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Archives of cardiovascular diseases
Volume 109, n° 3
pages 178-187 (mars 2016)
Doi : 10.1016/j.acvd.2015.09.009
Received : 23 July 2015 ;  accepted : 30 September 2015
Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: The 2005 French FAST-MI study
Pronostic vital à 5ans après réadaptation cardiaque de patients admis pour infarctus du myocarde : étude FAST-MI 2005

Marion Pouche a, Jean-Bernard Ruidavets a, , Jean Ferrières a, b, Marie-Christine Iliou c, Hervé Douard d, Luc Lorgis e, Didier Carrié b, Philippe Brunel f, Tabassome Simon g, Vincent Bataille a, Nicolas Danchin h
a Department of Epidemiology, Health Economics and Public Health, UMR1027 Inserm-University of Toulouse III, Toulouse University Hospital (CHU), 31073 Toulouse cedex 7, France 
b Department of Cardiology B, Toulouse Rangueil University Hospital (CHU), 31059 Toulouse cedex 9, France 
c Department of Cardiac Rehabilitation, AP–HP, Corentin-Celton Hospital, 92130 Issy-les Moulineaux, France 
d Department of Cardiology, Bordeaux University Hospital, 33604 Pessac, France 
e Department of Cardiology, University Hospital, Laboratory of Cardiometabolic Physiopathology and Pharmacology, Inserm U866, University of Burgundy, 21034 Dijon, France 
f Department of Cardiology, Nouvelles Cliniques Nantaises, 44277 Nantes cedex 2, France 
g Department of Pharmacology and Clinical Research Unit (URCEST), AP–HP, Saint-Antoine Hospital, Pierre-and-Marie-Curie University (UPMC-Paris 06), Inserm U970, 75012 Paris, France 
h Department of Cardiology, AP–HP, Georges-Pompidou European Hospital, René-Descartes University, Inserm U970, 75908 Paris, France 

Corresponding author at: Department of Epidemiology, Health Economics and Public Health, UMR1027 Inserm-University of Toulouse III, Toulouse University School of Medicine, 37, allées Jules-Guesde, 31062 Toulouse cedex 9, France.

Clinical studies have shown a beneficial effect of cardiac rehabilitation (CR) on mortality.


To study the effect of CR prescription at discharge on 5-year mortality in patients with acute myocardial infarction (AMI).


Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n =1523) and non-STEMI (NSTEMI; n =1371). The effect of CR prescription on mortality was analysed using a Cox proportional hazards model.


At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs. 67.5years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients. Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P <0.001). After multivariable adjustment, the association between CR and mortality remained significant (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.60–0.96). Analyses stratified by sex, age (<60 vs.60years) and AMI type showed that the inverse association was stronger in men (HR 0.64, 95% CI 0.48–0.87) than in women (HR 0.95, 95% CI 0.64–1.39), in younger (HR 0.34, 95% CI 0.15–0.77) than in older patients (HR 0.84, 95% CI 0.65–1.07) and in NSTEMI (HR 0.63, 95% CI 0.46–0.88) than in STEMI (HR 0.99, 95% CI 0.69–1.40).


After hospitalization for AMI, referral to CR remains a significant predictor of improved patient survival; some subgroups seem to gain greater benefit.

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Différents travaux ont montré un effet bénéfique de la réadaptation cardiaque (RC) sur la mortalité.


Nous avons étudié l’impact sur la mortalité à 5ans de la prescription de RC chez des patients admis pour infarctus du myocarde aigu (IM).


Les participants du registre hospitalier FAST-MI conduit en 2005, étaient les 2894 survivants après hospitalisation dont 1523 IM avec sus-décalage du segment ST et 1371 sans sus-décalage. L’impact de la prescription de RC sur la mortalité a été analysé en utilisant le modèle de Cox.


