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Meta-Analysis
. 2016 Jan 5;2016(1):CD001800.
doi: 10.1002/14651858.CD001800.pub3.

Exercise-based cardiac rehabilitation for coronary heart disease

Lindsey Anderson  1 , David R Thompson, Neil Oldridge, Ann-Dorthe Zwisler, Karen Rees, Nicole Martin, Rod S Taylor
Affiliations
Meta-Analysis

Exercise-based cardiac rehabilitation for coronary heart disease

Lindsey Anderson et al. Cochrane Database Syst Rev. .

Update in

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.

PubMed Disclaimer

Conflict of interest statement

RST, KR, NO and DRT were authors of the original Cochrane review. RST is an author on number of other Cochrane CR reviews and is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based CR intervention for people with heart failure and their carers (PGfAR RP‐PG‐0611‐12004). ADZ is an author on other Cochrane CR reviews and the Principal Investigator of ongoing CR trials (the DANREHAB trial and the CopenHeart trials). NM and LA have no known conflicts of interest.

Figures

1
1
Summary of study selection process
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Total mortality for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
4
4
CV mortality for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
5
5
Fatal and / or nonfatal MI for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
6
6
CABG for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
7
7
PCI for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
8
8
Hospital admissions for all studies at their longest follow‐up. Filled diamonds represent the risk ratio (RR) for individual studies at the longest reported follow‐up. The boxes are proportional to the weight of each
 study in the analysis and the lines represent their 95% confidence interval (CI). The open diamond represents the pooled RR, and its width represents its
 95% CI.
9
9
Funnel plot of comparison: 1 Exercise‐based rehabilitation versus usual care, outcome: 1.3 Fatal and/or nonfatal MI.
10
10
Funnel plot of comparison: 1 Exercise‐based rehabilitation versus usual care, outcome: 1.6 Hospital admissions.
1.1
1.1. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 1 Total mortality.
1.2
1.2. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 2 Cardiovascular mortality.
1.3
1.3. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 3 Fatal and/or nonfatal MI.
1.4
1.4. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 4 CABG.
1.5
1.5. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 5 PCI.
1.6
1.6. Analysis
Comparison 1 Exercise‐based rehabilitation versus usual care, Outcome 6 Hospital admissions.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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Specchia 1996 {published data only}
    1. Specchia G, Servi S, Scirè A, Assandri J, Berzuini C, Angoli L, et al. Interaction between exercise training and ejection fraction in predicting prognosis after a first myocardial infarction. Circulation 1996;94(5):978‐82. - PubMed
Ståhle 1999 {published data only}
    1. Hage C, Mattsson E, Ståhle A. Long term effects of exercise training on physical activity level and quality of life in elderly coronary patients ‐ a three‐ to six‐year follow‐up. Physiotherapy Research International 2003;8(1):13‐22. - PubMed
    1. Ståhle A, Lindquist I, Mattsson E. Important factors for physical activity among elderly patients one year after an acute myocardial infarction. Scandinavian Journal of Rehabilitation Medicine 2000;32(3):111‐6. - PubMed
    1. Ståhle A, Mattsson E, Rydén L, Unden AL, Nordlander R. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. A 1 year follow‐up randomized controlled study. European Heart Journal 1999;20(20):1475‐84. - PubMed
    1. Ståhle A, Nordlander R, Rydén L, Mattsson E. Effects of organized aerobic group training in elderly patients discharged after an acute coronary syndrome. A randomized controlled study.. Scandinavian Journal of Rehabilitation Medicine 1999;31(2):101‐7. - PubMed
    1. Ståhle A, Tollbäck A. Effects of aerobic group training on exercise capacity, muscular endurance and recovery in elderly patients with recent coronary events: A randomized, controlled study. Advances in Physiotherapy 2001;3:29‐37.
Stern 1983 {published data only}
    1. Stern MJ, Gorman PA, Kaslow L. The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction. Archives of Internal Medicine 1983;143(9):1719‐25. - PubMed
Toobert 2000 {published data only}
    1. Toobert DJ, Glasgow RE, Nettekoven LA, Brown JE. Behavioral and psychosocial effects of intensive lifestyle management for women with coronary heart disease. Patient Education and Counseling 1998;35(3):177‐88. - PubMed
    1. Toobert DJ, Glasgow RE, Radcliffe JL. Physiologic and related behavioral outcomes from the Women's Lifestyle Heart Trial. Annals of Behavioral Medicine 2000;22(1):1‐9. - PubMed
Vecchio 1981 {published data only}
    1. Vecchio C, Cobelli F, Opasich C, Assandri J, Poggi G, Griffo R. Early functional evaluation and physical rehabilitation in patients with wide myocardial infarction [Valutazione funzionale precoce e riabilitazione fisica nei pazienti con infarto miocardico esteso]. Giornale Italiano di Cardiologia 1981;11:419‐29. - PubMed
Vermeulen 1983 {published data only}
    1. Vermeulen A, Lie KI, Durrer D. Effects of cardiac rehabilitation after myocardial infarction: changes in coronary risk factors and long‐term prognosis. American Heart Journal 1983;105(5):798‐801. - PubMed
VHSG 2003 {published data only}
    1. Vestfold Heartcare Study Group. Influence on lifestyle measures and five‐year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease. European Journal of Cardiovascular Prevention and Rehabilitation 2003;10(6):429‐37. - PubMed
Wang 2012 {published data only}
    1. Wang W, Chair SY, Thompson DR, Twinn SF. Effects of home‐based rehabilitation on health‐related quality of life and psychological status in Chinese patients recovering from acute myocardial infarction. Heart & Lung 2012;41:15‐25. - PubMed
West 2012 {published data only}
    1. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi‐centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012;98:637‐44. - PubMed
WHO 1983 {published data only}
    1. World Health Organization. Rehabilitation and comprehensive secondary prevention after acute myocardial infarction. EURO Reports and Studies 84 1983.
Wilhelmsen 1975 {published data only}
    1. Sanne H. Exercise tolerance and physical training of non‐selected patients after myocardial infarction. Acta Medica Scandinavica 1973;Supplementum 551:1‐124. - PubMed
    1. Wilhelmsen L, Sanne H, Elmfeldt D, Grimby G, Tibblin G, Wedel H. A controlled trial of physical training after myocardial infarction. Effects on risk factors, nonfatal reinfarction, and death. Preventive Medicine 1975;4(4):491‐508. - PubMed
Yu 2003 {published data only}
    1. Yu CM, Li LS, Ho HH, Lau CP. Long‐term changes in exercise capacity, quality of life, body anthropometry, and lipid profiles after a cardiac rehabilitation program in obese patients with coronary heart disease. American Journal of Cardiology 2003;91(3):321‐5. - PubMed
Yu 2004 {published data only}
    1. Yu C, Li L, Lam M, Siu D, Miu R, Lau C. Effect of a cardiac rehabilitation program on left ventricular diastolic function and its relationship to exercise capacity in patients with coronary heart disease: experience from a randomized, controlled study. American Heart Journal 2004;147(5):e24. - PubMed
    1. Yu CM, Lau CP, Chau J, McGhee S, Kong SL, Cheung BM, et al. A short course of cardiac rehabilitation program is highly cost effective in improving long‐term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Archives of Physical Medicine and Rehabilitation 2004;85(12):1915‐22. - PubMed
Zwisler 2008 {published and unpublished data}
    1. Kruse M, Hochstrasser S, Zwisler AD, Kjellberg J. Comprehensive cardiac rehabilitation: A cost assessment based on a randomized clinical trial. International Journal of Technology Assessment in Health Care 2006;22(4):478‐83. - PubMed
    1. Zwisler AD, Soja AM, Rasmussen S, Frederiksen M, Abedini S, Appel J, et al. Hospital‐based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12‐month results of a randomized clinical trial. American Heart Journal 2008;155(6):1106‐13. - PubMed

