Put disease prevention first.

W orldwide, noncommunicable diseases are the dominant cause of death, with atherosclerotic cardiovascular disease a major contributor. 1 These deaths are spread across high-to low-income countries, with ≈1 in 3 of all cardiovas-cular disease deaths occurring in individuals aged <70 years, amounting to an estimated 6 million cases annually. 1 Analyses in many countries have shown that both an improvement in risk factors and advances in medical therapies have contributed to the fall in age-standardized mortality from coronary heart disease (CHD). 2 Importantly, leading a healthy lifestyle has broader implications for the prevention and management of other noncommunicable diseases including cancer, diabetes mellitus, and chronic respiratory diseases. After decades of major advances in the treatment of acute CHD events it is being appreciated increasingly that evidence-based long-term management of CHD is critical to achieve optimal reductions in mortality and morbidity. Each year, ≈50% of major coronary events occur in those with a hospital discharge diagnosis of CHD. 3 Half of these recurrent events are fatal. 3 A significant number of such CHD events will occur within the first year after hospitalization for nonfatal acute coronary syndromes. 4 Older trials of comprehensive cardiac rehabilitation inclusive of exercise, other aspects of a healthy lifestyle, and adherence to pharmacological therapies can improve the course of CHD and reduce all-cause and cardiovascular mortality by up to 25%. 5 However, concerns have emerged as to whether the benefits of cardiac rehabilitation continue to apply in an era where acute reperfusion therapy (eg, fibrinolysis/primary percutaneous coronary intervention) and a suite of preventive pharmacotherapies (aspirin and other antiplatelet agents, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibi-tors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and β-blockers) are very widely available. Indeed, much of the highest level trial evidence for cardiac rehabilitation 6 in survivors of acute myocardial infarction (with or without heart failure), those with stable angina, or treated with coronary revascularization is dated, with the patient group that undergo coronary artery bypass graft (CABG) surgery having been somewhat understudied. 7 Countering this view is a recent large US study of Medicare patients with mixed CHD diagnoses that corroborated improved survival associated with cardiac rehabilitation. 8 This issue of Circulation includes an important community-cohort study 9 of the association between attendance at cardiac rehabilitation and all-cause mortality in patients surviving the first 6 months after CABG surgery. In this sizable, mostly white, post-CABG cohort from Olmsted County, participation in cardiac …