À la sortie de l’hôpital, 22,1 % des patients avaient une prescription de RC. Les patients adressés en RC étaient plus jeunes (62,4 vs 67,5ans), plus fréquemment des hommes et ont présenté plus d’IM avec sus-décalage (67,8 % vs 48,3 %) que les non-adressés. Il y a eu 94 décès (14,7 %) parmi les patients adressés en RC et 585 (25,9 %) chez les non-adressés (p <0,001). Après ajustement multivarié, l’association entre la RC et la mortalité reste significative (0,76 [0,60–0,96]). L’analyse stratifiée sur le genre, l’âge (<60 vs60ans) et le type d’infarctus a montré que l’association était plus forte chez les hommes (0,64 [0,48–0,87]) que chez les femmes (0,95 [0,64–1,39]), chez les plus jeunes (0,34 [0,15–0,77]) que chez les plus âgés (0,84 [0,65–1,07]) et pour les IM avec sus-décalage (0,63 [0,46–0,88]) que sans sus-décalage (0,99 [0,69–1,40]).


Après hospitalisation pour IM aigu, la RC améliore significativement la survie des patients à moyen terme et quelques sous-groupes de patients semblent avoir un meilleur bénéfice.

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Keywords : Cardiac rehabilitation, Acute myocardial infarction, ST-segment elevation myocardial infarction, Non–ST-segment elevation myocardial infarction, Mortality

Mots clés : Réadaptation cardiaque, Infarctus du myocarde aigu, Infarctus du myocarde avec sus-décalage du segment ST, Infarctus du myocarde sans sus-décalage du segment ST, Mortalité

Abbreviations : AMI, CI, CR, HR, LVEF, NSTEMI, OR, STEMI


In France in 2009, as in other economically developed countries, cardiovascular diseases were the second most important cause of mortality after tumours [1], and accounted for one-third of deaths; of these, 36,539 were attributable to ischaemic heart disease. Throughout the world, according to the World Health Organization, ischaemic heart disease caused the death of 7 million people in 2011 [2].

Cardiac rehabilitation (CR) involves multidisciplinary management [3]. After functional assessment of the patient, management pursues at least four aims: therapeutic education; psychosociological management; secondary prevention of cardiovascular risk factors; and controlled return to physical activities and independence. All patients who require hospitalization or invasive management after myocardial infarction should participate in a CR programme in order to change their lifestyle and improve adherence to treatment (class IIa guidelines) [4]. In the USA, according to the American Heart Association, CR must be offered to patients with coronary disease, particularly if they have numerous modifiable risk factors [5].

Thanks to these measures for global patient management, CR contributes to a reduction in all-cause mortality and cardiovascular mortality, improves the level of cardiovascular risk factors (with a significant decrease in total blood cholesterol, systolic blood pressure and active tobacco use) and improves quality of life [6, 7, 8].

A meta-analysis of randomized trials of patients with ischaemic heart disease showed that compared with usual care, CR was associated with a 20% reduction in all-cause mortality and a 26% reduction in cardiovascular mortality [8]. The significant reduction in mortality and the markedly reduced risk of hospital readmission in patients undergoing CR were found again in the latest observational and pragmatic studies [9, 10, 11].

A prospective study [6] assessing cardiovascular risk factors after 6months of rehabilitation reported lower blood low-density lipoprotein cholesterol concentrations and reductions in the number of patients with hypertension and active smokers.

The long-term benefit of CR in the patient with ischaemic heart disease is less well known. A Swiss study [12] showed that functional capacities were maintained at 2years after 1month of rehabilitation. The GOSPEL study [13], which evaluated therapeutic education – now an important part of CR – showed a decrease in the rates of cardiovascular mortality and non-fatal myocardial infarction after 3years of follow-up. The study also reported better quality of life (diet, physical exercise, psychological stress).

In France, during the past 15years, medical management of acute coronary disease has improved greatly [14], resulting in a major reduction in hospital mortality [15, 16]. However, according to a recent study [17], adherence to non-pharmacological treatment is low in the medium-term, and compliance with medical treatment falls far short of perfect. A North American study showed that only two-thirds of patients took their treatment correctly, and that non-compliance multiplied the risk of death by 3.8 [18].

Using data from the FAST-MI registry, carried out in 2005, we evaluated over a 5-year period the maintenance of the benefit of CR in reducing mortality in a sample of patients who had presented with acute myocardial infarction (AMI) [19].

