Current state of cardiac rehabilitation in Germany: patient characteristics, risk factor management and control status, by education level

Figures & data

Table 1 Demographic and clinical factors, by education level

Parameter	Total n = 68,191	Low education level n = 40,266	Intermediate education level n = 16,110	High education level n = 6549	Other/unspecified n = 5266
Demographics
Age, years	63.7 ± 11.6	64.5 ± 11.5	61.3 ± 11.6	62.9 ± 11.1	66.7 ± 11.1
Gender, male	71.7%	68.4%	73.7%	86.5%	65.3%
Body mass index, kg/m^2	28.0 ± 4.6	28.3 ± 4.7	27.3 ± 4.3	27.2 ± 4.1	28.0 ± 4.7
Diagnosis for CR
STEMI	43.3% (29,496/68,191)	42.5% (17,101/40,266)	46.3% (7466/16,110)	44.1% (2890/6549)	38.7% (2039/5266)
NSTEMI	18.4% (12,566/68,191)	17.9% (7225/40,266)	19.2% (3100/16,110)	18.4% (1204/6549)	19.7% (1037/5266)
Unstable angina pectoris	18.3% (12,462/68,191)	19.2% (7741/40,266)	18.3% (2952/16,110)	18.9% (1241/6549)	10.0% (528/5266)
Therapy in acute hospital
Percutaneous coronary intervention	51.6% (33,377/64,670)	49.4% (18,718/37,856)	56.1% (8694/15,493)	54.6% (3452/6318)	50.2% (2513/5003)
Coronary artery bypass surgery	39.5% (25,784/65,313)	40.0% (15,392/38,451)	37.0% (5737/15,506)	39.4% (2484/6306)	43.0% (2171/5050)
Risk factors
Diabetes mellitus	32.8% (21,903/66,793)	36.4% (13,967/39,431)	28.0% (4417/15,760)	25.4% (1621/6390)	36.4% (1898/5212)
Dyslipidemia	95.6% (64,905/67,877)	96.2% (38,571/40,092)	95.6% (15,316/16,016)	94.1% (6141/6526)	93.0% (4877/5243)
Arterial hypertension	83.4% (56,530/67,811)	84.7% (33,901/40,030)	80.8% (12,939/16,016)	81.6% (5314/6515)	83.4% (4376/5250)
Smoking, current	16.8% (11,143/66,367)	16.8% (6596/39,197)	18.4% (2874/15,620)	15.5% (984/6368)	13.3% (689/5182)
Smoking, previous	45.5% (29,967/65,815)	44.3% (17,252/38,969)	48.8% (7532/15,431)	49.3% (3101/6291)	40.6% (2082/5124)
Peripheral arterial disease	12.2% (8177/66,987)	13.5% (5310/39,474)	10.5% (1670/15,861)	9.1% (598/6451)	11.7% (608/5201)
Previous stroke	8.8% (3963/45,162)	9.2% (2443/26,469)	7.5% (757/10,102)	8.1% (309/3899)	9.5% (454/4758)
Family history of CV disease	31.3% (20,720/66,099)	30.8% (11,990/38,962)	33.9% (5323/15,713)	34.4% (2188/6362)	24.1% (1219/5062)

Notes: Frequencies of categorical variables in subgroups were compared by Chi-square or Kruskal Wallis test. Continuous variables were compared by two-tailed Wilcoxon rank sum test. Due to the very large sample, for all reported items, differences between groups were highly significant (all P values <0.0001).

Abbreviations: STEMI, ST elevation myocardial infarction; NSTEMI, non-ST elevation myocardial infarction; CR, cardiac rehabilitation; CV, cardiovascular.

