Multidomain rehabilitation after myocardial infarction improves outcomes in older adults

1. In this randomized controlled trial, a multidomain rehabilitation program significantly reduced cardiovascular death and unplanned cardiac hospitalizations in older adults post-myocardial infarction (MI).

2. Program adherence was high, with 75% of participants in the intervention group completing the prescribed rehabilitation.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Cardiac rehabilitation programs are integral to post–MI care, yet frailty, comorbidities, and physical limitations often prevent older adults from fully benefiting. To address this gap, the Physical Activity Intervention in Elderly Patients with Myocardial Infarction (PIpELINe) trial evaluated whether a multidomain rehabilitation program tailored to older adults could reduce cardiovascular morbidity and mortality. The program combined exercise training, dietary guidance, and management of cardiovascular risk factors. Results demonstrated a significant reduction in the composite primary outcome of cardiovascular death or unplanned cardiac hospitalization in the intervention group compared with controls, with consistent benefits observed across subgroup analyses. The intervention was also associated with a lower incidence of several secondary outcomes, including death, cardiovascular death, unplanned hospitalization for cardiovascular causes or heart failure, myocardial infarction, coronary revascularization, cerebrovascular accident, unplanned hospitalization for any reason, infection, and bleeding requiring medical intervention. No serious adverse events were attributed to the intervention, supporting its safety in this high-risk population. Limitations of the study include the selective enrollment of participants who had survived one month post-MI, lack of blinding due to the nature of the intervention, and the inability to isolate the effects of individual program components. Nonetheless, the findings highlight the potential of a structured, multidomain approach to extend the benefits of rehabilitation to older adults following MI, underscoring the need for more accessible and tailored secondary prevention strategies.

Click here to read the study in NEJM

In-Depth [randomized controlled trial]: Acute interventions have reduced the mortality of MI in older adults, yet these patients frequently experience recurrent cardiovascular complications and comorbidities. Rehabilitation programs are often underutilized in this population due to mobility limitations, logistical barriers, and medical complexity, highlighting the need for more accessible interventions. The PIpELINe trial evaluated the efficacy of a multidomain program—including exercise training, dietary guidance, and management of cardiovascular risk factors—for older adults after hospitalization for MI. Eligible participants were over 65 years of age, had been admitted with STEMI or NSTEMI and successfully revascularized, and scored 4/9 on the Short Physical Performance Battery at the one-month post-discharge follow-up. Exclusion criteria were not explicitly reported. Across seven sites, 1283 patients were screened, of whom 512 met eligibility criteria; 342 were randomized to the intervention group and 170 to usual care. Intervention adherence was 75% after excluding 18 participants who died during the study. The primary outcome was the composite of cardiovascular death or unplanned cardiac hospitalization within one year of randomization. Incidence was significantly lower in the intervention group (12.6%) compared with controls (20.6%) (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.36–0.89; p=0.01). Most secondary outcomes also favored the intervention, with the most significant reductions seen in unplanned hospitalization for heart failure (HR, 0.20; 95% CI, 0.07–0.56), unplanned cardiovascular hospitalization (HR, 0.48; 95% CI, 0.29–0.79), and infection (HR, 0.58; 95% CI, 0.19–1.71). Minimal effects were observed for unplanned hospitalizations due to non-cardiovascular causes (HR, 1.06; 95% CI, 0.55–2.02) and for major bleeding events classified as BARC type 3–5 (HR, 0.99; 95% CI, 0.45–2.19). No serious adverse events were associated with program participation. Overall, the trial demonstrates that a structured multidomain rehabilitation program can significantly reduce cardiovascular mortality and morbidity in older adults post-MI, underscoring the importance of tailored, accessible secondary prevention strategies in this high-risk population.

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