Participants and inclusion criteria

The objective of FAST-MI was to provide an extensive description of the management and outcomes of patients who presented with acute myocardial infarction (AMI) (both ST-segment elevation myocardial infarction [STEMI] and non–ST-segment elevation myocardial infarction [NSTEMI]) and were admitted to intensive care units, whatever the type of institution (university hospitals, public hospitals or private clinics). All consecutive adult patients aged18years and admitted for AMI within 48hours of symptom onset were included. AMI was defined by elevation of troponin or creatine phosphokinase-myocardial band>2 times the upper limit of normal, associated with at least one of the following criteria: symptoms compatible with myocardial ischaemia; new pathological Q-waves; or ST or T changes compatible with myocardial ischaemia. Iatrogenic AMI was defined as an event occurring within 48hours of a therapeutic procedure. Patients with an AMI diagnosis invalidated in favour of another diagnosis, and those with unstable angina and no increase in cardiac biomarkers were not included.

The duration of recruitment was 31days per centre for all patients and 2months for patients with diabetes, between 1 October and 24 December 2005. Of the 374 centres in France that treated patients with AMI at that time, 223 (60%) participated in the study. A total of 3059 patients were included. Written informed consent was provided by each patient. The study was reviewed by the Committee for the Protection of Human Subjects in Biomedical Research of Saint-Antoine University Hospital, and the data file was declared to the Commission Nationale de l’Informatique et des Libertés. Follow-up data were collected through direct contact with the patients’ physicians, the patients or their families and the registry offices of their birthplaces. Follow-up was completed in all patients. The long-term outcome was defined as death at 5years.

Data collection

Baseline characteristics were collected prospectively. All data were recorded on computerized case record forms by dedicated research technicians who visited each of the centres at least once a week. The research technicians were also asked to ensure that recruitment was consecutive. Previous cardiovascular and non-cardiovascular history, risk factors (smoking status, hypertension or treated hypertension, dyslipidaemia or treated dyslipidaemia, family history, diabetes mellitus), clinical course during the hospital stay (symptoms, Killip class, maximum Killip class), therapeutic management during the first 48hours, management during the hospital stay (including percutaneous coronary interventions and thrombolysis) and treatment at discharge were recorded for each patient. Left ventricular ejection fraction (LVEF) assessed at entry and at any time during the hospital stay was recorded. The electronic case report form comprised 385 items, including medications administered before the index event, prehospital, during the first 24 and 48hours and at hospital discharge. Doses of oral medications were recorded, as well as information on CR prescription at hospital discharge and in-hospital, 5-day, 30-day and 180-day survival.

Patient follow-up

Patient follow-up was carried out by the reference investigators in the participating institutions, by the Société française de cardiologie research team or by both. The Société française de cardiologie research team used a sequential follow-up procedure: they first consulted data on death at the registrar's offices of the patient's birthplace; they then wrote to the family doctors and/or cardiologists; finally, they wrote to the patients themselves. In many instances, written contact was followed by telephone interviews with the patients or their family. A specific procedure was set up to categorize the clinical events occurring during follow-up. Hospital discharge letters were systematically sought for each event leading to hospitalization or death, and were analysed by a physician from the research team. All cardiovascular events for which the final diagnosis appeared unclear were reviewed by a three-member critical events committee. Follow-up at 5years was 94.7% complete and 157 (5.3%) patients were lost to follow-up.

Statistical methods

Data are presented as means and standard deviations for quantitative variables and percentages for categorical variables. The Chi2 test was used to compare the distribution of qualitative variables between referred to CR and non-referred groups. When basic assumptions were not satisfied, data were subjected to Fisher's exact test.

Mean values of quantitative variables were compared by Student's t -test. Shapiro-Wilk's and Levene's tests were used to test the normality of distribution of residuals and the homogeneity of variances, respectively. When basic assumptions of Student's t -test were not satisfied, a logarithmic transformation of the variables was done or a Wilcoxon-Mann-Whitney test was performed.