References to studies excluded from this review

Agren 1989 {published data only}
    1. Agren B, Olin C, Castenfors J, Nilsson‐Ehle P. Improvements of the lipoprotein profile after coronary bypass surgery: additional effects of an exercise training program. European Heart Journal 1989;10(5):451‐8. - PubMed
Andersson 2010 {published data only}
    1. Andersson A, Sundel K L, Unden A L, Schenck‐Gustafsson K, Eriksson I. A five‐year rehabilitation programme for younger women after a coronary event reduces the need for hospital care. Scandinavian Journal of Public Health 2010;38:566‐73. - PubMed
Aronov 2006 {published data only}
    1. Aronov DM, Krasnitski VB, Bubnova MG, Posdniakov IuM, Ioseliani DV, Shchegol'kov AN, et al. Exercise in outpatient complex rehabilitation and secondary prophylaxis in patients with ischemic heart disease after acute coronary events (a cooperative trial in Russia). Terapevticheskii Arkhiv 2006;78(9):33‐8. - PubMed
Asbury 2012 {published data only}
    1. Asbury EA, Webb CM, Probert H, Wright C, Barbir M, Fox K, et al. Cardiac rehabilitation to improve physical functioning in refractory angina: a pilot study. Cardiology 2012;122:170‐7. - PubMed
Astengo 2010 {published data only}
    1. Astengo M, Dahl A, Karlsson T, Mattsson‐Hulten L, Wiklund O, Wennerblom B. Physical training after percutaneous coronary intervention in patients with stable angina: effects on working capacity, metabolism, and markers of inflammation. European Journal of Cardiovascular Prevention & Rehabilitation 2010;17:349‐54. - PubMed
Ballantyne 1982 {published data only}
    1. Ballantyne FC, Clark RS, Simpson HS, Ballantyne D. The effect of moderate physical exercise on the plasma lipoprotein subfractions of male survivors of myocardial infarction. Circulation 1982;65(5):913‐8. - PubMed
Bär 1992 {published data only}
    1. Bär FW, Hoppener P, Diederiks J, Vonken H, Bekkers J, Hoofd W, Appels A, et al. Cardiac rehabilitation contributes to the restoration of leisure and social activities. Journal of Cardiopulmonary Rehabilitation 1992;12(2):117‐25.
Belardinelli 2007 {published data only}
    1. Belardinelli R, Lacalaprice F, Piccoli G, Iacobone G, Piva R. Long‐term benefits of cardiac rehabilitation in patients with incomplete revascularization: 5‐year follow‐up. Circulation 2007;116(16):3543.
Bilinska 2010 {published data only}
    1. Bilinska M, Kosydar‐Piechna M, Gasiorowska A, Mikulski T, Piotrowski W, Nazar K, et al. Influence of dynamic training on hemodynamic, neurohormonal responses to static exercise and on inflammatory markers in patients after coronary artery bypass grafting. Circulation Journal 2010;74:2598‐604. - PubMed
Bilinska 2013 {published data only}
    1. Bilinska M, Kosydar‐Piechna M, Mikulski T, Piotrowicz E, Gasiorowska A, Piotrowski W, et al. Influence of aerobic training on neurohormonal and hemodynamic responses to head‐up tilt test and on autonomic nervous activity at rest and after exercise in patients after bypass surgery. Cardiology Journal 2013;20:17‐24. - PubMed
Björntorp 1972 {published data only}
    1. Björntorp, Berchtold P, Grimby G, Lindholm B, Sanne H, Tibblin G, et al. Effects of physical training on glucose tolerance, plasma insulin and lipids and on body composition in men after myocardial infarction. Acta Medica Scandinavica 1972;192(1‐6):439‐43. - PubMed
Blumenthal 1997 {published data only}
    1. Blumenthal JA, Wei J, Babyak MA, Krantz DS, Frid DJ, Coleman RE, et al. Stress management and exercise training in cardiac patients with myocardial ischemia: effects on prognosis and evaluation of mechanisms. Archives of Internal Medicine 1997;157(19):2213‐23. - PubMed
Bourke 2010 {published data only}
    1. Bourke L, Tew GA, Milo M, Crossman DC, Saxton JM, Chico TJ. Study protocol: a randomised controlled trial investigating the effect of exercise training on peripheral blood gene expression in patients with stable angina. BMC Public Health 2010;10:620. - PMC - PubMed
