Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence

Abstract

Objectives: To determine the contemporary effectiveness of exercise-based cardiac rehabilitation (CR) in terms of all-cause mortality, cardiovascular mortality and hospital admissions.

Data sources: Studies included in or meeting the entry criteria for the 2016 Cochrane review of exercise-based CR in patients with coronary artery disease.

Study eligibility criteria: Randomised controlled trials (RCTs) of exercise-based CR versus a no-exercise control whose participants were recruited after the year 2000.

Study appraisal and synthesis methods: Two separate reviewers independently screened the characteristics of studies. One reviewer quality appraised any new studies and assessed their risk of bias using the Cochrane Collaboration's recommended risk of bias tool. Data were reported as the risk difference (95% CI).

Results: We included 22 studies with 4834 participants (mean age 59.5 years, 78.4% male). We found no differences in outcomes between exercise-based CR and a no-exercise control at their longest follow-up period for: all-cause mortality (19 studies; n=4194; risk difference 0.00, 95% CI -0.02 to 0.01, P=0.38) or cardiovascular mortality (9 studies; n=1182; risk difference -0.01, 95% CI -0.02 to 0.01, P=0.25). We found a small reduction in hospital admissions of borderline statistical significance (11 studies; n=1768; risk difference -0.05, 95% CI -0.10 to -0.00, P=0.05).

Conclusions and implications of key findings: Our analysis indicates conclusively that the current approach to exercise-based CR has no effect on all-cause mortality or cardiovascular mortality, when compared with a no-exercise control. There may be a small reduction in hospital admissions following exercise-based CR that is unlikely to be clinically important.

Prospero registration number: CRD42017073616.

Keywords: all-cause mortality; cardiovascular mortality; coronary artery disease; exercise-based cardiac rehabilitation; hospital admissions..

Figure 1

Summary of study selection process. RCTs, randomised controlled trials.

Figure 2

All-cause mortality for studies at their longest follow-up period. Filled squares represent the risk difference for individual studies at the longest reported follow-up. The boxes are proportional to the weight of each study, and the lines represent their 95% CI. The filled diamond represents the pooled risk difference. Weights are from random effects analysis. CR, cardiac rehabilitation.

Figure 3

Cardiovascular mortality for studies at their longest follow-up period. Filled squares represent the risk difference for individual studies at the longest reported follow-up. The boxes are proportional to the weight of each study and the lines represent their 95% CI. The filled diamond represents the pooled risk difference. Weights are from random effects analysis. CR, cardiac rehabilitation.

Figure 4

Hospital admissions for studies at their longest follow-up period. Filled squares represent the risk difference for individual studies at the longest reported follow-up. The boxes are proportional to the weight of each study and the lines represent their 95% CI. The filled diamond represents the pooled risk difference. Weights are from random effects analysis. CR, cardiac rehabilitation.