Cardiac rehabilitation and physical activity: systematic review and meta-analysis

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Abstract

Objective

To undertake a systematic review and meta-analysis to assess the impact of cardiac rehabilitation (CR) on physical activity (PA) levels of patients with heart disease and the methodological quality of these studies.

Methods

Databases (MEDLINE, EMBASE, CENTRAL, CINAHL, PsychINFO and SportDiscus) were searched without language restriction from inception to January 2017 for randomised controlled trials (RCTs) comparing CR to usual care control in adults with heart failure (HF) or coronary heart disease (CHD) and measuring PA subjectively or objectively. The direction of PA difference between CR and control was summarised using vote counting (ie, counting the positive, negative and non-significant results) and meta-analysis.

Results

Forty RCTs, (6480 patients: 5825 CHD, 655 HF) were included with 26% (38/145) PA results showing a statistically significant improvement in PA levels with CR compared with control. This pattern of results appeared consistent regardless of type of CR intervention (comprehensive vs exercise-only) or PA measurement (objective vs subjective). Meta-analysis showed PA increases in the metrics of steps/day (1423, 95% CI 757.07 to 2089.43, p<0.0001) and proportion of patients categorised as physically active (relative risk 1.55, 95% CI 1.19 to 2.02, p=0.001). The included trials were at high risk of bias, and the quality of the PA assessment and reporting was relatively poor.

Conclusion

Overall, there is moderate evidence of an increase in PA with CR participation compared with control. High-quality trials are required, with robust PA measurement and data analysis methods, to assess if CR definitely leads to important improvements in PA.

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Most cited references 44

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The Minimal Important Difference in Physical Activity in Patients with COPD

Heleen Demeyer, Chris Burtin, Miek Hornikx … (2016)

Background Changes in physical activity (PA) are difficult to interpret because no framework of minimal important difference (MID) exists. We aimed to determine the minimal important difference (MID) in physical activity (PA) in patients with Chronic Obstructive Pulmonary Disease and to clinically validate this MID by evaluating its impact on time to first COPD-related hospitalization. Methods PA was objectively measured for one week in 74 patients before and after three months of rehabilitation (rehabilitation sample). In addition the intraclass correlation coefficient was measured in 30 patients (test-retest sample), by measuring PA for two consecutive weeks. Daily number of steps was chosen as outcome measurement. Different distribution and anchor based methods were chosen to calculate the MID. Time to first hospitalization due to an exacerbation was compared between patients exceeding the MID and those who did not. Results Calculation of the MID resulted in 599 (Standard Error of Measurement), 1029 (empirical rule effect size), 1072 (Cohen's effect size) and 1131 (0.5SD) steps.day-1. An anchor based estimation could not be obtained because of the lack of a sufficiently related anchor. The time to the first hospital admission was significantly different between patients exceeding the MID and patients who did not, using the Standard Error of Measurement as cutoff. Conclusions The MID after pulmonary rehabilitation lies between 600 and 1100 steps.day-1. The clinical importance of this change is supported by a reduced risk for hospital admission in those patients with more than 600 steps improvement.

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Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction.

Marcus Henderson, Alison Jones, Paul R. West (2012)

It is widely believed that cardiac rehabilitation following acute myocardial infarction (MI) reduces mortality by approximately 20%. This belief is based on systematic reviews and meta-analyses of mostly small trials undertaken many years ago. Clinical management has been transformed in the past 30-40 years and the findings of historical trials may have little relevance now. The principal objective was to determine the effect of cardiac rehabilitation, as currently provided, on mortality, morbidity and health-related quality of life in patients following MI. The secondary objectives included seeking programmes that may be more effective and characteristics of patients who may benefit more. DESIGN, SETTING, PATIENTS, OUTCOME MEASURES: A multi-centre randomised controlled trial in representative hospitals in England and Wales compared 1813 patients referred to comprehensive cardiac rehabilitation programmes or discharged to 'usual care' (without referral to rehabilitation). The primary outcome measure was all-cause mortality at 2 years. The secondary measures were morbidity, health service use, health-related quality of life, psychological general well-being and lifestyle cardiovascular risk factors at 1 year. Patient entry ran from 1997 to 2000, follow-up of secondary outcomes to 2001 and of vital status to 2006. A parallel study compared 331 patients in matched 'elective' rehabilitation and 'elective' usual care (without rehabilitation) hospitals. There were no significant differences between patients referred to rehabilitation and controls in mortality at 2 years (RR 0.98, 95% CI 0.74 to 1.30) or after 7-9 years (0.99, 95% CI 0.85 to 1.15), cardiac events, seven of eight domains of the health-related quality of life scale ('Short Form 36', SF36) or the psychological general well-being scale. Rehabilitation patients reported slightly less physical activity. No differences between groups were reported in perceived overall quality of cardiac aftercare. Data from the 'elective' hospitals comparison concurred with these findings. In this trial, comprehensive rehabilitation following MI had no important effect on mortality, cardiac or psychological morbidity, risk factors, health-related quality of life or activity. This finding is consistent with systematic reviews of all trials reported since 1983. The value of cardiac rehabilitation as practised in the UK is open to question.

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Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease.

Laura Beaton, Andrew Pipe, J Kocourek … (2012)

The CardioFit Internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes. A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization. The CardioFit Internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care. Patients with CHD using an Internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

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Author and article information

Journal

Journal ID (nlm-ta): Heart

Journal ID (iso-abbrev): Heart

Journal ID (hwp): heartjnl

Journal ID (publisher-id): heart

Title: Heart

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 1355-6037

ISSN (Electronic): 1468-201X

Publication date (Print): September 2018

Publication date (Electronic): 13 April 2018

Volume: 104

Issue: 17

Pages: 1394-1402

Affiliations

[1 ] departmentEuropean Centre for Environment and Human Health , Knowledge Spa, Royal Cornwall Hospitals NHS Trust, University of Exeter Medical School , Truro, UK

[2 ] Institute of Health Research (Primary Care), University of Exeter Medical School , Exeter, UK

[3 ] departmentDepartment of Health Sciences , University of York , York, UK

[4 ] National Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, University of Southern Denmark , Odense, Denmark

[5 ] departmentDepartment of Sport and Health Sciences , University of Exeter , Exeter, UK

Author notes

[Correspondence to ] Grace Olivia Dibben, Knowledge Spa, Royal Cornwall Hospitals NHS Trust, University of Exeter Medical School, Truro TR13HD, UK; gd318@ 123456exeter.ac.uk

Article

Publisher ID: heartjnl-2017-312832

DOI: 10.1136/heartjnl-2017-312832

PMC ID: 6109237

PubMed ID: 29654095

SO-VID: 260b9e0a-a7f4-41aa-98f4-30020bfe1850

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 08 December 2017

Date revision received : 12 March 2018

Date accepted : 14 March 2018

Funding

Funded by: University of Exeter Postgraduate Studentship Grant;

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: cardiac rehabilitation,coronary artery disease,heart failure,meta-analysis,systemic review

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: cardiac rehabilitation, coronary artery disease, heart failure, meta-analysis, systemic review

Cardiac rehabilitation and physical activity: systematic review and meta-analysis

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Cardiovascular Innovations and Applications

Most cited references 44

The Minimal Important Difference in Physical Activity in Patients with COPD

Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction.

Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease.

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