Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2017 Apr 4;4(4):CD012264.
doi: 10.1002/14651858.CD012264.pub2.

Exercise-based cardiac rehabilitation in heart transplant recipients

Lindsey Anderson  1 , Tricia T Nguyen  1 , Christian H Dall  2 , Laura Burgess  3 , Charlene Bridges  4 , Rod S Taylor  1
Affiliations
Meta-Analysis

Exercise-based cardiac rehabilitation in heart transplant recipients

Lindsey Anderson et al. Cochrane Database Syst Rev. .

Abstract

Background: Heart transplantation is considered to be the gold standard treatment for selected patients with end-stage heart disease when medical therapy has been unable to halt progression of the underlying pathology. Evidence suggests that aerobic exercise training may be effective in reversing the pathophysiological consequences associated with cardiac denervation and prevent immunosuppression-induced adverse effects in heart transplant recipients.

Objectives: To determine the effectiveness and safety of exercise-based rehabilitation on the mortality, hospital admissions, adverse events, exercise capacity, health-related quality of life, return to work and costs for people after heart transplantation.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO) and Web of Science Core Collection (Thomson Reuters) to June 2016. We also searched two clinical trials registers and handsearched the reference lists of included studies.

Selection criteria: We included randomised controlled trials (RCTs) of parallel group, cross-over or cluster design, which compared exercise-based interventions with (i) no exercise control (ii) a different dose of exercise training (e.g. low- versus high-intensity exercise training); or (iii) an active intervention (i.e. education, psychological intervention). The study population comprised adults aged 18 years or over who had received a heart transplant.

Data collection and analysis: Two review authors independently screened all identified references for inclusion based on pre-specified inclusion criteria. Disagreements were resolved by consensus or by involving a third person. Two review authors extracted outcome data from the included trials and assessed their risk of bias. One review author extracted study characteristics from included studies and a second author checked them against the trial report for accuracy.

Main results: We included 10 RCTs that involved a total of 300 participants whose mean age was 54.4 years. Women accounted for fewer than 25% of all study participants. Nine trials which randomised 284 participants to receive exercise-based rehabilitation (151 participants) or no exercise (133 participants) were included in the main analysis. One cross-over RCT compared high-intensity interval training with continued moderate-intensity training in 16 participants. We reported findings for all trials at their longest follow-up (median 12 weeks).Exercise-based cardiac rehabilitation increased exercise capacity (VO2peak) compared with no exercise control (MD 2.49 mL/kg/min, 95% CI 1.63 to 3.36; N = 284; studies = 9; moderate quality evidence). There was evidence from one trial that high-intensity interval exercise training was more effective in improving exercise capacity than continuous moderate-intensity exercise (MD 2.30 mL/kg/min, 95% CI 0.59 to 4.01; N = 16; 1 study). Four studies reported health-related quality of life (HRQoL) measured using SF-36, Profile of Quality of Life in the Chronically Ill (PLC) and the World Health Organization Quality Of Life (WHOQoL) - BREF. Due to the variation in HRQoL outcomes and methods of reporting we were unable to meta-analyse results across studies, but there was no evidence of a difference between exercise-based cardiac rehabilitation and control in 18 of 21 HRQoL domains reported, or between high and moderate intensity exercise in any of the 10 HRQoL domains reported. One adverse event was reported by one study.Exercise-based cardiac rehabilitation improves exercise capacity, but exercise was found to have no impact on health-related quality of life in the short-term (median 12 weeks follow-up), in heart transplant recipients whose health is stable.There was no evidence of statistical heterogeneity across trials for exercise capacity and no evidence of small study bias. The overall risk of bias in included studies was judged as low or unclear; more than 50% of included studies were assessed at unclear risk of bias with respect to allocation concealment, blinding of outcome assessors and declaration of conflicts of interest. Evidence quality was assessed as moderate according to GRADE criteria.

Authors' conclusions: We found moderate quality evidence suggesting that exercise-based cardiac rehabilitation improves exercise capacity, and that exercise has no impact on health-related quality of life in the short-term (median 12 weeks follow-up), in heart transplant recipients. Cardiac rehabilitation appears to be safe in this population, but long-term follow-up data are incomplete and further good quality and adequately-powered trials are needed to demonstrate the longer-term benefits of exercise on safety and impact on both clinical and patient-related outcomes, such as health-related quality of life, and healthcare costs.