Follow-up was scheduled up to 5years. Cumulative survival curves of patients referred to CR and non-referred were determined by the Kaplan-Meier method, and were compared using the log-rank test for the individual endpoints of all-cause mortality. The relationship between baseline variables and mortality was assessed using Cox proportional hazards regression analysis. We tested the proportionality assumption using cumulative sums of martingale-based residuals. We performed regression analyses with polynomial models (quadratic and cubic) to examine for possible non-linear relations between continuous variables and mortality. All variables associated with a P value<0.20 in the univariate analysis were introduced into a multivariable Cox model. A backward procedure was applied to assess variables that were significantly and independently associated with mortality (P value<0.05). Because sex and type of acute coronary syndrome did not remain in the model, they were forced. Model assumptions were verified before analysis. All tests were two-tailed at the level of significance of 0.05. All analysis was carried out using SAS software, version 9.2 (SAS Institute, Cary, NC, USA).


Of the 3059 patients who met the inclusion criteria of the FAST-MI study, 2894 (94.6%) were discharged alive from hospital, and 639 (22.1%) of these received a prescription for CR.

Patient characteristics at admission to hospital are shown in Table 1. Patients referred to CR differed from non-referred patients: they were younger by a mean of 5years, and nearly one-quarter of men (23.8%) were referred to CR, whereas fewer than 1 in 5 women (18.2%) were referred.

With regard to cardiovascular risk factors, a larger proportion of referred patients were current smokers (37.9% vs. 28.8%) and were more likely to have a family history of ischaemic heart disease (30.5% vs. 22.0%); on the other hand, they were less likely to have arterial hypertension (49.8% vs. 58.8%), diabetes (16.7% vs. 21.1%), peripheral artery disease (6.3% vs. 9.8%) or renal failure (2.8% vs. 5.6%).

Of the patients admitted for acute coronary syndromes and discharged alive from hospital, 679 (23.5%) died during the 5-year follow-up. More patients died in the non-referred group (585 deaths, 25.9%) than in the referred group (94 deaths, 14.7%) (P <0.001). The survival curves (Figure 1) show real and significant benefit in patients who received a prescription for CR.

Figure 1

Figure 1. 

Five-year survival curves according to rehabilitation status. Source: French Registry on Acute ST-elevation and non–ST-elevation Myocardial Infarction 2005 (FAST-MI 2005), France.


Table 2 shows patients’ clinical characteristics and treatments received according to CR prescription. Patients referred to CR were more frequently admitted for STEMI (67.8%, n =433) than for NSTEMI (32.2%, n =206). The acute episode was markedly more serious in non-referred patients, with a higher mean Killip class and a lower LVEF. Patients referred to CR were more likely to have undergone primary angioplasty (34.5% vs. 22.2%) or thrombolysis (22.4% vs. 13.8%). Taken overall, prescription of recommended medications for coronary disease was higher in referred than in non-referred patients. Quadritherapy (statin, angiotensin-converting enzyme inhibitor, beta-blocker and antiplatelet agent) was prescribed in 52.4% of the referred group compared with 42.2% of the non-referred group.

Stratified analysis according to type of myocardial infarction showed that both STEMI and NSTEMI patients benefitted from CR, but that the latter group benefitted to a greater degree (Figure 2). Similarly, the benefit of referral to CR on 5-year survival was present in young patients aged<60years (2.3% of deaths compared with 7.8%) as well as in older patients aged60years (25.9% of deaths compared with 34.9%), but the benefit was less marked in the older patients, even if overall their life expectancy was lower (Figure 3).

Figure 2

Figure 2. 

Five-year survival curves according to rehabilitation status and acute coronary syndrome type. Non–ST+: non–ST-segment elevation myocardial infarction; ST+: ST-segment elevation myocardial infarction. Source: French Registry on Acute ST-elevation and non–ST-elevation Myocardial Infarction 2005 (FAST-MI 2005), France.


Figure 3

Figure 3. 

Five-year survival curves according to rehabilitation status and age. Source: French Registry on Acute ST-elevation and non–ST-elevation Myocardial Infarction 2005 (FAST-MI 2005), France.