Bubnova 2014 {published data only}
    1. Bubnova MG, Aronov DM, Krasnitskii VB, Ioseliani DG, Novikova NK, Rodzinskaia EM. Программа обучения дома упражнения после острого коронарного синдрома и / или эндоваскулярнойкоронарной интервенции: эффективность и проблемы мотивации пациента. [A home exercise training program after acute coronary syndrome and/or endovascular coronary intervention: efficiency and a patient motivation problem]. Terapevticheskii Arkhiv 2014;86:23‐32. - PubMed
Busch 2012 {published data only}
    1. Busch JC, Lillou D, Wittig G, Bartsch P, Willemsen D, Oldridge N, et al. Resistance and balance training improves functional capacity in very old participants attending cardiac rehabilitation after coronary bypass surgery.. Journal of the American Geriatrics Society 2012;60:2270‐6. Erratum in: Journal of the American Geriatrics Society 2013;61:3:479. - PubMed
Butler 2009 {published data only}
    1. Butler L, Furber S, Phongsavan P, Mark A, Bauman A. Effects of a Pedometer‐Based Intervention on Physical Activity Levels After Cardiac Rehabilitation: a randomized controlled trial. Journal of Cardiopulmonary Rehabilitation and Prevention 2009;29:105‐14. - PubMed
Carlsson 1997 {published data only}
    1. Carlsson R, Lindberg G, Westin L, Israelsson B. Influence of coronary nursing management follow up on lifestyle after acute myocardial infarction. Heart 1997;77(3):256‐9. - PMC - PubMed
Chang 2010 {published data only}
    1. Chang R, Koo M, Kan C, Yu Z, Chu I, Hsu C, et al. Effects of Tai Chi rehabilitation on heart rate responses in patients with coronary artery disease. American Journal of Chinese Medicine 2010;38:461‐72. - PubMed
Chatian 2014 {published data only}
    1. Chatian M, Tarchalski J L, Lisowski J, Poziomska‐Piatkowska E. Wpływ rehabilitacji ambulatoryjnej kardiologicznej na sprawności fizycznej na pacjentów po STEMI [The influence of the outpatient cardiologic rehabilitation on the physical fitness at patients after a STEMI]. Polski Merkuriusz Lekarski 2014;36:88‐91. - PubMed
Chow 2012 {published data only}
    1. Chow CK, Redfern J, Thiagalingam A, Jan S, Whittaker R, Hackett M, et al. Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message‐based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol. BMJ Open 2012;2:e000606. - PMC - PubMed
Edstrom‐Pluss 2009 {published data only}
    1. Edstrom‐Pluss C, Billing E, Held C, Henriksson P, Kiessling A, Karlsson MR, et al. Long‐term beneficial effects of an expanded cardiac rehabilitation after an acute myocardial infarction or coronary artery by‐pass grafting: a five year follow‐up of a randomized controlled study. Eur. Heart J. 2009;30:75‐6.
Espinosa 2004 {published data only}
    1. Espinosa Caliani S, Bravo Navas JC, Gomez‐Doblas JJ, Collantes Rivera R, Gonzalez Jimenez B, Martinez Lao M, et al. Postmyocardial infarction cardiac rehabilitation in low risk patients. Results with a coordinated program of cardiological and primary care. Revista Espanola de Cardiologia 2004;57:53‐9. - PubMed
Gao 2007 {published data only}
    1. Gao WG, Hu DY, Ma WL, Tang CZ, Li J, Hasimu B, et al. Effect of health management on the rehabilitation of patients undergoing coronary artery bypass graft. Journal of Clinical Rehabilitative Tissue Engineering Research 2007;11(25):4874‐8.
Ghashghaei 2012 {published data only}
    1. Ghashghaei FE, Sadeghi M, Marandi SM, Ghashghaei SE. Exercise‐based cardiac rehabilitation improves hemodynamic responses after coronary artery bypass graft surgery. Arya Atherosclerosis 2012;7:151‐6. - PMC - PubMed
Giallauria 2009 {published data only}
    1. Giallauria F, Galizia G, Lucci R, D'Agostino M, Vitelli A, Maresca L, et al. Favourable effects of exercise‐based Cardiac Rehabilitation after acute myocardial infarction on left atrial remodeling. International Journal of Cardiology 2009;136:300‐6. - PubMed