PubMed Disclaimer

Conflict of interest statement

LA is an author on a number of other Cochrane cardiac rehabilitation reviews.

CD is an author of several publications on exercise in heart transplant recipients.

TN declares she has no conflicts of interest.

LB declares she has no conflicts of interest.

CB declares she has no conflicts of interest.

RST is an author on a number of other Cochrane cardiac rehabilitation reviews and is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based cardiac rehabilitation intervention for people with heart failure and their carers (PGfAR RP‐PG‐0611‐12004).

Figures

1
1
Summary of 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
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
4
4
Funnel plot of comparison: 1 Exercise versus no‐exercise, outcome: 1.1 Exercise capacity (VO2peak)
1.1
1.1. Analysis
Comparison 1 Exercise versus no‐exercise, Outcome 1 Exercise capacity (VO2peak).
1.2
1.2. Analysis
Comparison 1 Exercise versus no‐exercise, Outcome 2 Sensitivity analysis (excluding Kobashigawa 1999).
1.3
1.3. Analysis
Comparison 1 Exercise versus no‐exercise, Outcome 3 Sensitivity analysis (excluding Wu 2008).
1.4
1.4. Analysis
Comparison 1 Exercise versus no‐exercise, Outcome 4 Sensitivity analysis (excluding Kobashigawa 1999 and Wu 2008).
2.1
2.1. Analysis
Comparison 2 High‐intensity interval training versus continued moderate‐intensity exercise, Outcome 1 Exercise capacity (VO2peak).
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Bernardi 2007 {published data only}
    1. Bernardi L, Radaelli A, Passino C, Falcone C, Auguadro C, Martinelli L, et al. Effects of physical training on cardiovascular control after heart transplantation. International Journal of Cardiology 2007;118(3):356‐62. - PubMed
Braith 2008 {published data only}
    1. Braith RW, Schofield RS, Hill J A, Casey DP, Pierce GL. Exercise training attenuates progressive decline in brachial artery reactivity in heart transplant recipients. Journal of Heart and Lung Transplantation 2008;27(1):52‐9. - PubMed
Dall 2014 {published data only}
    1. Dall C, Snoer MS, Christensen SB, Monk‐Hanen T, Frederiksen M, Langberg H, et al. Superior effect of high intensity interval training vs. continued moderate training on oxygen consumption and chronotropic response in heart transplant recipients. European Journal of Heart Failure. 2014; Vol. 16:106‐7.
    1. Dall CH, Gustafsson F, Christensen SB, Dela F, Langberg H, Prescott E. Effect of moderate‐ versus high‐intensity exercise on vascular function, biomarkers and quality of life in heart transplant recipients: A randomized, crossover trial. Journal of Heart and Lung Transplantation 2015;34(8):1033‐41. - PubMed
    1. Dall CH, Snoer M, Christensen S, Monk‐Hansen T, Frederiksen M, Gustafsson F, et al. Effect of high‐intensity training versus moderate training on peak oxygen uptake and chronotropic response in heart transplant recipients: a randomized crossover trial. American Journal of Transplantation 2014;14(10):2391‐9. - PubMed
    1. NCT01914406. High‐intensity interval training versus moderate continuous training in heart transplant recipients [High‐intensity interval training versus moderate continuous training in heart transplant recipients with impaired chronotropic response: A randomized controlled crossover trial]. clinicaltrials.gov/ct2/show/NCT01914406 (first received 25 July 2013).
Haykowsky 2009 {published data only}
    1. Haykowsky M, Taylor D, Kim D, Tymchak W. Exercise training improves aerobic capacity and skeletal muscle function in heart transplant recipients. American Journal of Transplantation 2009;9(4):734‐9. - PubMed
Hermann 2011 {published data only}
    1. Christensen SB, Dall CH, Hermann T, Prescott E, Gustafsson F. A high‐intensity exercise program decreases self‐reported anxiety in cardiac transplant recipients: A randomized study. Journal of Heart and Lung Transplantation 2010;1(2 Suppl):S34.