Before multivariable analysis (Table 3), referral to CR was associated with a lower risk of death in referred patients compared with non-referred patients (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.42–0.65; P <0.001). After adjustment (Table 3) for personal and family history, sex, age, treatment at discharge, LVEF, Killip class and revascularization procedures, the association remained significant (HR 0.76, 95% CI 0.60–0.96; P =0.02). Referral to CR decreased the risk of death at 5years by 24%. Further adjustment for treatments prescribed at discharge did not alter the results significantly.

Stratified analysis also revealed that some patient subgroups benefitted to a greater extent. The subgroup of young patients (age<60years) retained a highly significant benefit from CR, with a 66% decrease in mortality (HR 0.34, 95% CI 0.15–0.77; P =0.01). The subgroup of older referred patients (≥60years) maintained benefit, although this was less marked. After adjustment, NSTEMI patients retained excellent benefit from referral to CR on 5-year survival (HR 0.63, 95% CI 0.46–0.88; P =0.006) compared with STEMI patients.


CR after acute coronary syndromes improves the vital prognosis. In our sample, 5-year mortality decreased by 24% in patients who had a prescription for CR compared with those who did not. We also noted that the prescription rate of CR remained low, as it was proposed to only 22% of patients who presented with an acute episode of ischaemic heart disease.

Effect on mortality

In the meta-analysis by Taylor et al. [8] that comprised 48 studies, 30 of which were European, similar results were found: improved survival (odds ratio [OR] 0.80, 95% CI 0.68–0.93) and decreased mortality from cardiac-related causes (OR 0.74, 95% CI 0.61–0.96) in rehabilitated patients compared with those receiving standard treatment. However, the cohorts included in this meta-analysis were often old (nearly half dated from the 1980s) and so medical treatment was not the same (clopidogrel was introduced in 1998). In addition, the duration of follow-up was much shorter (mean follow-up 15months), and the population was heterogeneous, with North American patients, who have a higher cardiovascular risk than Europeans. Present-day CR is also different, and therapeutic education has now been introduced. It is therefore difficult to extrapolate this result to the current population.

Another study [20] has shown reduced mortality over 4years, and this effect was proportional to the number of rehabilitation sessions. Mortality was reduced by 14% and risk of myocardial infarction was reduced by 12% in patients who had 36 rehabilitation sessions compared with those who had 24 sessions. In patients who had 12 sessions, mortality was reduced by 22% and risk of myocardial infarction was reduced by 23%.

It has been reported widely that the various treatment modalities, particularly medications and CR, not only reduce mortality but also improve quality of life and decrease the number of new hospital admissions. This was shown by a Canadian study [10], which found decreased mortality (HR 0.59, 95% CI 0.49–0.70), a decreased risk of all-cause hospital admission (HR 0.77, 95% CI 0.71–0.84) and a decreased risk of admission for a cardiac-related reason (HR 0.68, 95% CI 0.55–0.83) in patients who had undergone full CR.

In our study, we observed a difference in terms of benefit between the various subpopulations after multivariable adjustment. Patients referred to CR aged<60years had a 66% reduction in 5-year mortality, while this reduction was 36% in men and 37% in NSTEMI patients. The highest reduced mortality rates observed in men and in the youngest patients in comparison with women and the oldest patients, respectively, are not mentioned in previous studies. There is no clear explanation, and one can merely hypothesize that women and oldest patients referred to CR experience a lower rate of completion or attendance [21].

For referred patients diagnosed with STEMI at admission, after adjustment, the association between CR and decreased mortality was no longer significant. The higher in-hospital mortality in STEMI patients compared with NSTEMI patients became less marked in the long-term [22]. This observation may be explained by the fact that NSTEMI patients were older, had more co-morbid diseases and involvement of several trunks on coronary angiography; they had a higher risk of recurrence of a cardiovascular event and also of heart failure, which may explain the excess mortality in this group [23]. By raising the ischaemic threshold in these patients, long-term survival may be improved.