Giallauria 2012 {published data only}
    1. Giallauria F, Acampa W, Ricci F, Vitelli A, Maresca L, Mancini M, et al. Effects of exercise training started within 2 weeks after acute myocardial infarction on myocardial perfusion and left ventricular function: a gated SPECT imaging study. European Journal of Preventive Cardiology 2012;19:1410‐9. - PubMed
Giallauria 2013 {published data only}
    1. Giallauria F, Acampa W, Ricci F, Vitelli A, Torella G, Lucci R, et al. Exercise training early after acute myocardial infarction reduces stress‐induced hypoperfusion and improves left ventricular function. European Journal of Nuclear Medicine & Molecular Imaging 2013;40:315‐24. - PubMed
Giannuzzi 2008 {published data only}
    1. Giannuzzi P, Temporelli PL, Marchioli R, Maggioni AP, Balestroni G, Ceci V, et al. Global secondary prevention strategies to limit event recurrence after myocardial infarction: Results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Archives of Internal Medicine 2008;168(20):2194‐204. - PubMed
Gielen 2003 {published data only}
    1. Gielen S, Erbs S, Linke A, Mobius‐Winkler S, Schuler G, Hambrecht R. Home‐based versus hospital‐based exercise programs in patients with coronary artery disease: effects on coronary vasomotion. American Heart Journal 2003;145(1):e3. - PubMed
Ha 2011 {published data only}
    1. Ha Yi‐Kyung, Jung Yoen‐Yi. Development and application of an early exercise program for open heart surgery patients [Korean]. Journal of Korean Critical Care Nursing 2011;4:1p.
Haddadzadeh 2011 {published data only}
    1. Haddadzadeh MH, Maiya AG, Padmakumar R, Shad B, Mirbolouk F. Effect of exercise‐based cardiac rehabilitation on ejection fraction in coronary artery disease patients: a randomized controlled trial. Heart Views 2011;12:51‐7. - PMC - PubMed
Hansen 2009 {published data only}
    1. Hansen D, Dendale P, Leenders M, Berger J, Raskin A, Vaes J, et al. Reduction of cardiovascular event rate: different effects of cardiac rehabilitation in CABG and PCI patients. Acta Cardiologica 2009;64:639‐44. - PubMed
Hansen 2010 {published data only}
    1. Hansen D, Dendale P, Raskin A, Schoonis A, Berger J, Vlassak I, et al. Long‐term effect of rehabilitation in coronary artery disease patients: randomized clinical trial of the impact of exercise volume. Clinical Rehabilitation 2010;24:319‐27. - PubMed
Hanssen 2009 {published data only}
    1. Hanssen TA, Nordrehaug JE, Eide GE, Hanestad BR. Does a telephone follow‐up intervention for patients discharged with acute myocardial infarction have long‐term effects on health‐related quality of life? A randomised controlled trial. Journal of Clinical Nursing 2009;18:1334‐45. - PubMed
Hawkes 2009 {published data only}
    1. Hawkes AL, Atherton J, Taylor CB, Scuffham P, Eadie K, Miller NH, et al. Randomised controlled trial of a secondary prevention program for myocardial infarction patients ('ProActive Heart'): study protocol. Secondary prevention program for myocardial infarction patients. BMC Cardiovascular Disorders 2009; Vol. 9, issue 1:16. - PMC - PubMed
Heldal 2000 {published data only}
    1. Heldal M, Sire S, Dale J. Randomised training after myocardial infarction: Short and long‐term effects of exercise training after myocardial infarction in patients on beta‐blocker treatment. A randomized, controlled study. Scandinavian Cardiovascular Journal 2000;34(1):59‐64. - PubMed
Houle 2011 {published data only}
    1. Houle J, Doyon O, Vadeboncoeur N, Turbide G, Diaz A, Poirier P. Innovative program to increase physical activity following an acute coronary syndrome: randomized controlled trial. Patient Education & Counseling 2011;85:e237‐44. - PubMed
Huerre 2010 {published data only}
    1. Huerre C, Guiot A, Marechaux S, Auffray JL, Bauchart JJ, Montaigne D, et al. Functional decline in elderly patients presenting with acute coronary syndromes: impact on midterm outcome. Archives of cardiovascular diseases 2010;103:19‐25. - PubMed
