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Meta-Analysis
. 2019 Apr 2;73(12):1430-1443.
doi: 10.1016/j.jacc.2018.12.072.

Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis

Rod S Taylor  1 , Sarah Walker  2 , Neil A Smart  3 , Massimo F Piepoli  4 , Fiona C Warren  5 , Oriana Ciani  6 , David Whellan  7 , Christopher O'Connor  8 , Steven J Keteyian  9 , Andrew Coats  10 , Constantinos H Davos  11 , Hasnain M Dalal  12 , Kathleen Dracup  13 , Lorraine S Evangelista  14 , Kate Jolly  15 , Jonathan Myers  16 , Birgitta B Nilsson  17 , Claudio Passino  18 , Miles D Witham  19 , Gloria Y Yeh  20 ; ExTraMATCH II Collaboration
Affiliations
Meta-Analysis

Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis

Rod S Taylor et al. J Am Coll Cardiol. .

Abstract

Background: Previous systematic reviews have indicated that exercise-based cardiac rehabilitation (ExCR) for patients with heart failure (HF) has a beneficial effect on health-related quality-of-life (HRQoL) and exercise capacity. However, there is uncertainty regarding potential differential effects of ExCR across HF patient subgroups.

Objectives: The authors sought to undertake an individual participant data (IPD) meta-analysis to: 1) assess the impact of ExCR on HRQoL and exercise capacity in patients with HF; and 2) investigate differential effects of ExCR according to a range of patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischemic etiology, ejection fraction, and exercise capacity.

Methods: A single dataset was produced, comprising randomized trials where ExCR (delivered for 3 weeks or more) was compared with a no exercise control group. Each trial provided IPD on HRQoL or exercise capacity (or both), with follow-up of 6 months or more. One- and 2-stage meta-analysis models were used to investigate the effect of ExCR overall and the interactions between ExCR and participant characteristics.

Results: IPD was obtained from 13 trials for 3,990 patients, predominantly (97%) with reduced ejection fraction HF. Compared with the control group, there was a statistically significant difference in favor of ExCR for HRQoL and exercise capacity. At 12-month follow-up, improvements were seen in 6-min walk test (mean 21.0 m; 95% confidence interval: 1.57 to 40.4 m; p = 0.034) and Minnesota Living With HF score (mean improvement 5.9; 95% confidence interval: 1.0 to 10.9; p = 0.018). No consistent evidence was found of differential intervention effects across patient subgroups.

Conclusions: These results, based on an IPD meta-analysis of randomized trials, confirm the benefit of ExCR on HRQoL and exercise capacity and support the Class I recommendation of current international clinical guidelines that ExCR should be offered to all HF patients. (Exercise Training for Chronic Heart Failure [ExTraMATCH II]: protocol for an individual participant data meta-analysis; PROSPERO: international database of systematic reviews CRD42014007170).

Keywords: MLHFQ; QoL; exercise capacity; heart failure; quality-of-life; rehabilitation.

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Figures

FIGURE 1.
FIGURE 1.. PRISMA-IPD Flow Diagram
A PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of individual Participant Data) flow diagram to show selection and synthesis of ExTraMATCH (Exercise Training for Chronic Heart Failure) II study data. 6MWT = 6-min walk test; HRQoL = health-related quality-of-life; MLHF = Minnesota Living with Heart Failure Questionnaire; peak Vo2 = peak oxygen uptake; RCT = randomized controlled trial.
FIGURE 2
FIGURE 2. Effect of ExCR on HRQoL and Exercise Capacity at 6 Months: 2-Stage IPD Meta-Analysis
The blue circle is centered on the point estimate of the effect of ExCR in each trial, with the horizontal line showing the 95% confidence interval (CI) of this estimate. An arrow to either the left or right shows that the CI extends beyond the area shown in the forest plot. The size of the blue square around the point estimate is proportional to the weight that the individual trial contributes to the meta-analysis. The diamond and vertical red line show the overall estimate of the effect of ExCR in the 2-stage meta-analysis. (A) Minnesota Living with Heart Failure Questionnaire (MLHFQ). (B) All HRQoL measures (standardized score). (C) Peak Vo2, directly reported. (D) 6MWT, directly reported. (E) All exercise capacity measures (standardized score). CBT = cognitive behavioral therapy; ExCR = exercise-based cardiac rehabilitation; HF-ACTION = Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; other abbreviations as in Figure 1.
FIGURE 2
FIGURE 2. Effect of ExCR on HRQoL and Exercise Capacity at 6 Months: 2-Stage IPD Meta-Analysis
The blue circle is centered on the point estimate of the effect of ExCR in each trial, with the horizontal line showing the 95% confidence interval (CI) of this estimate. An arrow to either the left or right shows that the CI extends beyond the area shown in the forest plot. The size of the blue square around the point estimate is proportional to the weight that the individual trial contributes to the meta-analysis. The diamond and vertical red line show the overall estimate of the effect of ExCR in the 2-stage meta-analysis. (A) Minnesota Living with Heart Failure Questionnaire (MLHFQ). (B) All HRQoL measures (standardized score). (C) Peak Vo2, directly reported. (D) 6MWT, directly reported. (E) All exercise capacity measures (standardized score). CBT = cognitive behavioral therapy; ExCR = exercise-based cardiac rehabilitation; HF-ACTION = Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; other abbreviations as in Figure 1.
FIGURE 3
FIGURE 3. Effect of ExCR on HRQoL and Exercise Capacity Across Patient Subgroups 12 Months
A plot to show the effect size for health-related quality-of-life outcomes (A and B) and exercise capacity outcomes (C and D), stratified by patient characteristics. All results are reported as a between group mean difference (ExCR-control) with a 95% confidence interval (CI) from 1-stage meta-analyses carried out by strata. The p values given are from the interaction tests in the main 1-stage meta-analysis. (A) Minnesota Living with Heart Failure Questionnaire (MLHFQ). (B) All HRQoL measures (standardized score). (C) Peak Vo2, directly reported. (D) 6MWT, directly reported. Abbreviations as in Figure 1.
FIGURE 3
FIGURE 3. Effect of ExCR on HRQoL and Exercise Capacity Across Patient Subgroups 12 Months
A plot to show the effect size for health-related quality-of-life outcomes (A and B) and exercise capacity outcomes (C and D), stratified by patient characteristics. All results are reported as a between group mean difference (ExCR-control) with a 95% confidence interval (CI) from 1-stage meta-analyses carried out by strata. The p values given are from the interaction tests in the main 1-stage meta-analysis. (A) Minnesota Living with Heart Failure Questionnaire (MLHFQ). (B) All HRQoL measures (standardized score). (C) Peak Vo2, directly reported. (D) 6MWT, directly reported. Abbreviations as in Figure 1.
CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Exercise-Based Heart Failure Rehabilitation: Health-Related Quality-of-Life and Exercise Capacity at 12 Months
A forest plot from the 2-stage individual participant data meta-analysis model to (A) Minnesota Living with Heart Failure Questionnaire and (B) 6-min walk test, directly reported. CBT = cognitive behavioral therapy; CI = confidence interval; HF-ACTION = Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure.
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References

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