In our study, a bias in the indication between the referral to CR and non-referral groups could underlie the differences observed. Moreover, we note that patients who were prescribed CR were more likely to have undergone coronary revascularization, and to have at discharge a treatment closer to the recommendations than patients not prescribed CR. Because of the nature of this study, caution is required when analysing and interpreting the influence of drug or interventional treatments on the incidence of mortality in the two groups. However, it is the only way to observe the efficacy of medical management under conditions of ordinary medical practice.

In an experimental study in patients with stable coronary disease, the practice of a physical activity was compared with coronary angioplasty. The results at 1year showed a greater reduction in the number of ischaemic events in the group of patients who had exercised regularly [24, 25].

Participation rate

In our study, the 22.1% participation rate for referral to CR is relatively low, but is the same as that found in the PREVENIR study (23.3%) carried out in 1998 [6]. A North American study reported similar levels, with 13.9% participation after an acute coronary syndrome, and 31% in patients who had had a coronary artery bypass [25]. The most recent figures, which are derived from a national post-acute hospitalization database (year 2011), show that CR was actually carried out, during the 6months following hospitalization for acute myocardial infarction, in 22.7% of patients [26]. Finally, we point out that the percentage of referral to CR in France has been very stable during the last 15years.

Nevertheless, it has long been recognized that CR improves prognosis. A meta-analysis dating from 1989 and including 4712 patients showed a 20% decrease in 3-year mortality in rehabilitated patients [27]. In Europe, less than half the patients eligible for CR actually attend the programmes [28].

A meta-analysis [29] identified factors that restrict participation or adherence to CR. These include: personal barriers (belief that CR is not beneficial, heart disease considered as the “will of God”, perceived low patient control over cardiovascular risk factors, negative perception of people taking part in rehabilitation, elderly and needy persons, language barrier); barriers related to medical staff who may give information that is contradictory or delivered at an inappropriate time, poor understanding of the aim of CR, exclusion criteria; environmental and socioprofessional barriers (inconvenient planning, incompatible timing); economic barriers (these do not apply in France as cardiac disease and rehabilitation are covered by the health system); family barriers (lack of family involvement in rehabilitation); and physical barriers, including lack of transport or transport difficulties. It is important to understand these barriers in order to improve adherence to CR [30].

One question remains unanswered: when is the right time to propose CR? One study showed that there was no risk of stent thrombosis during early CR if a 7-day delay was respected before submaximal exercise intensity, and 14days for maximal intensity in patients treated with two antiplatelet agents [31, 32].

A study analysing participation rate in CR according to early or later time to enrolment showed better patient adherence when an appointment was given<10days after the coronary event compared with an appointment>5weeks later [33].

Results of drug therapies

In our study, we observed that patients referred to CR had post-AMI drug treatment that was closer to the recommendations (beta-blocker, antiplatelet agent, statin and renin-angiotensin system inhibitor), and this trend was confirmed 1year later (Figure 4). We were unable to evaluate treatment observance, but treatment prescription at discharge already differed between the two groups.

Figure 4

Figure 4. 

Medical treatment 1year after discharge according to rehabilitation status. ACE: angiotensin-converting enzyme. Source: French Registry on Acute ST-elevation and non–ST-elevation Myocardial Infarction 2005 (FAST-MI 2005), France.


A North American study showed that at 1month, only two-thirds of patients continued to take their three therapeutic classes (beta-blocker, aspirin and statin) [18]. Non-adherence to medications increased 1-year mortality risk almost 4-fold.

With regard to adherence to non-pharmacological treatment, the European EUROACTION study [34] showed that therapeutic education yielded a benefit in terms of lifestyle changes and diet improvements, and that this difference was maintained at 1year. In the group that attended therapeutic education sessions there were fewer smokers, levels of physical endurance activity were closer to recommended levels (in patients who had had a cardiovascular event or who were only at high risk of such an event), a larger proportion of patients with a body mass index>25kg/m2 had lost weight and more patients – whether diabetic or not – had stable blood pressure.

