Cardiac Rehabilitation is Associated with Improved Clinical Outcomes in Patients with Chronic Total Occlusions: A Large-Scale, Propensity-Matched Analysis

Background: Chronic total occlusions (CTOs) are a common manifestation of coronary artery disease (CAD) and are associated with increased long-term mortality. While successful CTO revascularization improves symptoms and quality of life, a consistent mortality benefit has not been demonstrated in randomized trials. Outpatient cardiac rehabilitation (CR) has proven benefits in improving functional status, exercise capacity, and quality of life in patients with CAD, yet its impact on CTO patients has not been well studied. Objective: To evaluate the association between CR and long-term outcomes in CTO patients. Methods: Using the TriNetX Research Network, we analyzed de-identified patient data from 75 healthcare organizations using ICD codes. The study population included patients with CTO who started CR within 3 months of diagnosis vs patients with CTO who did not engage in CR. A secondary analysis was also conducted, which excluded patients with other indications for CR, including prior coronary artery bypass grafting (CABG) and prior or concurrent percutaneous coronary interventions (PCI). Results: Of 167,176 CTO patients, 10,021 enrolled in CR, including 1,608 without another CR indication. Patients were propensity-matched for independent risk factors for mortality. After 5 years, CR participation was associated with a significant reduction in mortality (HR 0.68; 95% CI, 0.61-0.75; p < 0.0001). This benefit was preserved even after excluding prior revascularization (HR 0.81; 95% CI, 0.67-0.99; p < 0.036). Conclusion: This study demonstrates that cardiac rehabilitation is associated with improved long-term survival in patients with CTOs.