Exercise-based cardiac rehabilitation for patients undergoing coronary artery operation: a systematic review and meta-analysis based on current randomized controlled trials

Abstract

Background: Currently, exercise-based cardiac rehabilitation (CR) has been receiving increasing interest for its potentially beneficial effects on the health related quality of life (HRQoL) and outcomes of patients with coronary heart disease (CHD). The aim of this study was to evaluate the effect of exercise-based CR on patients after coronary artery bypass graft (CABG) and percutaneous coronary interventions (PCI).

Methods: We searched PubMed, Embase, Cochrane Library, and Web of Science from inception to 1 December 2023 for relevant studies that evaluated the effect of exercise-based CR on patients after CABG and PCI. Our primary outcomes included mortality, complications, hospital admissions, and HRQoL between patients receiving exercise-based CR and usual care. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2 and Stata 12.0.

Results: We finally indicated and included 25 randomized controlled trials (RCTs) with 4106 participants for the present analysis. Our pooled results indicated that, compared to usual care, exercise-based CR did not increase the all-cause (relative risk, RR: 0.84; 95% confidence interval, CI: 0.54-1.31) and cardiovascular (RR: 0.98; 95% CI: 0.38-2.54) mortality for patients after coronary artery operation. Similarly, exercise-based CR had an equal effect on coronary artery complications for patients after coronary artery surgery, including CABG (RR: 0.60; 95% CI: 0.32 ‒ 1.15) and PCI (RR: 0.92; 95% CI: 0.55-1.54). It was indicated that exercise-based CR significantly reduced the incidence of myocardial infarction (MI) by half with an RR of 0.50 (95% CI: 0.28-0.90). In addition, exercise-based CR also significantly reduced all-cause hospital admissions with an RR of 0.74 (95% CI: 0.62-0.88). Compared to usual care, exercise-based CR obviously improved HRQoL of patients after coronary artery operation evaluated with SF-36 summary scores (standardized mean difference, SMD: 0.24; 95% CI: 0.11-0.38) and SF-36 8 domains (SMD: 0.35; 95% CI: 0.24-0.46).

Conclusions: Our analysis indicated that exercise-based CR had a significant effect on the improvement of HRQoL in patients after coronary artery surgeries without increasing mortality or the incidence of re-intervention with operations.

Figure 1.

Flow diagram of literature search and the selection of included studies for meta-analysis.

Figure 2.

Forest plot of the exercise-based cardiac rehabilitation effect on all-cause and cardiovascular mortality of patients after coronary artery surgeries. Horizontal lines after each study indicates the range of its 95% CI. Small diamond in each horizontal line indicates the effect size for each study. The large diamond frame indicates the pooled results of each group. CI, confidence interval; CR, cardiac rehabilitation; RR, relative risk.

Figure 3.

Forest plot of the exercise-based cardiac rehabilitation effect on coronary artery complications (including MI, CABG, and PCI) for patients after coronary artery surgeries. Horizontal lines after each study indicates the range of its 95% CI. Small diamond in each horizontal line indicates th effect size for each study. The large diamond frame indicates the pooled results of each group. CI, confidence interval; CR, cardiac rehabilitation; RR, relative risk; MI, myocardial infarction; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention

Figure 4.

Forest plot of the exercise-based cardiac rehabilitation effect on all-cause hospital admissions for patients after coronary artery surgeries. Horizontal lines after each study indicates the range of its 95% CI. Small diamond in each horizontal line indicates the effect size for each study. The large diamond frame indicates the pooled results of each group. CI, confidence interval; CR, cardiac rehabilitation; RR, relative risk.

Figure 5.

Forest plot of the exercise-based cardiac rehabilitation effect on HRQoL SF-36 scale – summary scores for patients after coronary artery surgeries.Horizontal lines after each study indicates the range of its 95% CI. Small diamond in each horizontal line indicates the effect size for each study. The large diamond frame indicates the pooled results of each group. SMD, standardized mean difference; CI, confidence interval; CR, cardiac rehabilitation; HRQoL, health-related quality of life.

Figure 6.

Forest plot of the exercise-based cardiac rehabilitation effect on HRQoL SF-36 scale-8 domains for patients after coronary artery surgeries. Horizontal lines after each study indicates the range of its 95% CI. Small diamond in each horizontal line indicates the effect size for each study. The large diamond frame indicates the pooled results of each group. SMD, standardized mean difference; CI, confidence interval; CR, cardiac rehabilitation; HRQoL, health-related quality of life.

Figure 7.

Funnel plot with pseudo 95% confidence limits showing publication bias of mortality (A), coronary artery complications, (B) and all-cause hospital admissions (C). Dotted lines on both sides indicate pseudo 95% CI. Dots indicate observed studies. RR, relative risk; se, standard error; CI, confidence interval.