The GOSPEL study [13] produced similar findings: long-term (3-year) educational and rehabilitation measures reduced cardiovascular mortality, non-fatal myocardial infarction and cerebrovascular accidents, and also led to an improved lifestyle (healthy diet, better stress management and improved lipid concentrations). A Canadian study showed similar results: patients who adhered to lifestyle and dietary rules (following a diet and practising a physical activity) had a 50% reduction in risk of major events (new infarction, stroke and death) at 6months. Smokers who did not adhere to the non-pharmacological treatment had a risk of major events four times higher than that of non-smokers who adhered to these rules [17].

The reduction in mortality is also related to improvement in functional capacity. CR, whether continuous or intermittent, improves functional capacity [35], and this is related to survival. A study by Myers et al. [36], carried out in 6213 patients who had undergone exercise testing for various clinical reasons, showed that, adjusted for age, the factor that modified mortality in this population was maximum functional capacity measured in metabolic equivalents, to the same degree as or even more than risk factors such as tobacco use, diabetes or arterial hypertension. A patient who had an exercise capacity of<5 metabolic equivalents had a mortality risk that was two-fold higher than a patient with a capacity of 8 metabolic equivalents. Improved functional capacity, obtained by practice of a physical activity, decreases the risk of mortality. Health professionals must therefore promote physical activity, just as they encourage smoking cessation or management of arterial hypertension.


CR enables overall management of the patient. This study, carried out in a French cohort in 2005, showed that 5-year survival was improved by 25% in the group of patients referred to CR, due to improvement in cardiovascular risk factors, better functional capacity and medical treatment that was closer to the guidelines. However, once again, the rate of referral to CR was low, related to a number of factors. Referral rate to CR was stable compared with the PREVENIR study of 1998, while the most recent guidelines of the European Society of Cardiology (ESC) make CR a class IB recommendation. In these young patients, who are starting to live with a chronic disease, it would also be interesting to assess long-term quality of life.

Disclosure of interest

J.F.: speaker fees from the companies AstraZeneca, Merck, Novartis and Servier; research grants from the companies AstraZeneca, Bristol-Myers Squibb, MSD, Pfizer, Sanofi-Aventis and Solvay Pharma.

P.B.: consulting for the company Boston Scientific.

M.-C.I.: speaker fees from the companies Servier Medical, Boehringer Ingelheim and AstraZeneca; research grants from the company Res Med.

T.S.: research grants from the companies AstraZeneca, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, MSD, Novartis, Pfizer, Sanofi-Aventis and Servier; speaker, advisory board and consulting fees from the companies AstraZeneca, Bayer-Schering, Eli Lilly, MSD and Sanofi-Aventis.

N.D.: research grants from AstraZeneca, Eli Lilly, Merck, Pfizer, Sanofi-Aventis, Servier and The Medicines Company; fees for speaking in industry-sponsored symposia and/or consulting from the companies AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Lilly, Menarini, Merck, Novartis, Novo, Pfizer, Sanofi-Aventis, Servier and The Medicines Company.

The other authors declare that they have no competing interest.


We are deeply indebted to all physicians who took care of the patients at the participating institutions, to the ICTA contract research organization (Fontaine-lès-Dijon, France) and to the devoted personnel of URCEST (Assistance publique–Hôpitaux de Paris and University Paris 6) and Inserm UMR1027 (Toulouse). Special thanks go to Vincent Bataille for his careful data management, to Benoît Pace (Société française de cardiologie) for his invaluable assistance in designing the electronic case report form and to Geneviève Mulak (Société française de cardiologie) who, with the help of Elodie Drouet, aptly supervised patient follow-up.Sources of funding : FAST-MI 2005 is a registry of the French Society of Cardiology ( Identifier: NCT00673036). FAST-MI 2005 was supported by unrestricted grants from Pfizer and Servier, and an additional grant from the Caisse nationale d’assurance maladie des travailleurs salariés. Pfizer, Servier and the Caisse nationale d’assurance maladie had no role in the design and conduct of the study, data collection or management; they were not involved in the analysis and interpretation of the data or in the preparation, review and approval of the manuscript.


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