Jiang 2007 {published data only}
    1. Jiang X, Sit JW, Wong TKS. A nurse‐led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Journal of Clinical Nursing 2007;16(10):1886‐97. - PubMed
Karpova 2009 {published data only}
    1. Karpova ES, Kotel'nikova EV, Lipchanskaia TP, Poliakova NV, Liamina NP. Rehabilitative and prophylactic measures including physical training for the correction of risk factors in patients presenting with ischemic heart disease following percutaneous coronary interventions. Voprosy Kurortologii, Fizioterapii i Lechebnoi Fizicheskoi Kultury 2009;6:6‐9. - PubMed
Kavanagh 1973 {published data only}
    1. Kavanagh T, Shephard RJ, Doney H, Pandit V. Exercise versus hypnotherapy in coronary rehabilitation. Canadian Family Physician 1973;19:62‐6. - PMC - PubMed
Kentala 1972 {published data only}
    1. Kentala E. Physical fitness and feasibility of physical rehabilitation after myocardial infarction in men of working age. Annals of Clinical Research 1972;4(Suppl 9):1‐84. - PubMed
Kim 2011 {published data only}
    1. Kim C, Kim DY, Moon CJ. Prognostic influences of cardiac rehabilitation in Korean acute myocardial infarction patients. Annals of Rehabilitation Medicine 2011;35:375‐80. - PMC - PubMed
Kim 2012 {published data only}
    1. Kim C, Choi HE, Kim BO, Lim MH. Impact of Exercise‐based Cardiac Rehabilitation on In‐stent Restenosis with Different Generations of Drug Eluting Stent. Annals of Rehabilitation Medicine 2012;36:254‐61. - PMC - PubMed
Kim 2013 {published data only}
    1. Kim HJ, Oh JK, Kim C, Jee H, Shin KA, Kim YJ. Effects of six‐week cardiac rehabilitation and exercise on adiponectin in patients with acute coronary syndrome. Kardiologia Polska 2013;71:924‐30. - PubMed
Krachler 1997 {published data only}
    1. Krachler M, Lindschinger M, Eber B, Watzinger N, Wallner S. Trace elements in coronary heart disease. Biological Trace Element Research 1997;60(3):175‐85. - PubMed
Kubilius 2012 {published data only}
    1. Kubilius R, Jasiukeviciene L, Grizas V, Kubiliene L, Jakubseviciene E, Vasiliauskas D. The impact of complex cardiac rehabilitation on manifestation of risk factors in patients with coronary heart disease. Medicina (Kaunas, Lithuania) 2012;48:166‐73. - PubMed
Lee 2013 {published data only}
    1. Lee HY, Kim JH, Kim BO, Byun YS, Cho S, Goh CW, et al. Regular exercise training reduces coronary restenosis after percutaneous coronary intervention in patients with acute myocardial infarction. International Journal of Cardiology 2013;167:2617‐22. - PubMed
Li 2004 {published data only}
    1. Li H, Guo L, Sun JZ, Feng JZ, Wang P, Wu GL, et al. Effect of exercise therapy on the quality of life in patients after successful percutaneous transluminal coronary angioplasty. Chinese Journal of Clinical Rehabilitation 2004;8(9):1601‐3.
Liao 2003 {published data only}
    1. Liao X, Ma H, Dong Y. Effects of early rehabilitation programme on heart rate variability and quality of life in patients with uncomplicated acute myocardial infarction. Journal of Rehabilitation Medicine 2003;18(3):153‐5.
Lie 2009 {published data only}
    1. Lie I, Arnesen H, Sandvik L, Hamilton G, Bunch EH. Health‐related quality of life after coronary artery bypass grafting. The impact of a randomised controlled home‐based intervention program. Quality of Life Research 2009; Vol. 18, issue 2:201‐7. - PubMed
Mameletzi 2011 {published data only}
    1. Mameletzi D, Kouidi E, Koutlianos N, Deligiannis A. Effects of long‐term exercise training on cardiac baroreflex sensitivity in patients with coronary artery disease: a randomized controlled trial. Clinical Rehabilitation 2011;25:217‐27. - PubMed
Mandic 2013 {published data only}
    1. Mandic S, Hodge C, Stevens E, Walker R, Nye ER, Body D, et al. Effects of Community‐Based Cardiac Rehabilitation on Body Composition and Physical Function in Individuals with Stable Coronary Artery Disease: 1.6‐Year Follow‐up. Biomed Research International 2013;2013:7. - PMC - PubMed
