups. Patients from both groups returned to work after similar periods of time (table 3).

This is the first randomized study with a sufficient number of patients to analyze the feasibility and multilevel results of an intensive CRP vs standard CRP.

Several studies have clearly demonstrated the benefits of CRPs in the secondary prevention of ischemic heart disease by modifying the control of cardiovascular risk factors and promoting healthy lifestyle changes.2,11,12

However, depending on the target population, current rehabilitation protocols need to be improved and updated. They should be more cost-effective, more patient-centered, and provide more comprehensive secondary prevention.24

One of the key parameters of CRPs is their optimal duration, yet few studies have assessed this aspect. Current CRPs vary in their duration from 8 to 12 weeks: however, in practice, their duration is based more on habit than on a high-level evidence.10,25,26 As a result, it remains unclear which is the best model for current CRPs.11,12,27

In line with the results of most cardiac rehabilitation studies, the present study shows that, in general, CRPs improve functional capacity, quality of life, and adherence to the Mediterranean diet, effectively reduce LDLc levels, and are associated with low rates of cardiovascular events and death.2,5,6,11,15 However, the results of the present study, which included 500 patients with previous ACS, showed that an intensive short CRP can be as effective as standard CRP. This favorable result may be due to the use of booster sessions after the main intensive CRP had been completed as well as stricter patient follow-up.

The foregoing aspects are of relevance, because fewer patients have been included in the small number of previous studies on the impact of CRP duration on efficacy parameters, thus making it difficult to realistically compare many of the relevant parameters.10,28

In this study, the mean age of the participants was 58 years, 87% were men, and 49% were in active employment. These characteristics are also in line with those described in previous studies, which have shown that many of the patients who undergo CRP are relatively young and have work commitments.29,30

Thus, taking into account that many patients participating in CRPs have a limited period of sick leave, which may hinder adherence to programs, a short intensive protocol could be of benefit to many of them.

Although body weight and abdominal circumference remained stable in our participants, there were improvements in LDLc, HDLc, and triglyceride levels in both groups. Similar results have been obtained in previous studies.10,28 However, if we consider the results of our study and those conducted in other European countries8,31 it is clear that more efforts are needed to promote body weight reduction among overweight patients and to improve lipid control.8,31

Regarding physical activity, at 12 months, the results of final stress testing improved by at least 1 MET in most patients (more than or equal to 93%), without significant differences between the groups. Previous studies have also shown that cardiac rehabilitation improves functional capacity.10,27,28,32 Studies have investigated whether cardiorespiratory fitness in patients undergoing CRP can be improved by high-intensity interval training vs moderate-intensity continuous training.33,34

The Mediterranean diet should be promoted as an objective of secondary prevention,9 as shown by the results of the PREDIMED study, which demonstrated the benefits of the Mediterranean diet in lowering the incidence of major cardiovascular events.35 In our study, both groups significantly increased their adherence to the Mediterranean diet, although adherence was higher in the standard CRP group.

Regarding tobacco use, several studies have found a significant prevalence of persistent smoking after a heart attack, reaching 55% in the EUROASPIRE V survey.8,10 Regardless of group, there was a higher rate of smoking cessation among our patients than among those in previous studies. This is a highly relevant finding, because the benefits of many treatments could be reduced or even suppressed in persistent smokers.13,14

In areas such as health-related quality of life, several studies have also demonstrated the beneficial effects of CRP.5,10,32,36 The results of the present study are similar and suggest that benefits could be independent of CRP duration.

Patients with cardiovascular disease frequently experience depression and anxiety, which could be associated with worse prognosis. Thus, depression and anxiety and their severity should be investigated in this population.37 Previous studies have shown that CRP can improve psychological aspects.10,38 Nevertheless, we found that there were no significant changes in scores on the Beck Depression Inventory, there were significant improvements in scores only in the standard CRP group on the STAI, and there was a nonsignificant trend in the intensive CRP group on the STAI.

Regarding prognosis, some studies have shown that a minimum of 25 to 36 cardiac rehabilitation sessions are needed to reduce mortality or a minimum of 36 such sessions to reduce the number of percutaneous coronary interventions,12,39,40 whereas other studies have found benefits regardless of CRP duration.41 Our study suggests that similar benefits could be obtained with an intensive protocol vs a standard one, taking into account the aforementioned lack of statistical power to detect differences in cardiovascular events. figure 2 shows a flowchart for patients candidate for a CRP depicting a protocol similar to that used in the MxM (Más por Menos) study.

Figure 2.

Flowchart of an intensive cardiac rehabilitation program. CRP, cardiac rehabilitation program; LVEF, left ventricular ejection fraction; MxM, MxM cardiac rehabilitation program. * See inclusion criteria in the text.

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Intensive or standard CRPs are effective in increasing adherence to secondary prevention measures at 1 year. Both programs led to improved smoking cessation rates, adherence with the Mediterranean diet, functional capacity, quality of life, and LDLc control. Therefore, intensive CRPs could be an alternative in selected patients and hospitals.

Unconditional grant from Menarini.

None declared.