    1. Christensen SB, Dall CH, Prescott E, Pedersen SS, Gustafsson F. A high‐intensity exercise program improves exercise capacity, self‐perceived health, anxiety and depression in heart transplant recipients: a randomized, controlled trial. Journal of Heart and Lung Transplantation 2012;31(1):106‐7. - PubMed
    1. Dall C, Christensen SB, Hermann TS, Prescott E, Gustafsson F. A high‐intensity exercise program improves peak VO₂ and reduces markers of systemic inflammation in cardiac transplant recipients: A randomized study. European Journal of Cardiovascular Prevention and Rehabilitation 2010;29(2 Suppl):S75.
    1. Dall C, Snoer M, Frederiksen M, Langberg H, Gustafsson F, Prescott E. Intensive interval training is superior to moderate aerobic training in heart transplant recipients. European Journal of Preventive Cardiology 2012;19(1 Suppl):S96.
    1. Hermann TS, Dall CH, Christensen SB, Goetze JP, Prescott E, Gustafsson F. Effect of high intensity exercise on peak oxygen uptake and endothelial function in long‐term heart transplant recipients. American Journal of Transplantation 2011;11(3):536‐41. - PubMed
Kobashigawa 1999 {published data only}
    1. Kobashigawa JA, Leaf DA, Gleeson MP, Hamilton MA, Chelimskyfallick C, Moriguchi JD, et al. A randomised study of cardiac rehabilitation in heart‐transplant recipients. Journal of the American College of Cardiology. 1994; Vol. 655:A356.
    1. Kobashigawa JA, Leaf DA, Lee N, Gleeson MP, Liu H, Hamilton MA, et al. A controlled trial of exercise rehabilitation after heart transplantation. New England Journal of Medicine 1999;340(4):272‐7. - PubMed
Nytrøen 2012 {published data only}
    1. NCT01091194. Effect of exercise after heart transplantation (TEX) [Effect of high intensity interval‐based aerobic exercise 1‐8 years after heart transplantation. 1 year follow up]. clinicaltrials.gov/ct2/show/NCT01091194 (first received 18 March 2010).
    1. Nytrøen K, Rustad LA, Aukrust P, Ueland T, Hallén I, Holm I, et al. Effect of high intensity interval training in heart transplant recipients ‐ a randomized controlled trial. Circulation 2012;126(Suppl 21):2.
    1. Nytrøen K, Rustad LA, Aukrust P, Ueland T, Hallén J, Holm I, et al. High‐intensity interval training improves peak oxygen uptake and muscular exercise capacity in heart transplant recipients. American Journal of Transplantation 2012;12(11):3134‐42. - PubMed
    1. Nytrøen K, Rustad LA, Erikstad I, Aukrust P, Ueland T, Gude E, et al. High intensity interval training decreases progression of cardiac allograft vasculopathy in heart transplant recipients ‐ A randomized controlled trial. European Heart Journal. 2013; Vol. 34 suppl 1:3747.
    1. Nytrøen K, Rustad LA, Erikstad I, Aukrust P, Ueland T, Lekva T, et al. Effect of high‐intensity interval training on progression of cardiac allograft vasculopathy. Journal of Heart and Lung Transplantation 2013;32(11):1073‐80. - PubMed
Pascoalino 2015 {published data only}
    1. Pascoalino LN, Ciolac EG, Tavares AC, Castro RE, Ayub‐Ferreira SM, Bacal F, et al. Exercise training improves ambulatory blood pressure but not arterial stiffness in heart transplant recipients. Journal of Heart and Lung Transplantation 2015;34(5):693‐700. - PubMed
Tegtbur 2003 {published data only}
    1. Tegtbur U, Busse M W, Jung K, Markofsky A, Machold H, Brinkmeier U, et al. Phase III rehabilitation after heart transplantation [Phase III Rehabilitation nach Herztransplantation]. Zeitschrift fur Kardiologie 2003;92(11):908‐15. - PubMed
Wu 2008 {published data only}
    1. Wu YT, Chien CL, Chou NK, Wang SS, Lai JS, Wu YW. Efficacy of a home‐based exercise program for orthotopic heart transplant recipients. Cardiology 2008;111(2):87‐93. - PubMed

