Background
Mortality from coronary heart disease (CHD) in developed nations has fallen over the past three decades; however, CHD still accounts for around 20% of deaths in Europe.1 In the UK, around 110 000 men and 65 000 women are admitted with acute coronary syndrome every year and it is estimated that there are 2.3 million people living with CHD.2
Cardiac rehabilitation (CR) is offered to individuals after cardiac events in order to facilitate recovery and prevent relapse by optimising cardiovascular risk reduction, fostering healthy behaviours and compliance to these behaviours, and promoting an active lifestyle.3 While a central component is exercise training,4 ,5 it is recommended that CR programmes provide lifestyle education on CHD risk factor management plus counselling and psychological support—so-called ‘comprehensive CR’.6 ,7 Such programmes are designed to limit the physiological and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction following myocardial infarction (MI), control cardiac symptoms, stabilise or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients (eg, by improving functional capacity to support early return to work7).
Recent Cochrane reviews demonstrate that CR improves health-related quality of life (HRQoL) and reduces hospital admissions compared with usual care in various patient groups including those with MI, heart failure and following percutaneous coronary intervention and coronary artery bypass graft.8 ,9 National and international professional guidelines including the National Institute for Health and Care Excellence (NICE) in the UK, the American Heart Association/American College of Cardiology, and the European Society of Cardiology recommend CR as an effective and safe intervention in the management of CHD and heart failure.10–15
Despite these apparent benefits and recommendations, participation in CR in the UK and abroad remains suboptimal, particularly for heart failure.16 ,17 A 2012 UK-based survey found that only 16% of CR centres provided a programme specifically designed for people with heart failure; commonly cited reasons for the lack of provision of CR were a lack of resources and exclusion from commissioning agreements.16 Two main reasons given by patients for failing to take part in CR are difficulties with regular attendance at their local hospital and reluctance to join group-based classes.18
Home-based rehabilitation programmes have been introduced as an alternative to the conventional centre-based CR to widen access and participation. For example, the Heart Manual (developed by National Health Service (NHS) Lothian) is a self-help manual supported by a trained professional, which is designed to assist in recovery and improve patients' understanding and management of their condition following MI, and is now widely used in the UK, Italy, Canada, Australia and New Zealand.19 ,20
While the previous Cochrane review found home-based and centre-based CR programmes to be equally effective in improving participant outcomes,21 ,22 the majority of evidence was in low-risk patients following MI or revascularisation. We are aware of a number of randomised head-to-head trials of centre-based versus home-based CR in heart failure that have been published since the previous review.23–25
The aim of this study was to update the previous (2010) Cochrane systematic review and meta-analysis of the randomised controlled trial evidence comparing home-based and centre-based CR.