Martinez 2011 {published data only}
    1. Martinez DG, Nicolau JC, Lage RL, Toschi‐Dias E, Matos LD, Alves MJ, et al. Effects of long‐term exercise training on autonomic control in myocardial infarction patients. Hypertension 2011;58:1049‐56. - PubMed
Mayer‐Berger 2014 {published data only}
    1. Mayer‐Berger W, Simic D, Mahmoodzad J, Burtscher R, Kohlmeyer M, Schwitalla B, et al. Efficacy of a long‐term secondary prevention programme following inpatient cardiovascular rehabilitation on risk and health‐related quality of life in a low‐education cohort: A randomized controlled study. European Journal of Preventive Cardiology 2014;21:145‐52. - PubMed
Mezey 2008 {published data only}
    1. Mezey B, Kullmann L, Smith K, Sarolta B, Sandori K, Belicza E, et al. Outpatient cardiac rehabilitation: initial experience in the first Hungarian multicenter study. Orvosi Hetilap 2008;149(8):353‐9. - PubMed
Mohammed 2012 {published data only}
    1. Mehani SHM. Autonomic adaptation and functional capacity outcomes after hospital‐based cardiac rehabilitation post coronary artery by pass graft. Indian Journal of Physiotherapy and Occupational Therapy 2012; Vol. 6, issue 3:263.
Moholdt 2012a {published data only}
    1. Moholdt T, Aamot IL, Granoien I, Gjerde L, Myklebust G, Walderhaug L, et al. Aerobic interval training increases peak oxygen uptake more than usual care exercise training in myocardial infarction patients: a randomized controlled study. Clinical Rehabilitation 2012;26:33‐44. - PubMed
Moholdt 2012b {published data only}
    1. Moholdt T, Bekken Vold M, Grimsmo J, Slordahl SA, Wisloff U. Home‐based aerobic interval training improves peak oxygen uptake equal to residential cardiac rehabilitation: a randomized, controlled trial. PLoS ONE [Electronic Resource] 2012;7:e41199. - PMC - PubMed
Molino‐Lova 2013 {published data only}
    1. Molino‐Lova R, Pasquini G, Vannetti F, Paperini A, Forconi T, Polcaro P, et al. Effects of a structured physical activity intervention on measures of physical performance in frail elderly patients after cardiac rehabilitation: a pilot study with 1‐year follow‐up. Internal and Emergency Medicine 2013;8:581‐9. - PubMed
Murphy 2012 {published data only}
    1. Murphy SM, Edwards RT, Williams N, Raisanen L, Moore G, Linck P, et al. An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative.. Journal of Epidemiology & Community Health 2012;66:745‐53 Erratum in: Journal of Epidemiology & Community Health 2012;66:11:1082. - PMC - PubMed
Pater 2000 {published data only}
    1. Pater C, Jacobsen C, Rollag A, Sandvik L, Erikssen J, Kogstad E. Design of a randomized controlled trial of comprehensive rehabilitation in patients with myocardial infarction, stabilized acute coronary syndrome, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting: Akershus Comprehensive Cardiac Rehabilitation Trial (the CORE Study). Current Controlled Trials in Cardiovascular Medicine 2000;1(3):177‐83. - PMC - PubMed
Pedersen 2013 {published data only}
    1. Pedersen LR, Olsen RH, Frederiksen M, Astrup A, Chabanova E, Hasbak P, et al. Copenhagen study of overweight patients with coronary artery disease undergoing low energy diet or interval training: the randomized CUT‐IT trial protocol. BMC Cardiovascular Disorders 2013;13:106. - PMC - PubMed
Peschel 2007 {published data only}
    1. Peschel T, Sixt S, Beitz F, Sonnabend M, Muth G, Thiele H, et al. High, but not moderate frequency and duration of exercise training induces downregulation of the expression of inflammatory and atherogenic adhesion molecules. European Journal of Cardiovascular Prevention and Rehabilitation 2007;14(3):476‐82. - PubMed
Piestrzeniewicz 2004 {published data only}
