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Journal of the American College of... Mar 2021Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes... (Review)
Review
Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Exercise training and other components of cardiac rehabilitation (CR) are safe and beneficial and result in significant improvements in quality of life, functional capacity, exercise performance, and heart failure (HF)-related hospitalizations in patients with HF. Despite outcome benefits, cost-effectiveness, and strong practice guideline recommendations, CR remains underused. Clinicians, health care leaders, and payers should prioritize incorporating CR as part of the standard of care for patients with HF.
Topics: Cardiac Rehabilitation; Functional Status; Heart Failure; Humans; Quality of Life; Treatment Outcome
PubMed: 33736829
DOI: 10.1016/j.jacc.2021.01.030 -
European Heart Journal Feb 2023Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous... (Meta-Analysis)
Meta-Analysis Review
AIMS
Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous meta-analyses of randomized controlled trials (RCTs) is questioned. Therefore, a contemporary updated meta-analysis was undertaken.
METHODS AND RESULTS
Database and trial registry searches were conducted to September 2020, seeking RCTs of exercise-based interventions with ≥6-month follow-up, compared with no-exercise control for adults with myocardial infarction, angina pectoris, or following coronary artery bypass graft, or percutaneous coronary intervention. The outcomes of mortality, recurrent clinical events, and health-related quality of life (HRQoL) were pooled using random-effects meta-analysis, and cost-effectiveness data were narratively synthesized. Meta-regression was used to examine effect modification. Study quality was assessed using the Cochrane risk of bias tool. A total of 85 RCTs involving 23 430 participants with a median 12-month follow-up were included. Overall, exercise-based CR was associated with significant risk reductions in cardiovascular mortality [risk ratio (RR): 0.74, 95% confidence interval (CI): 0.64-0.86, number needed to treat (NNT): 37], hospitalizations (RR: 0.77, 95% CI: 0.67-0.89, NNT: 37), and myocardial infarction (RR: 0.82, 95% CI: 0.70-0.96, NNT: 100). There was some evidence of significantly improved HRQoL with CR participation, and CR is cost-effective. There was no significant impact on overall mortality (RR: 0.96, 95% CI: 0.89-1.04), coronary artery bypass graft (RR: 0.96, 95% CI: 0.80-1.15), or percutaneous coronary intervention (RR: 0.84, 95% CI: 0.69-1.02). No significant difference in effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias.
CONCLUSION
This review confirms that participation in exercise-based CR by patients with coronary heart disease receiving contemporary medical management reduces cardiovascular mortality, recurrent cardiac events, and hospitalizations and provides additional evidence supporting the improvement in HRQoL and the cost-effectiveness of CR.
Topics: Adult; Humans; Cardiac Rehabilitation; Coronary Disease; Myocardial Infarction; Exercise Therapy; Exercise; Quality of Life
PubMed: 36746187
DOI: 10.1093/eurheartj/ehac747 -
Trends in Cardiovascular Medicine Aug 2017Cardiac rehabilitation is a valuable treatment for patients with a broad spectrum of cardiac disease. Current guidelines support its use in patients after acute coronary... (Review)
Review
Cardiac rehabilitation is a valuable treatment for patients with a broad spectrum of cardiac disease. Current guidelines support its use in patients after acute coronary syndrome, coronary artery bypass grafting, coronary stent placement, valve surgery, and stable chronic systolic heart failure. Its use in these conditions is supported by a robust body of research demonstrating improved clinical outcomes. Despite this evidence, cardiac rehabilitation referral and attendance remains low and interventions to increase its use need to be developed.
Topics: Cardiac Rehabilitation; Exercise Therapy; Health Status; Heart Diseases; Humans; Patient Compliance; Patient Education as Topic; Practice Guidelines as Topic; Practice Patterns, Physicians'; Recovery of Function; Referral and Consultation; Social Support; Time Factors; Treatment Outcome
PubMed: 28318815
DOI: 10.1016/j.tcm.2017.02.005 -
European Heart Journal May 2023Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base,... (Review)
Review
Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, 'hybrid') and according to stage of disease and patient preference.
Topics: Humans; Cardiac Rehabilitation; Quality of Life; Heart Failure; Exercise Therapy
PubMed: 36905176
DOI: 10.1093/eurheartj/ehad118 -
Reviews in Cardiovascular Medicine Mar 2019Coronary heart disease is a serious threat to human health. In China, medical care for the population has been focused on therapy with little follow-up of treated... (Review)
Review
Coronary heart disease is a serious threat to human health. In China, medical care for the population has been focused on therapy with little follow-up of treated patients. The efficacy of therapy; however, is highly dependent on post-therapy recovery. Cardiac rehabilitation can significantly enhance patient physical strength and help delay and prevent the development of coronary atherosclerosis. Although the clinical significance of cardiac rehabilitation has been established, the compliance of patients is generally low. In efforts to improve patient compliance, domestic and foreign researchers have extensively studied and applied treatment models of cardiac rehabilitation according to the specific conditions and cultural background of each country. This study aimed to review the treatment models of cardiac rehabilitation in patients with coronary heart disease and related factors affecting patient compliance to provide a better perspective of how patients with coronary heart disease can benefit from cardiac rehabilitation.