Table 2 Drug treatment at entry and discharge, by education status

Parameter at entry and discharge	Total n = 68,191	Low education level n = 40,266	Intermediate education level n = 16,110	High education level n = 6549	Other/unspecified n = 5266	P value*
Statins, any (%)	76.3 → 88.9	75.3 → 88.9	78.1 → 89.1	79.1 → 86.6	75.1 → 90.8	<0.0001 → <0.0001
Simvastatin	48.9 → 68.4	48.7 → 69.1	47.2 → 66.2	47.0 → 61.0	57.9 → 78.8	<0.0001 → <0.01
Dose	28.6 ± 12.4 → 29.4 ± 13.5	28.5 ± 12.5 → 29.4 ± 13.5	29.0 ± 12.5 → 29.7 ± 13.9	28.5 ± 12.5 → 29.6 ± 13.5	29.0 ± 12.3 → 28.6 ± 12.7	<0.0001 → <0.0001
Pravastatin	6.1→ 4.3	6.3 → 4.5	6.2 → 4.3	6.2 → 4.7	4.3 → 2.8	<0.0001 → <0.05
Dose	26.8 ± 12.3→ 29.1 ± 12.8	26.4 ± 11.8 → 28.8 ±11.4	26.9 ± 12.8→ 29.3 ± 15.1	26.2 ± 13.7→ 29.2 ± 15.1	30.8 ± 12.1→ 31.5 ± 11.8	<0.0001 → <0.0001
Atorvastatin	13.7 → 11.1	13.3 → 10.6	15.2 → 12.4	17.9 → 15.3	7.4 → 5.7	<0.0001 → <0.001
Dose	24.3 ± 15.1 → 25.1 ± 15.0	23.5 ± 14.1 → 24.4 ± 14.1	25.3 ± 16.3 → 26.3 ± 16.6	25.3 ± 16.3 → 25.5 ± 15.3	25.8 ± 14.7 → 25.2 ± 14.5	<0.0001 → <0.0001
Fluvastatin	6.6 → 4.4	6.0 → 4.0	8.4 → 5.5	6.5 → 4.7	5.3 → 3.4	<0.0001 → <0.34
Dose	59.9 ± 22.0 → 59.8 ± 22.0	53.8 ± 23.3 → 58.8 ± 22.2	57.1 ± 22.6 → 60.2 ± 21.8	53.8 ± 23.3 → 58.8 ± 22.2	57.4 ± 22.4 → 60.4 ± 21.7	<0.0001 → <0.36
Other statin	1.2 → 1.6	1.2 → 1.5	1.2 → 2.0	1.7 → 1.8	0.3 → 0.5	0.45 → <0.0001
Dose	35.5 ± 30.8 → 23.4 ± 24.2	35.5 ± 31.0 → 23.3 ± 24.0	36.7 ± 32.2 → 22.8 ± 23.4	31.6 ± 26.6 → 26.2 ± 28.0	45.4 ± 31.1 → 14.6 ± 11.3	<0.0001 → <0.0001
CAI	5.6 → 43.6	5.5 → 43.8	5.7 → 44.7	5.5 → 41.2	5.5 → 41.5	0.76 → <0.0001
Aspirin	83.0 → 82.5	82.6 → 82.4	84.4 → 83.2	83.6 → 81.7	81.5 → 82.0	<0.0001 → <0.05
Clopidogrel	46.9 → 43.0	44.9 → 40.8	45.7 → 42.0	51.0 → 47.1	50.0 → 47.3	<0.0001 → <0.0001
Aspirin + clopidogrel	43.4 → 38.7	41.7 → 37.0	47.2 → 42.4	44.9 → 40.4	42.5 → 38.5	<0.0001 → <0.0001
Beta-blocker	85.1 → 89.0	84.1 → 88.4	86.6 → 89.9	86.5 → 89.5	85.7 → 89.8	<0.0001 → <0.0001
ACE inhibitor	70.8 → 73.4	71.3 → 74.5	71.1 → 73.0	66.5 → 67.0	71.7 → 74.9	<0.0001 → <0.0001
ARB	10.6 → 13.9	9.7 → 12.7	11.5 → 14.9	14.0 → 18.9	10.2 → 13.5	<0.0001 → <0.0001
Oral antidiabetic drug	14.5 → 16.0	15.7 → 17.2	12.5 → 13.8	11.3 → 12.8	15.2 → 18.0	<0.0001 → <0.0001
Insulin	11.1 → 11.5	12.2 → 12.6	9.0 → 9.2	8.1 → 8.6	13.2 → 13.2	<0.0001 → <0.0001

Notes: Values are percentages at entry and → at discharge. Mean doses are provided with standard deviation.

* Frequencies of categorical variables in subgroups were compared by Chi-square or Kruskal Wallis test. Continuous variables were compared by two-tailed Wilcoxon rank sum test.

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CAI, cholesterol absorption inhibitor.

Table 3 Outcomes and guideline achievement at entry and discharge, by education level