    1. Piestrzeniewicz K, Navarro‐Kuczborska N, Bolinska H, Jegier A, Maciejewski M. The impact of comprehensive cardiac rehabilitation in young patients after acute myocardial infarction treated with primary coronary intervention on the clinical outcome and leading again a "normal" life [Korzystne efekty kompleksowej rehabilitacji kardiologicznej u osob do 55 roku zycia, po zawale miesnia sercowego, leczonych za pomoca pierwotnej angioplastyki]. Polskie Archiwum Medycyny Wewnetrznej 2004;111(3):309‐17. - PubMed
Pluss 2011 {published data only}
    1. Pluss CE, Billing E, Held C, Henriksson P, Kiessling A, Karlsson MR, et al. Long‐term effects of an expanded cardiac rehabilitation programme after myocardial infarction or coronary artery bypass surgery: a five‐year follow‐up of a randomized controlled study. Clinical Rehabilitation 2011;25:79‐87. - PubMed
Poortaghi 2011 {published data only}
    1. Poortaghi S, Atri SB, Safayian A, Baghernia A. General health improves with home‐based cardiac rehabilitation program. Saudi Medical Journal 2011;32:407‐11. - PubMed
Poortaghi 2013 {published data only}
    1. Poortaghi S, Baghernia A, Golzari SE, Safayian A, Atri SB. The effect of home‐based cardiac rehabilitation program on self efficacy of patients referred to cardiac rehabilitation center. BMC Research Notes 2013;6:287. - PMC - PubMed
Ribeiro 2012 {published data only}
    1. Ribeiro F, Alves AJ, Teixeira M, Miranda F, Azevedo C, Duarte JA, et al. Exercise training enhances autonomic function after acute myocardial infarction: a randomized controlled study. Revista Portuguesa de Cardiologia 2012;31:135‐41. - PubMed
Rideout 2012 {published data only}
    1. Rideout A, Lindsay G, Godwin J. Patient mortality in the 12 years following enrolment into a pre‐surgical cardiac rehabilitation programme. Clinical Rehabilitation 2012;26:642‐7. - PubMed
Roviaro 1984 {published data only}
    1. Roviaro S, Holmes DS, Holmsten RD. Influence of a cardiac rehabilitation program on the cardiovascular, psychological, and social functioning of cardiac patients. Journal of Behavioral Medicine 1984;7(1):61‐81. - PubMed
Sadeghi 2013 {published data only}
    1. Sadeghi M, Garakyaraghi M, Khosravi M, Taghavi M, Sarrafzadegan N, Roohafza H. The impacts of cardiac rehabilitation program on echocardiographic parameters in coronary artery disease patients with left ventricular dysfunction. Cardiology Research and Practice 2013; Vol. 2013. - PMC - PubMed
Sagar 2012 {published data only}
    1. Sagar N, Bangi NA, Moiz JA. Effect of supervised versus home based phase II cardiac rehabilitation program on exercise capacity and quality of life in post CABG patients. Indian Journal of Physiotherapy and Occupational Therapy ‐ An International Journal 2012; Vol. 6:59‐64.
Sato 2010 {published data only}
    1. Sato S, Makita S, Uchida R, Ishihara S, Masuda M. Effect of Tai Chi training on baroreflex sensitivity and heart rate variability in patients with coronary heart disease. International Heart Journal 2010;51:238‐41. - PubMed
Sawatzky 2014 {published data only}
    1. Sawatzky JA, Kehler DS, Ready AE, Lerner N, Boreskie S, Lamont D, et al. Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study. Clinical Rehabilitation 2014; Vol. 28:648‐57. - PubMed
Schumacher 2006 {published data only}
    1. Schumacher A, Peersen K, Sommervoll L, Seljeflot I, Arnesen H, Otterstad JE. Physical performance is associated with markers of vascular inflammation in patients with coronary heart disease. European Journal of Cardiovascular Prevention and Rehabilitation 2006;13(3):356‐62. - PubMed
Schwaab 2011 {published data only}
    1. Schwaab B, Waldmann A, Katalinic A, Sheikhzadeh A, Raspe H. In‐patient cardiac rehabilitation versus medical care ‐ a prospective multicentre controlled 12 months follow‐up in patients with coronary heart disease. European Journal of Cardiovascular Prevention & Rehabilitation 2011;18:581‐6. - PubMed
Shabani 2010 {published data only}
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References to studies awaiting assessment

