Clinical study
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials

https://doi.org/10.1016/j.amjmed.2004.01.009Get rights and content

Abstract

Purpose

To review the effectiveness of exercise-based cardiac rehabilitation in patients with coronary heart disease.

Methods

A systematic review and meta-analysis of randomized controlled trials was undertaken. Databases such as MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2003. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise training alone or in combination with psychological or educational interventions.

Results

We included 48 trials with a total of 8940 patients. Compared with usual care, cardiac rehabilitation was associated with reduced all-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96); greater reductions in total cholesterol level (weighted mean difference, –0.37 mmol/L [–14.3 mg/dL]; 95% CI: –0.63 to –0.11 mmol/L [–24.3 to –4.2 mg/dL]), triglyceride level (weighted mean difference, –0.23 mmol/L [–20.4 mg/dL]; 95% CI: –0.39 to –0.07 mmol/L [–34.5 to –6.2 mg/dL]), and systolic blood pressure (weighted mean difference, –3.2 mm Hg; 95% CI: –5.4 to –0.9 mm Hg); and lower rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83). There were no significant differences in the rates of nonfatal myocardial infarction and revascularization, and changes in high- and low-density lipoprotein cholesterol levels and diastolic pressure. Health-related quality of life improved to similar levels with cardiac rehabilitation and usual care. The effect of cardiac rehabilitation on total mortality was independent of coronary heart disease diagnosis, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date.

Conclusion

This review confirms the benefits of exercise-based cardiac rehabilitation within the context of today's cardiovascular service provision.

Section snippets

Literature search

Randomized controlled trials were identified from previously published systematic reviews and meta-analyses 5, 6, 7, 8. This list of studies was updated by searching a number of clinical databases, including MEDLINE, EMBASE, CINAHL, and SciSearch, up to March 2003. The Cochrane Library was also searched. The search strategy was developed to maximize sensitivity of article identification and was not restricted by language. It used both controlled vocabulary (e.g., Medical Subject Headings

Results

Over 5000 titles were retrieved from the various search sources and 425 full papers were identified for possible inclusion. Studies were excluded for a variety of reasons: nonrandomized design (18%), inappropriate patient group(s) (9%), inappropriate intervention (22%), the control group received an exercise intervention (14%), inappropriate outcome(s) (21%), inadequate follow-up (14%), and preliminary results available only in abstract form (2%) 17, 18. One trial published after the search

Discussion

This systematic review confirms the findings of previous meta-analyses that exercise-based cardiac rehabilitation reduces both cardiac and total mortality but not the risk of recurrent myocardial infarction or revascularization 5, 6, 7, 8. In fact, our review shows that the mortality effects of exercise therapy appear to be consistent across a number of coronary heart disease groups (e.g., post–myocardial infarction, postrevascularization, angina) as well as a range of exercise-based

Acknowledgements

We thank the Cochrane Heart Group for their administrative support. We also acknowledge the various external reviewers for their comments on subsequent reports on which this paper is based.

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    This study was supported by the Canadian Coordinating Office for Health Technology Assessment, the British Heart Foundation, and the UK Physiotherapy Research Foundation. Dr. Taylor is a former Chair of the British Association of Cardiac Rehabilitation Scientific Committee. Dr. Stone is past president of the Canadian Association of Cardiac Rehabilitation.

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