The relationship between left ventricular ejection fraction (LVEF) and outcomes after cardiac rehabilitation (CR) is not well established; therefore we assessed the prognostic role of LVEF at the end of ambulatory CR program in patients (pts) who received coronary revascularization. LVEF was evaluated at hospital discharge and re-assessed at the end of CR in all ST-elevation myocardial infarction and coronary artery bypass graft pts, while in pts with non-ST-elevation MI or elective percutaneous coronary intervention the echocardiography was repeated if they had an impaired LVEF at discharge. New hospitalizations for cardiovascular causes at 1-year, and cardiovascular mortality during long-term follow-up were analyzed. We enrolled in CR 3078 pts, 86% showed LVEF ≥40% and 9% LVEF <40%. Of those with a discharge LVEF <40%, 56% improved LVEF (LVEF ≥40%) after CR. At 1-year, heart failure was the main cause of new hospitalizations in LVEF <40% group compared with LVEF ≥40% group (5% vs 0.4%, p <0.01).

During a mean follow up of 48 ± 25 months, cardiovascular death occurred in 9% of pts with LVEF <40% and in 2% with LVEF ≥40% (p = 0.014). At Cox multivariate analysis, LVEF <40% at the end of CR and age were independent predictors of hospitalization and mortality for cardiovascular causes, while coronary artery bypass graft was a protective factor. In conclusion, during CR the improvement of LVEF occurs in a relevant proportion of patients, the re-assessment of LVEF at the end of the CR is helpful for risk stratification because left ventricle dysfunction at the end of CR is associated with worse cardiovascular outcomes.