References to studies excluded from this review

Anonymous 2014 {published data only}
    1. Anonymous. Clinical digest. Stable heart transplant patients benefit from high‐intensity interval training. Nursing Standard 2014;28(52):17.
Belardinelli 2006 {published data only}
    1. Belardinelli R, Agostoni P. Physical exercise in patients with chronic heart failure and in patients with cardiac transplantation. Medicina Dello Sport 2006;59:237‐45.
Christensen 2012 {published data only}
    1. Christensen SB, Dall CH, Prescott E, Pedersen SS, Gustafsson F. A high‐intensity exercise program improves exercise capacity, self‐perceived health, anxiety and depression in heart transplant recipients: A randomized, controlled trial. Journal of Heart and Lung Transplantation 2012;31(1):106‐7. - PubMed
Karapolat 2007 {published data only}
    1. Karapolat H, Eyigör S, Zoghi M, Yagdi T, Nalbangil S, Durmaz B. Comparison of hospital‐supervised exercise versus home‐based exercise in patients after orthotopic heart transplantation: effects on functional capacity, quality of life, and psychological symptoms. Transplantation Proceedings 2007;39(5):1586‐8. - PubMed
Kawauchi 2013 {published data only}
    1. Kawauchi TS, Almeida PO, Lucy KR, Bocchi EA, Feltrim MI, Nozawa E. Randomized and comparative study between two intra‐hospital exercise programs for heart transplant patients. Revista Brasileira de Cirurgia Cardiovascular 2013;28(3):338‐46. - PubMed
Kugler 2008 {published data only}
    1. Kugler C, Tegtbur U, Malehsa D, Bara C, Strueber M, Haverich A, et al. Randomized rehabilitation to improve exercise capacity and HRQoL after heart transplantation. Journal of Heart and Lung Transplantation 2008;27(2 Suppl):S114‐5.
Nytrøen 2014 {published data only}
    1. Nytrøen K, Rustad LA, Gude E, Hallén J, Fiane AE, Rolid K, et al. Muscular exercise capacity and body fat predict VO2 peak in heart transplant recipients. European Journal of Preventive Cardiology 2014;21(1):21‐9. - PubMed
Pierce 2008 {published data only}
    1. Pierce GL, Schofield RS, Casey DP, Hamlin SA, Hill JA, Braith RW. Effects of exercise training on forearm and calf vasodilation and proinflammatory markers in recent heart transplant recipients: a pilot study. European Journal of Cardiovascular Prevention and Rehabilitation 2008;15(1):10‐8. - PubMed
Pokan 2004 {published data only}
    1. Pokan R, Duvillard SP, Ludwig J, Rohrer A, Hofmann P, Wonisch M, et al. Effect of high‐volume and ‐intensity endurance training in heart transplant recipients. Medicine and Science in Sports and Exercise 2004;36(12):2011‐6. - PubMed
Stevinson 1999 {published data only}
    1. Stevinson C. Exercise helps restore physical work capacity following heart transplantation. Focus on Alternative and Complementary Therapies 1999; Vol. 4, issue 3:145‐6.

References to studies awaiting assessment

Braith 2005 {published data only}
    1. Braith RW, Magyari PM, Pierce GL, Edwards DG, Hill JA, White LJ, et al. Effect of resistance exercise on skeletal muscle myopathy in heart transplant recipients. American Journal of Cardiology 2005;95(10):1192‐8. - PubMed
Emmanuel 2015 {published data only}
    1. Emmanuel Ciolac EG, Castro RE, Bocchi EA, Guimaraes GV. Effects of exercise training on heart rate response to exercise in heart transplant recipients. European Journal of Preventive Cardiology. 2015; Vol. 22, issue 1 Suppl:S48.
Tegtbur 2005 {published data only}
    1. Tegtbur U, Busse MW, Jung K, Pethig K, Haverich A. Time course of physical reconditioning during exercise rehabilitation late after heart transplantation. Journal of Heart and Lung Transplantation 2005;24(3):270–4. - PubMed

References to ongoing studies

NCT01760538 {unpublished data only}
    1. Study on Heart Rate Variability in Cardiac Transplant Recipients with Exercise and After Exercise Training. Ongoing study August 2001.
NCT02602834 {unpublished data only}
    1. Imminently Effect of Interval Training With High Intensity (HIT) After Heart Transplantation. Ongoing study May 2015.
Nytrøen 2016 {published and unpublished data}
    1. Nytrøen K, Yardley M, Rolid K, Bjørkelund E, Karason K, Wigh JP, et al. Design and rationale of the HITTS randomized controlled trial: Effect of high‐intensity interval training in de novo heart transplant recipients in Scandinavia. American Heart Journal 2016;172:95‐105. - PubMed
    1. Rolid K, Gullestad L, Nytroen K. High‐intensity interval training in de novo heart transplant recipients‐description of a study design. European Journal of Cardiovascular Nursing 2014;13:S51.

Additional references

ACSM 2017
    1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 10th Edition. Philadelphia: Wolters Kluwer Health, 2017.
Anderson 2016
    1. Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, et al. Exercise‐based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2016, Issue 1. [DOI: 10.1002/14651858.CD001800.pub3] - DOI - PMC - PubMed
Anderson 2016a
    1. Anderson L, Dall CH, Nguyen TT, Burgess L, Taylor RS. Exercise‐based cardiac rehabilitation in heart transplant recipients. Cochrane Database of Systematic Reviews 2016, Issue 6. [DOI: 10.1002/14651858.CD012264] - DOI - PMC - PubMed
BACPR 2012
    1. British Association for Cardiovascular Prevention and Rehabilitation. The BACPR standards and core components for cardiovascular disease prevention and rehabilitation, 2nd edition. www.bacpr.com/resources/46C_BACPR_Standards_and_Core_Components_2012.pdf (accessed 20 April 2016).
Bengel 2001
    1. Bengel FM, Ueberfuhr P, Schiepel N, Nekolla SG, Reichart B, Schwaiger M. Effect of sympathetic reinnervation on cardiac performance after heart transplantation. New England Journal of Medicine 2001;345(10):731‐8. - PubMed
Bethell 2008
    1. Bethell H, Lewin R, Evans J, Turner S, Allender S, Petersen S. Outpatient cardiac rehabilitation attendance in England: variability by region and clinical characteristics. Journal of Cardiopulmonary Rehabilitation and Prevention 2008;28(6):386‐91. - PubMed
Blair 1996
    1. Blair SN, Kampert JB, Kohl HW, Harold W, Barlow CE, Macera CA, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all‐cause mortality in men and women. Journal of the American Medical Association 1996;276(3):205–10. - PubMed
Braith 2000
    1. Braith RW, Edwards DG. Exercise following heart transplantation. Sports Medicine 2000;30(3):171‐92. - PubMed
Brown 2011
    1. Brown JPR, Clark AM, Dalal H, Welch K, Taylor RS. Patient education in the management of coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 12. [DOI: 10.1002/14651858.CD008895] - DOI - PubMed
Butler 2004
    1. Butler J, Khadim G, Paul KM, Davis SF, Kronenberg MW, Chomsky DB, et al. Selection of patients for heart transplantation in the current era of heart failure therapy. Journal of the American College of Cardiology 2004;43(5):787‐93. - PubMed
Colvin 2015
    1. Colvin MM, Cook JL, Chang P, Francis G, Hsu DT, Kiernan MS, et al. Antibody‐mediated rejection in cardiac transplantation: emerging knowledge in diagnosis and management: a scientific statement from the American Heart Association. Circulation 2015;131(18):1608‐39. - PubMed
Colvin‐Adams 2014
    1. Colvin‐Adams M, Smithy JM, Heubner BM, Skeans MA, Edwards LB, Waller C, et al. OPTN/SRTR 2012 Annual Data Report: heart. American Journal of Transplantation 2014;14(Suppl 1):113‐38. - PubMed
Colvin‐Adams 2015
    1. Colvin‐Adams M, Smith JM, Heubner BM, Skeans MA, Edwards LB, Waller CD, et al. OPTN/SRTR 2013 Annual Data Report: heart. American Journal of Transplantation 2015;15(Suppl 2):1‐28. - PubMed
Corra 2005
    1. Corra U, Giannuzzi P, Adamopoulos S, Bjornstad H, Bjarnason‐Weherns B, Cohen‐Solal A, et al. Executive summary of the position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology (ESC): core components of cardiac rehabilitation in chronic heart failure. European Journal of Cardiovascular Prevention and Rehabilitation 2005;12(4):321‐5. - PubMed
Costanzo 2010
    1. Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. Journal of Heart and Lung Transplantation 2010;29(8):914‐56. - PubMed
Dalal 2012
    1. Dalal HM, Wingham J, Palmer J, Taylor R, Petre C, Lewin R, et al. Why do so few patients with heart failure participate in cardiac rehabilitation? A cross‐sectional survey from England, Wales and Northern Ireland. BMJ Open 2012;2(2):e000787. - PMC - PubMed
Didsbury 2013
    1. Didsbury M, McGee RG, Tong A, Craig JC, Chapman JR, Chadban S, et al. Exercise training in solid organ transplant recipients: a systematic review and meta‐analysis. Transplantation 2013;95(5):679‐87. - PubMed
Douard 1997
    1. Douard H, Parrens E, Billes MA, Labbe L, Baudet E, Broustet JP. Predictive factors of maximal aerobic capacity after cardiac transplantation. European Heart Journal 1997;18(11):1823‐8. - PubMed
Egger 1997
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta‐analysis detected by a simple, graphical test. British Medical Journal 1997;315(7109):629‐34. - PMC - PubMed
Fleg 2005
    1. Fleg JL, Morrell CH, Bos AG, Brant LJ, Talbot LA, Wright JG, et al. Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circulation 2005;112(5):674‐82. - PubMed
GRADEpro GDT 2015 [Computer program]
    1. GRADE Working Group, McMaster University. GRADEpro GDT. Available from www.gradepro.org. Version accessed prior to 3 March 2017. Hamiltion (ON): GRADE Working Group, McMaster University, 2015.
Gulati 2003
    1. Gulati M, Pandey DK, Arnsdorf MF, Lauderdale DS, Thisted RA, Wicklund RH, et al. Exercise capacity and the risk of death in women: the St James Women Take Heart Project. Circulation 2003;108(13):1554–9. - PubMed
Haykowsky 2005
    1. Haykowsky M, Eves N, Figgures L, McLean A, Koller M, Taylor D, et al. Effect of exercise training on VO2 peak and left ventricular systolic function in recent cardiac transplant recipients. American Journal of Cardiology 2005;95(8):1002‐4. - PubMed
Heran 2011
    1. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, et al. Exercise‐based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD001800.pub2] - DOI - PMC - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Hollenberg 2004
    1. Hollenberg SM, Klein LW, Parrillo JE, Scherer M, Burns D, Tamburro P, et al. Changes in coronary endothelial function predict progression of allograft vasculopathy after heart transplantation. Journal of Heart and Lung Transplantation 2004;23(3):265‐71. - PubMed
Hsieh 2011
    1. Hsieh PL, Wu YT, Chao WJ. Effects of exercise training in heart transplant recipients: a meta‐analysis. Cardiology 2011;120(1):27‐35. - PubMed
ISHLT 2015
    1. International Society for Heart and Lung Transplantation. Transplant registry quarterly reports. www.ishlt.org/registries/quarterlyDataReportStep3.asp (accessed 20 April 2016).
Jendzjowsky 2007
    1. Jendzjowsky NG, Tomczak CR, Lawrance R, Taylor DA, Tymchak WJ, Riess KJ, et al. Impaired pulmonary oxygen uptake kinetics and reduced peak aerobic power during small muscle mass exercise in heart transplant recipients. Journal of Applied Physiology 2007;103(5):1722‐7. - PubMed
Kao 1994
    1. Kao AC, Trigt P 3rd, Shaeffer‐McCall GS, Shaw JP, Kuzil BB, Page RD, et al. Central and peripheral limitations to upright exercise in untrained cardiac transplant recipients. Circulation 1994;89(6):2605‐15. - PubMed
Kao 1995
    1. Kao AC, Trigt P 3rd, Shaeffer‐McCall GS, Shaw JP, Kuzil BB, Page RD, et al. Allograft diastolic dysfunction and chronotropic incompetence limit cardiac output response to exercise two to six years after heart transplantation. Journal of Heart and Lung Transplantation 1995;14:11‐22. - PubMed
Karapolat 2008
    1. Karapolat H, Eyigor S, Zoghi M, Yagdi T, Nalbantgil S, Durmaz B, et al. Effects of cardiac rehabilitation program on exercise capacity and chronotropic variables in patients with orthotopic heart transplant. Clinical Research in Cardiology 2008;97(7):449‐56. - PubMed
Keteyian 1991
    1. Keteyian S, Shepard R, Ehrman J, Fedel F, Glick C, Rhoads K, et al. Cardiovascular responses of heart transplant patients to exercise training. Journal of Applied Physiology 1991;70(6):2627‐31. - PubMed
Kobashigawa 1999a
    1. Kobashigawa JA. Postoperative management following heart transplantation. Transplant Proceedings 1999;31(5):2038‐46. - PubMed
Kobashigawa 2012
    1. Kobashigawa JA. The future of heart transplantation. American Journal of Transplantation 2012;12(11):2875‐91. - PubMed
Kokkinos 2008
    1. Kokkinos P, Myers J, Kokkinos JP, Pittaras A, Narayan P, Manolis A, et al. Exercise capacity and mortality in black and white men. Circulation 2008;117(5):614–22. - PubMed
Kokkinos 2010a
    1. Kokkinos P, Myers J. Exercise and physical activity: clinical outcomes and applications. Circululation 2010;122(16):1637‐48. - PubMed
Kokkinos 2010b
    1. Kokkinos P, Myers J, Faselis C, Panagiotakos DB, Doumas M, Pittaras A, et al. Exercise capacity and mortality in older men: a 20‐year follow‐up study. Circulation 2010;122(8):790‐7. - PubMed
Lampert 1996
    1. Lampert E, Mettauer B, Hoppeler H, Charloux A, Charpentier A, Lonsdorfer J. Structure of skeletal muscle in heart transplant recipients. Journal of American College of Cardiology 1996;28(4):980‐4. - PubMed
Lefebvre 2011
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Lietz 2007
    1. Lietz K, Miller LW. Improved survival of patients with end‐stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/US United Network of Organ Sharing data, 1990 to 2005. Journal of American College of Cardiology 2007;50(13):1282‐90. - PubMed
Lund 2013
    1. Lund LH, Edwards LB, Kucheryavaya AY, Dipchand AI, Benden C, Christie JD, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirtieth Official Adult Heart Transplant Report ‐ 2013; focus theme: age. Journal of Heart and Lung Transplantation 2013;32(10):951‐64. - PubMed
Mandak 1995
    1. Mandak JS, Aaronson KD, Mancini DM. Serial assessment of exercise capacity after heart transplantation. Journal of Heart and Lung Transplantation 1995;14(3):468‐78. - PubMed
Manson 2002
    1. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. New England Journal of Medicine 2002;347(10):716‐25. - PubMed
Marconi 2003
    1. Marconi C, Marzorati M. Exercise after heart transplantation. European Journal of Applied Physiology 2003;90(3‐4):250‐9. - PubMed
McMurray 2012
    1. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European heart Journal 2012;33(14):1787‐847. - PubMed
Myers 2002
    1. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. New England Journal of Medicine 2002;346(11):793–801. - PubMed
Nair 2011
    1. Nair N, Ball T, Uber PA, Mehra MR. Current and future challenges in therapy for antibody‐mediated rejection. Journal of Heart and Lung Transplantation 2011;30(6):612‐7. - PubMed
NICE 2013
    1. National Institute for Health and Care Excellence. MI ‐ Secondary Prevention: Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction: Partial Update of NICE CG48. www.nice.org.uk/guidance/cg172 (accessed 20 April 2016).
Nytrøen 2013c
    1. Nytrøen K, Gullestad L. Exercise after heart transplantation: an overview. World Journal of Transplantation 2013;3(4):78‐90. - PMC - PubMed
Osada 1997
    1. Osada N, Chaitman BR, Donohue TJ, Wolford TL, Stelken AM, Miller LW. Long‐term cardiopulmonary exercise performance after heart transplantation. American Journal of Cardiology 1997;79(4):451–6. - PubMed
Paffenbarger 1993
    1. Paffenbarger RS Jr, Hyde RT, Wing AL, Lee IM, Jung DL, Kampert JB. The association of changes in physical‐activity level and other lifestyle characteristics with mortality among men. New England Journal of Medicine 1993;328(8):538–45. - PubMed
Paulus 1992
    1. Paulus WJ, Bronzwaer JG, Felice H, Kishan N, Wellens F. Deficient acceleration of left ventricular relaxation during exercise after heart transplantation. Circulation 1992;86(4):1175‐85. - PubMed
Piepoli 2010
    1. Piepoli MF, Corrà U, Benzer W, Bjarnason‐Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. European Journal of Cardiovascular Prevention and Rehabilitation 2010;17(1):1‐17. - PubMed
RevMan 2014 [Computer program]
    1. The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre: The Cochrane Collaboration, 2014.
Rosenbaum 2016
    1. Rosenbaum AN, Kremers WK, Schirger JA, Thomas RJ, Squires RW, Allison TG, et al. Association between early cardiac rehabilitation and long‐term survival in cardiac transplant recipients. Mayo Clinic Proceedings 2016;91(2):149‐56. - PubMed
Sandvik 1993
    1. Sandvik L, Erikssen J, Thaulow E, Erikssen G, Mundal R, Rodahl K. Physical fitness as a predictor of mortality among healthy, middle‐aged Norwegian men. New England Journal of Medicine 1993;328(8):533–537. - PubMed
Schünemann 2011
    1. Schünemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziou P, Guyatt GH. Chapter 12: Interpreting results and drawing conclusions. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions. Available from www.cochrane‐handbook.org.
Shah 2012
    1. Shah MR, Starling RC, Schwartz Longacre L, Mehra MR, Working Group Participants. Heart transplantation research in the next decade ‐ a goal to achieving evidence‐based outcomes: National Heart, Lung, and Blood Institute Working Group. Journal of American College of Cardiology 2012;59(14):1263‐9. - PMC - PubMed
Sibilitz 2016
    1. Sibilitz KL, Berg SK, Tang LH, Risom SS, Gluud C, Lindschou J, et al. Exercise‐based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database of Systematic Reviews 2016, Issue 3. [DOI: 10.1002/14651858.CD010876] - DOI - PubMed
StataCorp 2013 [Computer program]
    1. StataCorp. Stata Statistical Software: Release 13. College Station, TX: StataCorp, 2013.
Stehlik 2012
    1. Stehlik J, Edwards LB, Kucheryavaya AY, Benden C, Christie JD, Dipchand AI, et al. The Registry of the International Society for Heart and Lung Transplantation: 29th official adult heart transplant report. Journal of Heart and Lung Transplantation 2012;31(10):1052‐64. - PubMed
Stehlik 2014
    1. Stehlik J, Stevenson LW, Edwards LB, Crespo‐Leiro MG, Delgado JF, Dorent R, et al. Organ allocation around the world: insights from the ISHLT International Registry for Heart and Lung Transplantation. Journal of Heart and Lung Transplantation 2014;33(10):975‐84. - PubMed
Taylor 2007
    1. Taylor DO, Edwards LB, Boucek MM, Trulock EP, Aurora P, Christie J, et al. Registry of the International Society for Heart and Lung Transplantation: twenty‐fourth official adult heart transplant report ‐ 2007. Journal of Heart and Lung Transplantation 2007;26(8):769‐81. - PubMed
Taylor 2014
    1. Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal H, et al. Exercise‐based rehabilitation for heart failure. Cochrane Database of Systematic Reviews 2014, Issue 4. [DOI: 10.1002/14651858.CD003331.pub4] - DOI - PMC - PubMed
Taylor 2015
    1. Taylor RS, Dalal H, Jolly K, Zawada A, Dean SG, Cowie A, et al. Home‐based versus centre‐based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2015, Issue 8. [DOI: 10.1002/14651858.CD007130] - DOI - PubMed
Tierney 2011
    1. Tierney S, Mamas M, Skelton D, Woods S, Rutter MK, Gibson M, et al. What can we learn from patients with heart failure about exercise adherence? A systematic review of qualitative papers. Health Psychology 2011;30(4):401. - PubMed
Tjang 2008
    1. Tjang YS, Heijden GJ, Tenderich G, Grobbee DE, Korfer R. Survival analysis in heart transplantation: results from an analysis of 1290 cases in a single center. European Journal of Cardiothoracic Surgery 2008;33(5):856‐61. - PubMed
Tonsho 2014
    1. Tonsho M, Michel S, Ahmed Z, Alessandrini A, Madsen JC. Heart transplantation: challenges facing the field. Cold Spring Harbor Perspectives in Medicine 2014;4(5):a015636. - PMC - PubMed
Yancy 2013
    1. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of American College of Cardiology 2013;62(16):e147‐239. - PubMed
Yardley 2016
    1. Yardley M, Gullestad L, Nytrøen K. The long term effects of high intensity exercise; a 5 years follow‐up of a randomized controlled trial in heart transplant recipients. European Journal of Heart Failure. 2016; Vol. 18:260.