Topics: Cardiac Rehabilitation; Coronary Disease; Health Knowledge, Attitudes, Practice; Humans; Patient Compliance; Patient Participation; Self Care; Treatment Outcome
PubMed: 31184093
DOI: 10.31083/j.rcm.2019.01.53 -
Monaldi Archives For Chest Disease =... Oct 2016Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD).... (Review)
Review
Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD). Cardiac rehabilitation for patients, mostly with heart failure, with implanted electronic devices as pacemakers or ICD is a unique opportunity not only to optimize the medical treatment, to increase their exercise capacity and improves their clinical condition but also to supervise the correct functioning of the device. CRT reduces clinical symptoms and increases slightly the exercise capacity. But in these patients, the clinical improvements are likely to be explained by both the enhancement of cardiac function induced by the device and by the improved peripheral (muscular and vascular) and cardiac effects of exercise. The additional expected gain by exercise in this population is between 14 to 25%. In patients implanted with an ICD, exercise training is safe, without increasing shocks or anti-tachycardia pacing therapy. The comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves exercise capacity, quality of life, general and mental health. Nevertheless, further large scale studies was needed to evaluate the most appropriate management and demonstrate definitively the role of cardiac rehabilitation in this particular group of patients.
Topics: Aged; Cardiac Rehabilitation; Cardiac Resynchronization Therapy; Defibrillators, Implantable; Exercise; Exercise Tolerance; Female; Heart Failure; Humans; Male; Middle Aged; Pacemaker, Artificial; Quality of Life; Secondary Prevention; Treatment Outcome
PubMed: 27748467
DOI: 10.4081/monaldi.2016.756 -
Cleveland Clinic Journal of Medicine Jul 2018Cardiac rehabilitation, consisting of prescribed exercise and counseling for risk modification, has proven benefits for patients with cardiovascular disease.... (Review)
Review
Cardiac rehabilitation, consisting of prescribed exercise and counseling for risk modification, has proven benefits for patients with cardiovascular disease. Nevertheless, rates of referral and use remain low. Efforts to increase program referral and participation are ongoing.
Topics: Cardiac Rehabilitation; Cardiovascular Diseases; Exercise Therapy; Humans; Risk Reduction Behavior
PubMed: 30004380
DOI: 10.3949/ccjm.85a.17037 -
The Cochrane Database of Systematic... Jan 2019Chronic heart failure (HF) is a growing global health challenge. People with HF experience substantial burden that includes low exercise tolerance, poor health-related... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Chronic heart failure (HF) is a growing global health challenge. People with HF experience substantial burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous (2014) Cochrane systematic review reported that exercise-based cardiac rehabilitation (CR) compared to no exercise control shows improvement in HRQoL and hospital admission among people with HF, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane Review include the following: (1) most trials were undertaken in patients with HF with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with preserved (≥ 45%) ejection fraction HF (HFpEF) were under-represented; and (2) most trials were undertaken in the hospital/centre-based setting.
OBJECTIVES
To determine the effects of exercise-based cardiac rehabilitation on mortality, hospital admission, and health-related quality of life of people with heart failure.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and three other databases on 29 January 2018. We also checked the bibliographies of systematic reviews and two trial registers.
SELECTION CRITERIA
We included randomised controlled trials that compared exercise-based CR interventions with six months' or longer follow-up versus a no exercise control that could include usual medical care. The study population comprised adults (> 18 years) with evidence of HF - either HFrEF or HFpEF.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened all identified references and rejected those that were clearly ineligible for inclusion in the review. We obtained full papers of potentially relevant trials. Two review authors independently extracted data from the included trials, assessed their risk of bias, and performed GRADE analyses.
MAIN RESULTS
We included 44 trials (5783 participants with HF) with a median of six months' follow-up. For this latest update, we identified 11 new trials (N = 1040), in addition to the previously identified 33 trials. Although the evidence base includes predominantly patients with HFrEF with New York Heart Association classes II and III receiving centre-based exercise-based CR programmes, a growing body of studies include patients with HFpEF and are undertaken in a home-based setting. All included studies included a no formal exercise training intervention comparator. However, a wide range of comparators were seen across studies that included active intervention (i.e. education, psychological intervention) or usual medical care alone. The overall risk of bias of included trials was low or unclear, and we downgraded results using the GRADE tool for all but one outcome.Cardiac rehabilitation may make little or no difference in all-cause mortality over the short term (≤ one year of follow-up) (27 trials, 28 comparisons (2596 participants): intervention 67/1302 (5.1%) vs control 75/1294 (5.8%); risk ratio (RR) 0.89, 95% confidence interval (CI) 0.66 to 1.21; low-quality GRADE evidence) but may improve all-cause mortality in the long term (> 12 months follow up) (6 trials/comparisons (2845 participants): intervention 244/1418 (17.2%) vs control 280/1427 (19.6%) events): RR 0.88, 95% CI 0.75 to 1.02; high-quality evidence). Researchers provided no data on deaths due to HF. CR probably reduces overall hospital admissions in the short term (up to one year of follow-up) (21 trials, 21 comparisons (2182 participants): (intervention 180/1093 (16.5%) vs control 258/1089 (23.7%); RR 0.70, 95% CI 0.60 to 0.83; moderate-quality evidence, number needed to treat: 14) and may reduce HF-specific hospitalisation (14 trials, 15 comparisons (1114 participants): (intervention 40/562 (7.1%) vs control 61/552 (11.1%) RR 0.59, 95% CI 0.42 to 0.84; low-quality evidence, number needed to treat: 25). After CR, a clinically important improvement in short-term disease-specific health-related quality of life may be evident (Minnesota Living With Heart Failure questionnaire - 17 trials, 18 comparisons (1995 participants): mean difference (MD) -7.11 points, 95% CI -10.49 to -3.73; low-quality evidence). Pooling across all studies, regardless of the HRQoL measure used, shows there may be clinically important improvement with exercise (26 trials, 29 comparisons (3833 participants); standardised mean difference (SMD) -0.60, 95% CI -0.82 to -0.39; I² = 87%; Chi² = 215.03; low-quality evidence). ExCR effects appeared to be consistent different models of ExCR delivery: centre vs. home-based, exercise dose, exercise only vs. comprehensive programmes, and aerobic training alone vs aerobic plus resistance programmes.
