Exercise-Based Cardiac Rehab for Coronary Disease
What is the evidence for recommending exercise-based cardiac rehabilitation (CR) for coronary heart disease (CHD) in the modern era?
A systematic review and meta-analysis was conducted in the published literature to July 2014. The authors included randomized controlled trials with at least 6 months of follow-up, comparing CR to no-exercise controls following myocardial infarction or revascularization, or with a diagnosis of angina pectoris or CHD defined by angiography. Studies were pooled using random-effects meta-analyses and were undertaken to examine potential treatment effect modifiers.
Sixty-three studies (majority European) with 14,486 participants and median follow-up of 12 months were included. Twenty-four studies were exercise only and 38 were comprehensive CR. Median size was 126 patients with a range of 28 to 2,304 patients. Median age was 56 years and <15% were women. Overall, CR led to a reduction in cardiovascular (CV) mortality (relative risk [RR], 0.74; 95% confidence interval [CI], 0.64-0.86) and reduction in the risk of hospital admissions (RR, 0.82; 95% CI, 0.70-0.96). There was no significant impact on total mortality, myocardial infarction, or revascularization. The majority of studies (13 of 20) showed higher levels of health-related quality of life in one or more domains following exercise-based CR compared with controls. The impact on health care costs was inconsistent, but trended to be cost-effective.
This review confirms that exercise-based CR reduces CV mortality and provides important data showing reductions in hospital admissions and improvements in quality of life. These benefits appear to be consistent across patients and intervention types, and were independent of study quality, setting, and publication date.
Reviews of the value of CR that included studies prior to the utility of evidence-based treatment of CHD have been thought to be biased ‘for’ because of higher event rates prior to the use of statins, aspirin, and beta-blockers. The endpoints in this review may in fact underestimate the value of CR post-MI since the mean follow-up was only 12 months and the review included lower risk indications than myocardial infarction.
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