Review
Cardiac rehabilitation for people with heart disease: An overview of Cochrane systematic reviews

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Highlights

  • A contemporary review of the evidence for cardiac rehabilitation (CR) is presented.

  • The findings of six Cochrane systematic reviews of 148 RCTs of CR are summarised.

  • Exercise-based CR is effective and safe for stable patients with HF or post-MI or PCI.

  • We present recommendations for design and conduct of future RCTs and systematic reviews of CR.

Abstract

Introduction

Overviews are a new approach to summarising evidence and synthesising results from related systematic reviews.

Objectives

To conduct an overview of Cochrane systematic reviews to provide a contemporary review of the evidence for cardiac rehabilitation (CR), identify opportunities for merging or splitting existing Cochrane reviews, and identify current evidence gaps to inform new review titles.

Methods

The Cochrane Database of Systematic Reviews was searched to identify reviews that address the objectives of this overview. Data presentation is descriptive with tabular presentations of review- and trial-level characteristics and results.

Results

The six included Cochrane systematic reviews were of high methodological quality and included 148 randomised controlled trials in 97,486 participants. Compared to usual care alone, exercise-based CR reduces hospital admissions and improves patient health related quality of life (HRQL) in low to moderate risk heart failure and coronary heart disease (CHD) patients. At 12 months or more follow-up, there was evidence of some reduction in mortality in patients with CHD. Psychological- and education-based interventions appear to have little impact on mortality or morbidity but may improve HRQL. Home- and centre-based programmes are equally effective in improving HRQL at similar costs. Selected interventions can increase the uptake of CR programmes but evidence to support interventions that improve adherence is weak.

Conclusions

This overview confirms that exercise-based CR is effective and safe in the management of clinically stable heart failure and post-MI and PCI patients. We discuss the implications of this overview on the future direction of the Cochrane CR reviews portfolio.

Introduction

Cardiac rehabilitation (CR) can be defined as “The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease” [1].

The gold standard level of evidence to inform clinical and policy decisions on the use of new and existing therapeutic interventions is the systematic review of randomised controlled trials (RCTs), which can include a meta-analysis. The largest single producer of systematic reviews in health care is the Cochrane Collaboration, with more than 8400 published at the time of writing. Compared with systematic reviews published in paper-based journals, studies have consistently shown Cochrane systematic reviews to have greater methodological quality [2], [3], [4]. In the first two systematic reviews and meta-analyses of CR published more than 20 years ago, Oldridge and O'Connor reported a 20–25% reduction in all-cause and cardiovascular mortality, pooling data from 10 and 22 RCTs respectively, comparing rehabilitation and control in over 4300 post-myocardial infarction patients [5], [6]. In 2001, Jolliffe et al. published the first Cochrane review of exercise-based CR, updating the evidence to 32 RCTs in 8440 post-myocardial infarction and revascularisation patients, and confirming a similar 27% mortality benefit of exercise-based CR [7].

With funding support of the National Institute of Health Research (NIHR) in the United Kingdom, over the last 10 years the portfolio of published cardiac rehabilitation Cochrane reviews has grown to six systematic reviews/meta-analyses: Exercise-based rehabilitation for heart failure [8] ; Home‐based versus centre‐based cardiac rehabilitation [9]; Exercise‐based cardiac rehabilitation for coronary heart disease [10]; Psychological interventions for coronary heart disease [11]; Patient education in the management of coronary heart disease [12] and Promoting patient uptake and adherence in cardiac rehabilitation [13]. The development of the portfolio of Cochrane reviews has reflected many of the key areas of evolution in the provision of CR and how this model of service delivery can differ across international healthcare jurisdictions. These include the shift from emphasis on exercise training alone to comprehensive secondary prevention, including risk factor and dietary education and management of psychological factors; the broadening of the population of patients receiving CR services to include those with heart failure; the development of alternative settings of CR delivery that include home provision in addition to the traditional supervised hospital or centre-based programmes and the need to focus the outcomes of CR to inform the needs of healthcare policy makers (e.g. impacts on hospital admission, health-related quality of life (HRQL), and healthcare costs). The Cochrane CR review portfolio remains dynamic, with three reviews having undergone an update in the last 12 months [8], [9], [13].

Overviews of systematic reviews (overviews) are a new approach to summarising evidence, synthesising results from multiple systematic reviews into a single usable document [14]. By providing a single synthesis of all relevant evidence in a particular area, overviews may be useful for therapeutic and policy decision-making, providing a comprehensive “friendly front end” to the evidence, so that the reader does not have to assimilate data from separate systematic reviews. Overviews can also help inform the strategic direction of conduct and structuring of future systematic reviews. For example, the latest version of the Cochrane review of exercise-based CR for coronary heart disease (CHD) includes 47 RCTs in over 10,000 patients and may therefore benefit from being organised into sub-reviews (“splitting”) according to CHD indications, i.e. post-MI, revascularisation and angina. Finally, overviews provide an opportunity to identify potential “evidence gaps” and therefore inform areas where new Cochrane reviews should be prioritised.

This overview seeks to present a concise summary of the research question, methods and findings of the Cochrane reviews on CR. We also seek to identify the opportunities for merging or splitting across future Cochrane reviews, identify evidence gaps to inform de novo Cochrane CR review titles, and provide recommendations to encourage uniformity of future reporting systematic reviews and RCTs of CR. While it is currently recognised that ‘comprehensive’ CR programmes should contain exercise, education and psychological components, for clarity in this overview, we will pre-fix “CR” with the focus of the intervention where we feel it might help the reader in interpreting the evidence, e.g. exercise-based CR or education-based CR.

Section snippets

Methods

This overview was conducted in accordance with the recommendations for Cochrane overviews [14].

Identification of reviews

The review selection process is summarised in the flow diagram in Fig. 1. Our database search yielded 91 titles from which we identified one published Cochrane review (in addition to the previously identified six reviews) and three Cochrane review protocols which were judged to meet the inclusion criteria. On review of the full text we excluded the published Cochrane review [20] as while it evaluated physical therapy with an exercise component for elective cardiac surgery patients, only one

Summary of main results

CR programmes have become an integral part of the standard of care for patients with heart disease. The scope of contemporary CR has shifted from exercise interventions alone to more comprehensive secondary prevention programmes that include risk factor education and psychological support. This overview identified six Cochrane systematic reviews of RCTs that have assessed the outcomes of various aspects of the delivery of CR and its component interventions. The key outcome findings of our

Contributions of authors

Both authors were involved in the conception and design of the protocol and the review. LJA and RST undertook the study selection, data extraction and risk of bias assessment. The manuscript was drafted by both authors.

Declarations of interest

Lindsey Anderson declares that she has no conflicts of interest. RST was a co-author on five of the included systematic reviews.

Acknowledgements

We are grateful for the help of Nicole Martin at the Cochrane Heart Group, for her help in developing the search strategy for this overview. We are extremely grateful to our external reference group members (Dr Mike Knapton, Prof Gill Furze, Dr Neil Smart, Prof Patrick Doherty, Dr Ann-Dorthe Zwisler, Prof Neil Oldridge, Dr Phil Adams, Dr Christopher O'Conner, Dr Juan Pablo-Casas and Dr Mark Huffman) for their invaluable advice and support in the preparation of this manuscript. We thank the

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    Funding: This study has no external funding. LJA is a University of Exeter Medical School funded Cochrane review Research Fellow.

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