Devi 2014 {published data only}
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References to ongoing studies

Alsaleh 2012 {published data only}
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CTRI/2012/02/002408 {unpublished data only}
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IRCT2014061418075N2 {unpublished data only}
    1. IRCT2014061418075N2. The Effect of a Cardiac Rehabilitation Program on Quality of Life in Acute Coronary Syndrome ‎Patients. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2014061418075N2 (accessed 6 March 2015).
JPRN‐UMIN000005177 {unpublished data only}
    1. JPRN‐UMIN000005177. Japanese prospective multicenter study on outpatient cardiac rehabilitation after the percutaneous coronary intervention. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=JPRN‐UMIN000005177 (accessed 6 March 2015).
JPRN‐UMIN000010031 {unpublished data only}
    1. JPRN‐UMIN000010031. Impact of comprehensive cardiac rehabilitation program on stabilization of coronary plaque after acute coronary syndrome. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=JPRN‐UMIN000010031 (acessed 6 March 2015).
NCT00725088 {unpublished data only}
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NCT01916525 {unpublished data only}
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NCT01941355 {unpublished data only}
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NCT02025257 {unpublished data only}
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NCT02219815 {unpublished data only}
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NCT02235753 {unpublished data only}
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Santaularia 2013 {published data only}
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References to other published versions of this review

Anderson 2015
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