Parameter at entry and discharge	Total n = 68,191	Low education level n = 40,266	Intermediate education level n = 16,110	High education level n = 6549	Other/unspecified n = 5266	P value*
Total cholesterol (mg/dL)	192.1 ± 47.5 → 158.0 ± 35.9	193.3 ± 47.7 → 158.8 ± 36.1	193.0 ± 46.9 → 157.5 ± 35.3	187.1 ± 46.8 → 154.3 ± 34.9	186.3 ± 47.5 → 157.6 ± 37.7	<0.0001 → <0.0001
LDL-C (mg/dL)	118.8 ± 38.4 → 89.4 ± 28.2	119.7 ± 38.3 → 90.0 ± 28.2	119.7 ± 38.5 → 89.0 ± 28.2	115.9 ± 38.1 → 87.3 ± 27.5	112.9 ± 38.9 → 88.3 ± 29.2	<0.0001 → <0.0001
HDL-C (mg/dL)	43.5 ± 12.8 → 43.9 ± 12.1	43.7 ± 12.9 → 43.9 ± 12.2	43.5 ± 13.0 → 44.2 ± 12.2	42.6 ± 12.6 → 43.5 ± 11.9	42.9 ± 12.0 → 42.9 ± 11.4	<0.0001 → <0.0001
Triglycerides (mg/dL)	160.9 ± 80.6 → 139.1 ± 67.0	161.8 ± 81.3 → 140.0 ± 67.7	161.6 ± 80.1 → 139.0 ± 64.7	156.3 ± 78.1 → 133.9 ± 63.5	157.4 ± 79.3 → 138.9 ± 72.9	<0.0001 → <0.0001
Guideline achievement at entry and at discharge (%)
LDL-C < 100 mg/dL	31.1 → 69.6	30.1 → 69.0	29.7 → 70.4	33.5 → 72.0	39.5 → 69.8	<0.0001 → <0.0001
TC < 200 mg/dL	60.1 → 88.1	59.1 → 87.6	59.5 → 89.0	64.3 → 89.6	64.6 → 87.9	<0.0001 → <0.0001
HDL-C > 50 mg/dL (women)/> 40 mg/dL (men)	44.5 → 46.4	44.5 → 45.4	44.9 → 48.3	46.7 → 50.8	41.5 → 41.5	<0.0001 → <0.0001
Triglycerides < 150 mg/dL	54.2 → 66.8	53.9 → 66.3	53.2 → 66.8	56.7 → 68.5	57.1 → 68.8	<0.0001 → <0.001
Systolic/diastolic BP at entry and discharge (mmHg)	130.8 ± 20.3/77.1 ± 11.6 → 122.4 ± 14.4/73.1 ± 9.2	131.8 ± 20.3/77.4 ± 11.7 → 123.0 ± 14.5/73.3 ± 9.3	129.5 ± 19.9/77.0 ± 11.3 → 121.1 ± 13.7/73.0 ± 8.9	128.8 ± 20.3/76.7 ± 11.4 → 120.9 ± 13.7/72.9 ± 8.9	130.2 ± 21.1/75.3 ± 11.9 → 123.4 ± 16.0/71.9 ± 9.7	<0.0001 → <0.0001 <0.0001 → <0.0001
HbA1c (%)	6.5 ± 1.1	6.5 ± 1.1	6.3 ± 1.1	6.3 ± 1.1	6.6 ± 1.1	<0.0001
Creatinine (mg/dL)	1.2 ± 0.8 → 1.2 ± 0.8	1.2 ± 0.8 → 1.2 ± 0.9	1.1 ± 0.7 → 1.1 ± 0.7	1.1 ± 0.7 → 1.2 ± 0.7	1.2 ± 0.7 → 1.2 ± 0.8	<0.0001 → <0.0001
Fasting blood glucose (mg/dL)	107.7 ± 31.9 → 103.9 ± 26.0	108.8 ± 32.5 → 104.7 ± 26.5	104.9 ± 29.3 → 101.6 ± 23.0	104.2 ± 29.1 → 99.4 ± 22.3	110.4 ± 36.4 → 109.0 ± 31.9	<0.0001 → <0.0001
Maximum exercise (W)	77.8 ± 37.7 → 94.6 ± 40.0	72.8 ± 36.5 → 89.5 ± 38.4	83.5 ± 37.7 → 101.9 ± 40.1	90.0 ± 40.0 → 109.4 ± 42.7	80.4 ± 37.0 → 90.6 ± 40.9	<0.0001 → <0.0001

Notes: HbA1c was measured at entry only.

* The frequencies of categorical variables in subgroups were compared by chi square or Kruskal Wallis test. Continuous variables were compared by two-tailed Wilcoxon rank sum test.

Abbreviations: LDL-C, low density lipoprotein cholesterol; HDL-C, high density lipoprotein cholesterol; TC, total cholesterol; BP, blood pressure.

Table 4 Factors associated with good control in the multivariate regression model

Parameter	OR	95% CI
Age (10-year intervals)	0.99	0.99, 0.99
Gender (male, female)	1.38	1.30, 1.46
Diabetes mellitus	0.90	0.85, 0.95
Current smoking	0.96	0.90, 1.02
Peripheral arterial disease	0.88	0.82, 0.95
BMI ≤ 30 kg/m^2	0.91	0.86, 0.96
Mid level educationa	0.94	0.89, 0.99
High level of educationa	1.01	0.94, 1.09

Notes: A total of 49,907 observations was used in this model. Good control was defined as attainment of LDL-C < 100 mg/dL and blood pressure ≤ 130/80 mmHg at end of cardiac rehabilitation, and improvement of these values during cardiac rehabilitation. The c statistic, which measures how well the model predicts which parameters are more likely to result in good control, was 0.56. For further explanation of the model, please refer to the methods section.

a Versus low level education.

Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio.