Exercise-based cardiac rehabilitation for coronary heart disease

  • Review
  • Intervention

Authors


Abstract

Background

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane systematic review previously published in 2011.

Objectives

To assess the effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with usual care on mortality, morbidity and HRQL in patients with CHD.

To explore the potential study level predictors of the effectiveness of exercise-based CR in patients with CHD.

Search methods

We updated searches from the previous Cochrane review, by searching Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 6, 2014) from December 2009 to July 2014. We also searched MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Science Citation Index Expanded (December 2009 to July 2014).

Selection criteria

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months’ follow-up, compared with a no exercise control. The study population comprised men and women of all ages who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or who have angina pectoris, or coronary artery disease. We included RCTs that reported at least one of the following outcomes: mortality, MI, revascularisations, hospitalisations, health-related quality of life (HRQL), or costs.

Data collection and analysis

Two review authors independently screened all identified references for inclusion based on the above inclusion and exclusion criteria. One author extracted data from the included trials and assessed their risk of bias; a second review author checked data. We stratified meta-analysis by the duration of follow up of trials, i.e. short-term: 6 to 12 months, medium-term: 13 to 36 months, and long-term: > 3 years.

Main results

This review included 63 trials which randomised 14,486 people with CHD. This latest update identified 16 new trials (3872 participants). The population included predominantly post-MI and post-revascularisation patients and the mean age of patients within the trials ranged from 47.5 to 71.0 years. Women accounted for fewer than 15% of the patients recruited. Overall trial reporting was poor, although there was evidence of an improvement in quality of reporting in more recent trials.

As we found no significant difference in the impact of exercise-based CR on clinical outcomes across follow-up, we focused on reporting findings pooled across all trials at their longest follow-up (median 12 months). Exercise-based CR reduced cardiovascular mortality compared with no exercise control (27 trials; risk ratio (RR) 0.74, 95% CI 0.64 to 0.86). There was no reduction in total mortality with CR (47 trials, RR 0.96, 95% CI 0.88 to 1.04). The overall risk of hospital admissions was reduced with CR (15 trials; RR 0.82, 95% CI 0.70 to 0.96) but there was no significant impact on the risk of MI (36 trials; RR 0.90, 95% CI 0.79 to 1.04), CABG (29 trials; RR 0.96, 95% CI 0.80 to 1.16) or PCI (18 trials; RR 0.85, 95% CI 0.70 to 1.04).

There was little evidence of statistical heterogeneity across trials for all event outcomes, and there was evidence of small study bias for MI and hospitalisation, but no other outcome. Predictors of clinical outcomes were examined across the longest follow-up of studies using univariate meta-regression. Results show that benefits in outcomes were independent of participants' CHD case mix (proportion of patients with MI), type of CR (exercise only vs comprehensive rehabilitation) dose of exercise, length of follow-up, trial publication date, setting (centre vs home-based), study location (continent), sample size or risk of bias.

Given the heterogeneity in outcome measures and reporting methods, meta-analysis was not undertaken for HRQL. In five out of 20 trials reporting HRQL using validated measures, there was evidence of significant improvement in most or all of the sub-scales with exercise-based CR compared to control at follow-up. Four trial-based economic evaluation studies indicated exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years.

The quality of the evidence for outcomes reported in the review was rated using the GRADE method. The quality of the evidence varied widely by outcome and ranged from low to moderate.

Authors' conclusions

This updated Cochrane review supports the conclusions of the previous version of this review that, compared with no exercise control, exercise-based CR reduces the risk of cardiovascular mortality but not total mortality. We saw a significant reduction in the risk of hospitalisation with CR but not in the risk of MI or revascularisation. We identified further evidence supporting improved HRQL with exercise-based CR. More recent trials were more likely to be well reported and include older and female patients. However, the population studied in this review still consists predominantly of lower risk individuals following MI or revascularisation. Further well conducted RCTs are needed to assess the impact of exercise-based CR in higher risk CHD groups and also those presenting with stable angina. These trials should include validated HRQL outcome measures, explicitly report clinical event outcomes including mortality and hospital admissions, and assess costs and cost-effectiveness.

Plain language summary

Exercise-based rehabilitation for coronary heart disease

Background

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and reduce the chances of future problems such as heart attacks. Exercise-based cardiac rehabilitation aims to improve the health and outcome of people with CHD.

Study characteristics

We searched the scientific literature for randomised controlled trials (experiments that randomly allocate participants to one of two or more treatment groups) looking at the effectiveness of exercise-based treatments compared with no exercise in people of all ages with CHD. The search is current to July 2014.

Key results
This latest update identified 16 trials (3872 participants). We included a total of 63 trials that studied 14,486 people with CHD, predominantly heart attack survivors and those who had undergone heart bypass surgery or angioplasty (a procedure which widens narrowed or obstructed arteries or veins). The findings of this update are consistent with the previous (2011) version of this Cochrane review and show important benefits of exercise-based cardiac rehabilitation that include a reduction in the risk of death due to a cardiovascular cause and hospital admission and improvements in health-related quality of life, compared with not undertaking exercise. There was a considerable variation across studies in the reporting of health-related quality of life outcome. A small body of economic evidence was identified indicating exercise-based cardiac rehabilitation to be cost-effective. Further evidence is needed to understand the effect of exercise training in people with CHD who are higher risk and in those with established angina (chest pain).

Quality of evidence
Although the reporting of methods has improved in recent trials, lack of reporting made it difficult to assess the overall methodological quality and risk of possible bias of the evidence.

Laienverständliche Zusammenfassung

Trainingsbasierte Rehabilitation bei Koronarer Herzkrankheit

Hintergrund

Die Koronare Herzkrankheit (KHK) ist die weltweit häufigste Todesursache. Durch die sinkenden KHK-Sterblichkeitsraten lebt jedoch eine zunehmende Anzahl von Menschen mit KHK, die möglicherweise Unterstützung im Umgang mit ihren Symptomen und bei der Minderung des Risikos möglicher Folgeprobleme wie beispielsweise Herzinfarkten benötigen. Ziel einer trainingsbasierten Herz-Rehabilitation ist die Verbesserung der Gesundheit und die positive Beeinflussung des Krankheitsverlaufs von Patienten mit KHK.

Studienmerkmale

Wir durchsuchten die wissenschaftliche Literatur nach randomisierten kontrollierten Studien (Experimenten, in denen Teilnehmer einer von mindestens zwei Behandlungsgruppen zufällig zugeteilt werden), die die Wirksamkeit von trainingsbasierten Behandlungen verglichen mit keinem Training (d.h. mit der üblichen Versorgung, z.B. mit Medikamenten, aber ohne eine strukturierte Trainingstherapie oder Beratung) bei Menschen jeglichen Alters mit KHK untersuchten. Die Suche ist auf dem Stand von Juli 2014.

Hauptergebnisse
Diese jüngste Aktualisierung erbrachte 16 neue Studien (3872 Teilnehmer). Wir schlossen insgesamt 63 Studien ein, in denen 14.486 Menschen mit KHK untersucht wurden, hauptsächlich Patienten nach Herzinfarkt und solche, die mittels Bypass-Operation oder einer Angioplastie (eine Prozedur zur Weitung verengter oder verlegter Arterien oder Venen) behandelt worden waren. Die Ergebnisse dieser Aktualisierung stimmen mit denen der vorherigen (2011) Version dieses Cochrane Reviews überein und zeigen den bedeutenden Nutzen einer trainingsbasierten Herz-Rehabilitation. Der Nutzen umfasst eine Verringerung des Sterberisikos durch kardiovaskuläre (das Herz und Gefäßsystem betreffende) Ursachen und Krankenhauseinweisungen sowie Verbesserungen der gesundheitsbezogenen Lebensqualität im Vergleich zu keinem Training. Die Studien unterschieden sich erheblich in der Ergebnisdarstellung der gesundheitsbezogenen Lebensqualität. Es wurden einige wenige ökonomische (wirtschaftliche Aspekte betreffende) Belege gefunden, die darauf hinweisen, dass eine trainingsbasierte Herz-Rehabilitation kosteneffektiv ist. Weitere wissenschaftliche Belege sind erforderlich, um die Effekte von Training für Menschen mit KHK, die ein höheres Risiko tragen, und solchen mit Angina Pectoris (Brustenge, anfallsartig auftretende Schmerzen im Brustraum) zu verstehen.

Qualität der Evidenz (des wissenschaftlichen Belegs)
Obwohl sich die Darstellung der Methoden in den neueren Studien verbessert hat, erschwerte das Fehlen von Angaben die Bewertung der methodischen Gesamtqualität und des Risikos einer möglichen Verzerrung (Verfälschung) der Evidenz.

Anmerkungen zur Übersetzung

C. Braun, G. Diermayr, Koordination durch Cochrane Schweiz

Streszczenie prostym językiem

Rehabilitacja oparta o wysiłek fizyczny w chorobie wieńcowej

Wprowadzenie

Choroba wieńcowa (ChW) jest najczęstszą pojedynczą przyczyną zgonów na świecie. Ponieważ jednak umieralność z powodu ChW maleje, to coraz więcej osób żyje z tą chorobą. Mogą one potrzebować wsparcia w leczeniu objawowym oraz w zmniejszaniu ryzyka wystąpienia powikłań, np. zawału serca. Rehabilitacja kardiologiczna oparta o wysiłek fizyczny w ChW ma na celu poprawę ogólnego stanu zdrowia oraz rokowania u chorych.

Zakwalifikowane badania

Przeszukano piśmiennictwo naukowe pod kątem badań z randomizacją (losowym przydziałem uczestników do jednej z dwóch lub więcej grup), w których oceniano skuteczność ćwiczeń fizycznych, w porównaniu z ich, brakiem, u osób z ChW niezależnie od wieku. Ostatnie wyszukiwanie przeprowadzono w lipcu 2014 roku.

Główne wyniki⏎ ⏎ 

Podczas ostatniej aktualizacji przeglądu znaleziono 16 badań z randomizacją (3872 uczestników). Do analizy włączono ogółem 63 badania, w których uczestniczyło 14 486 osób z ChW, głównie po przebytym zawale serca oraz po operacji wszczepienia bypassów lub po angioplastyce (zabiegu poszerzenia zwężonego lub zablokowanego odcinka tętnicy).Wnioski z niniejszej aktualizacji są zgodne z poprzednią wersją przeglądu Cochrane (2011) i wykazują poważne korzyści płynące z rehabilitacji kardiologicznej opartej na wysiłku fizycznym, takie jak zmniejszenie ryzyka zgonu z przyczyn sercowo-naczyniowych, hospitalizacji oraz poprawę jakości życia związanej ze zdrowiem, w porównaniu z brakiem aktywności fizycznej. Wyniki dotyczące jakości życia związanej ze zdrowiem różniły się znacząco w poszczególnych badaniach.Nieliczne zidentyfikowane dane ekonomiczne wskazują, że rehabilitacja kardiologiczna oparta o wysiłek fizyczny jest opłacalna. Potrzeba więcej danych, aby lepiej ocenić wpływ wysiłku fizycznego na poszczególne grupy chorych na ChW - obciążone zarówno większym, jak i mniejszym ryzykiem powikłań i zgonu.

Jakość danych naukowych

Niedokładne opisy metodologii, mimo poprawy w nowszych badaniach, utrudniają ocenę jakości metodologicznej i ryzyka wystąpienia ewentualnego błędu systematycznego.

Uwagi do tłumaczenia

Tłumaczenie: Sylwia Łach. Redakcja: Łukasz Strzeszyński

Laički sažetak

Tjelovježba za rehabilitaciju koronarne bolesti srca

Dosadašnje spoznaje

Koronarna bolest srca (KBS) je najčešći uzrok smrti širom svijeta Međutim, kako se smanjuje stopa smrtnosti uzrokovana KBS-om, sve veći broj ljudi živi s tom bolesti i može im trebati odgovarajuća skrb za ublažavanje simptoma i smanjenje vjerojatnosti budućih problema kao što je srčani udar. Rehabilitacija koja se temelji na tjelovježbi provodi se kako bi se poboljšalo zdravlje i ishodi oboljelih od KBS-a.

Obilježja studija

U ovom Cochrane sustavnom pregledu pretražena je znanstvena literatura kako bi se pronašli randomizirani kontrolirani pokusi (studije u kojima se ispitanici nasumično razvrstavaju u terapijske skupine) u kojima je istražena djelotvornost tjelovježbe kao načina rehabilitacije u usporedbi s nikakvom tjelovježbom u oboljelih od KBS-a bez obzira na njihovu dob. Dokazi se temelje na istraživanjima objavljenima do srpnja 2014.

Ključni rezultati
Najnovijim pretraživanjem literature pronađeno je 16 novih studija (3872 ispitanika) o tjelovježbi za rehabilitaciju KBS-a. Tako da su u ovu najnoviju verziju Cochrane sustavnog pregleda na ovu temu uključena ukupno 63 randomizirana kontrolirana pokusa s 14486 uključenih ispitanika. Ispitanici su uglavnom bile osobe koje su preživjele srčani udar i osobe koje su imale kirurški zahvat s premosnicama (engl. heart bypass surgery) ili angioplastiku (postupak kojim se šire sužene krvne žile). Rezultati ove najnovije verzije Cochrane sustavnog pregleda u skladu su s prethodnom verzijom (iz 2011.) i pokazuju važnost tjelovježbe u rehabilitaciji srčanih bolesti, koja se očituje u smanjenju rizika od smrti zbog srčano-žilnih bolesti i primitaka u bolnicu, kao i povećanjem kvalitete života povezane sa zdravljem, u usporedbi s osobama u kojih tjelovježba nije bila dio rehabilitacije. Studije su se značajno razlikovale po načinu prikazivanja kvalitete života povezane sa zdravljem. Mali broj dokaza iz studija koje su ispitivale ekonomske aspekte takve rehabilitacije pokazuju da je rehabilitacija srčanih bolesnika koja se temelji na tjelovježbi isplativa. Potrebna su daljnja istraživanja da bi se ispitalo kakav je učinak tjelovježbe u osoba s KBS koje imaju visok rizik i onih koje imaju dokazanu anginu.

Kvaliteta dokaza
Iako se prikaz dokaza popravio u novijim istraživanjima, loš način prikazivanja podataka otežava procjenu ukupne metodološke kvalitete i rizik od potencijalne pristranosti u pronađenim dokazima.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr