Exercise-Based Rehabilitation for Coronary Heart Disease

Summary

A Cochrane review [Abstract] 1 included 85 studies with a total of 23 430 subjects with coronary heart disease (CHD; predominantly post-MI and post-revascularisation patients, mean age of patients within the studies ranged from 47 to 77 years). Exercise-based cardiac rehabilitation (CR) is defined as a supervised or unsupervised inpatient, outpatient, community- or home-based intervention which includes some form of exercise training that is applied to a cardiac patient population. The intervention could be exercise training alone or exercise training in addition to psychosocial or educational interventions, or both. 47 studies compared comprehensive programmes (i.e. exercise plus education or psychological management, or both, or other components), while 38 reported on an exercise-only intervention. The CR programmes were commonly delivered in either an exclusively supervised centre-based setting or a centre-based setting in combination with some home exercise sessions. Twenty-one studies were conducted in an exclusively home-based setting.

Short-term follow-up (6 to 12 months): Exercise-based CR reduced myocardial infarction, MI (RR 0.72, 95% CI 0.55 to 0.93; 22 studies, n=7 423; NNTB 75, 95% CI 47 to 298), and all-ause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 studies, n=2 030; NNTB 12, 95% CI 9 to 21), but not cardiovascular hospitalisation (RR 0.80, 95% CI 0.41 to 1.59, 6 studies, n=1 087; statistical heterogeneity I² =53%), all-cause mortality (RR 0.87, 95% CI 0.73 to 1.04; 25 studies, n=8 823), cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 studies, n=5 360), coronary artery bypass graft, CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 studies, n=4 473), and percutaneous coronary intervention, PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 studies, n=3 465).Medium-term follow-up (> 12 to 36 months): There was a reduction in cardiovascular mortality (RR 0.77, 95% CI 0.63 to 0.93; 5 studies, n=3 614), but not in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 16 studies, n=11 073), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 studies, n=9 565), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 studies, n=1 983), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 studies, n=2 826), all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 studies, n=5 995), and cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 studies, n=943).Long-term follow-up (> 3 years): Exercise-based CR reduced cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 studies, n=1 392) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 studies, n=1 560), but there was no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10; 11 studies, n=3 828), CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 studies, n=675), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 studies, n=567).

Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias.Exercise-based CR slightly increased HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The 8 trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).