AUTHORS' CONCLUSIONS
This updated Cochrane Review provides additional randomised evidence (11 trials) to support the conclusions of the previous version (2014) of this Cochane Review. Compared to no exercise control, CR appears to have no impact on mortality in the short term (< 12 months' follow-up). Low- to moderate-quality evidence shows that CR probably reduces the risk of all-cause hospital admissions and may reduce HF-specific hospital admissions in the short term (up to 12 months). CR may confer a clinically important improvement in health-related quality of life, although we remain uncertain about this because the evidence is of low quality. Future ExCR trials need to continue to consider the recruitment of traditionally less represented HF patient groups including older, female, and HFpEF patients, and alternative CR delivery settings including home- and using technology-based programmes.
Topics: Adult; Aged; Cardiac Rehabilitation; Cause of Death; Chronic Disease; Exercise Therapy; Exercise Tolerance; Female; Health Status; Heart Failure; Hospitalization; Humans; Male; Middle Aged; Quality of Life; Randomized Controlled Trials as Topic; Stroke Volume; Young Adult
PubMed: 30695817
DOI: 10.1002/14651858.CD003331.pub5 -
Circulation Research Feb 2022Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended... (Review)
Review
Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.
Topics: Cardiac Rehabilitation; Cardiovascular Diseases; Diet, Healthy; Exercise; Female; Humans; Male; Sex Characteristics; Smoking Cessation; Treatment Outcome; Weight Loss
PubMed: 35175838
DOI: 10.1161/CIRCRESAHA.121.319894 -
ESC Heart Failure Aug 2022Cardiac rehabilitation (CR) is an evidence-based, secondary preventive strategy that improves mortality and morbidity rates in patients with heart failure (HF). However,... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
Cardiac rehabilitation (CR) is an evidence-based, secondary preventive strategy that improves mortality and morbidity rates in patients with heart failure (HF). However, the implementation and continuation of CR remains unsatisfactory, particularly for outpatients with physical frailty. This study investigated the efficacy and safety of a comprehensive home-based cardiac rehabilitation (HBCR) programme that combines patient education, exercise guidance, and nutritional guidance using information and communication technology (ICT).
METHODS AND RESULTS
This study was a single-centre, open-label, randomized, controlled trial. Between April 2020 and November 2020, 30 outpatients with chronic HF (New York Heart Association II-III) and physical frailty were enrolled. The control group (n = 15) continued with standard care, while the HBCR group (n = 15) also received comprehensive, individualized CR, including ICT-based exercise and nutrition guidance using ICT via a Fitbit® device for 3 months. The CR team communicated with each patient in HBCR group once a week via the application messaging tool and planned the training frequency and intensity of training individually for the next week according to each patient's symptoms and recorded pulse data during exercise. Dietitians conducted a nutritional assessment and then provided individual nutritional advice using the picture-posting function of the application. The primary outcome was the change in the 6 min walking distance (6MWD). The participants' mean age was 63.7 ± 10.1 years, 53% were male, and 87% had non-ischaemic heart disease. The observed change in the 6MWD was significantly greater in the HBCR group (52.1 ± 43.9 m vs. -4.3 ± 38.8 m; P < 0.001) at a 73% of adherence rate. There was no significant change in adverse events in either group.
CONCLUSIONS
Our comprehensive HBCR programme using ICT for HF patients with physical frailty improved exercise tolerance and improved lower extremity muscle strength in our sample, suggesting management with individualized ICT-based programmes as a safe and effective approach. Considering the increasing number of HF patients with frailty worldwide, our approach provides an efficient method to keep patients engaged in physical activity in their daily life.
Topics: Aged; Cardiac Rehabilitation; Communication; Exercise Therapy; Female; Frailty; Heart Failure; Humans; Male; Middle Aged; Technology
PubMed: 35534907
DOI: 10.1002/ehf2.13934