The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes

J Cardiopulm Rehabil Prev. 2022 Jul 1;42(4):227-234. doi: 10.1097/HCR.0000000000000646. Epub 2021 Nov 24.


Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR.

Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate.

Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables.

Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Cardiac Rehabilitation*
  • Cardiorespiratory Fitness*
  • Hand Strength
  • Humans
  • Outcome Assessment, Health Care
  • Prospective Studies
  • Social Class