Efficacy of Exercise-based Cardiac Rehabilitation Post-Myocardial Infarction
A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Patrick R Lawler, MD; Kristina B. Fillon, PhD; Mark J Eisenberg
American Heart Journal 2011; 162(4):571-584.
This systematic review published at the beginning of last year makes encouraging reading and is worthy of inclusion as a reference for those of you involved in research or needing to provide evidence that cardiac rehab (CR) works – at least for our ACS/STEMI/NSTEMI patients. This is especially important in the light of the recent and somewhat negative publication of the results of the RAMIT* trial by Robert West and colleagues (2011 online only as yet). All English-language randomised controlled trials (RCTs) looking at the effects of exercise-based CR in patients post MI were included. The researchers found a total of 34 RCTs which fitted their criterion (representing 6,111 patients). They reported that overall patients who participated in exercise-based CR had a lower risk of re-infarction whereas in the Cochrane review (2004) Taylor et al had been unable to demonstrate that CR reduced the risk of re-infarction. Moreover, both cardiac mortality and mortality from all-causes was also shown to be lower in the exercising CR groups. In addition, exercise-based CR had favourable effects on some of the cardiovascular risk factors: smoking, blood pressure, body weight and lipid profile.
Sally Turner PhD, MSc, MCSP Research Officer, ACPICR
References
* Robert R West, Dee A Jones, Andrew H Henderson. Rehabilitation after myocardial infarction (RAMIT); multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction (Heart Online 22nd December 2011).
Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease; systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116:682-692
Exercise based rehabilitation for heart failure. Cochrane Database of Systematic Reviews 2010.
Davies Ed, J., Moxham, T., Rees, K., Singh, S.,Coats Andrew, JS.,Ebrahim, S.,Lough, F., Taylor Rod, S. DOI: 10.1002/14651858.CD003331.pub3.
Exercise training may offer important improvements in patients' health-related quality of life.
Cardiac rehabilitation programme for coronary heart disease patients: An integrative literature review. Eshah NF and Bond AE : International Journal of Nursing Practice 2009; 15 (3):131–139.
Bottom-line conclusion: Cardiac rehabilitation programmes provided significant improvement in participants' quality of life, exercise capacity, lipid profile, body mass index, body weight, blood pressure, resting heart rate, survival rate, mortality rate and decreased myocardial infarction (MI) risk factors, although there was limited participation.
Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis.
Hwang, R. and T. Marwick. European Journal of Cardiovascular Prevention and Rehabilitation 2009; 16 (5): 527-35.
This review assessed the effectiveness of home-based exercise programmes compared with usual medical care in patients with chronic heart failure and concluded that there were short-term benefits. The reliability of the conclusions is unclear due to the unexplained variability and lack of information about the quality of included studies.
Cardiac rehabilitation improves survival in older patients with coronary disease.
Suaya JA, Stason WB, Ades PA et al: J Am Coll Cardiol 2009; 54: 25-33
Most of the data on the benefits of cardiac rehabilitation comes from randomised controlled trials and meta-analyses data that focussed on young to middle aged low risk men. A recent study provides evidence that an older American population who had been hospitalised for heart disease or revascularisation procedures benefitted from attendance at cardiac rehab. Just over 12% of the older population participated in an average of 24 sessions of cardiac rehab. Attendance at cardiac rehab appeared to reduce mortality by between 21-34%. This benefit did not differentiate between the different clinical subgroups involved in the study population – subjects recruited to the study were post MI, post revasc., or had a diagnosis of heart failure. Moreover, for the patients who attended 25 or more sessions of cardiac rehab, the risk of dying was 19% less over the following 5 years than matched users who completed less than 25 rehab sessions (p<0.001).
High-Calorie-Expenditure Exercise - A New Approach to Cardiac Rehabilitation for Overweight Coronary Patients.
Ades PA, Savage MS, Toth MJ et al: Circulation 2009, 119: 2671-2678
The majority of patients who join rehab programmes are overweight and more than half of these patients have metabolic syndrome. (Metabolic syndrome is a combination of medical problems that increase risk of developing heart disease and diabetes. People with metabolic syndrome have some or all of the following: high blood glucose, high blood pressure, abdominal obesity, low HDL elevated cholesterol and high triglycerides; Public Health Agency of Canada 2008). This study from the USA looked at the effect of two different exercise regimes on overweight patients whilst they attended 5 months of supervised cardiac rehabilitation. The high calorie expenditure group had an exercise expenditure goal of > 3000-3500 kcal/week and their exercise prescription consisted of longer duration exercise lasting 45-60 minutes and more frequent exercise – 5-7 times weekly. This compared with the ‘standard’ care group who exercised for a shorter duration of 25-40 minutes a session, and only 3 times each week. Walking was the preferred type of exercise. All patients completed homework exercise diaries to monitor exercise, aid compliance with the study, and to estimate calorific expenditure. By 5 months, most of the patients had progressed to performing the exercise prescription at home, with one session of supervised exercise a week.
Results from this study showed that there was a 28% reduction in the prevalence of metabolic syndrome in the patients who had undergone the high calorie expenditure exercise regime. The high calorie expenditure group also lost more weight than those who had received standard care.
Effects of moderate-to-high intensity resistance training in patients with chronic heart failure. Spruit, MA., Eterman, RM., Hellwig, VA., Janssen, PP., Wouters, EF., Uszko-Lencer, NH. Heart 2009; 95 (17): 1399-1408.
A predesigned data extraction form was used to obtain data on trial design and relevant results. Methodological quality of the identified trials were scored using the Delphi list.
Most of the 10 trials identified had moderate-to-severe methodological limitations. Effects of resistance training (alone or in combination with endurance training) are inconclusive for outcomes like exercise capacity and disease-specific quality of life.
Even though moderate-to-high intensity resistance training does not seem be harmful for patients with CHF, the current peer-reviewed evidence seems inadequate to generally recommend incorporation of resistance training into exercise-based rehabilitation programmes for patients with CHF.
Home-based versus centre-based cardiac rehabilitation.
Taylor Rod S, Dalal H, Jolly K, Moxham T, Zawada A. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007130.
OBJECTIVE: To compare the effect of home based and supervised centre based cardiac rehabilitation on mortality and morbidity, health related quality of life, and modifiable cardiac risk factors in patients with coronary heart disease.
CONCLUSIONS: Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients' adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the "Heart Manual." The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.
