Question: What is the effectiveness of comprehensive cardiac rehabilitation versus standard care with no cardiac rehabilitation to improve outcome in patients after MI ?
30
Grading:1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
Reference number 710
Beswick AD;Rees K;Griebsch I;Taylor FC;Burke M;West RR;Victory J;Brown J;Taylor RS;Ebrahim S;
Provision, uptake and cost of cardiac rehabilitation programmes: Improving services to under-represented groups
20048Health Technology Assessment (Winchester, England)pgs 82
Study Type: Systematic Review
Patient Characteristics
Intervention
Comparisons
Study Length
Outcomes
Funding DOH
Effect All studies reported that there was benefit of intervention to improve uptake (healthcare led-professional interventions at the patient level, trained lay volunteers, coordination of referral post-discharge care at the service level, written or aural motivational communications). This may be indicative of publication bias. For adherence, the authors of the HTA stated that they found few studies of sufficient quality to make specific recommendations of methods to improve adherence to cardiac rehabilitation. Their opinion was that the most promising approach was the use of self management techniques based around individualised assessment, problem solving, goal setting and follow-up.
Reference number 1358
Brown A;Taylor R;Noorani H;Stone J;Skidmore B;
Exercise-based cardiac rehabilitation programs for coronary artery disease: a systematic clinical and economic review
200334Ottawa pgs
Study Type: Systematic Review
Patient Characteristics
Intervention
Comparisons
Study Length
Outcomes
Funding
Effect Cardiac rehabilitation programs that include exercise, both exercise-only (EX CR) and comprehensive care programs (CCR), have beneficial effects on cardiac mortality (RR: 0.73, 95% CI 0.56 to 0.96 and 0.80, 95% CI 0.65 to 0.99, respectively). However, with respect to total mortality, exercise-only programs show a statistically significant reduction, whereas the comprehensive care programs showed a trend in that direction (RR: 0.76, 95% CI 0.59–0.98 and 0.87, 95% CI 0.74-1.04, respectively). There was no effect with either intervention on non-fatal MI, CABG, or PTCA. For HRQoL, few studies showed intervention improved HRQoL compared with usual care.
Reference number 1360
Joliffe JA;
Exercise-based rehabilitation for coronary heart disease
2003Cochrane Library pgs
Study Type: Systematic Review
Patient Characteristics
Intervention
Comparisons
Study Length
Outcomes
Funding Effect For the exercise only intervention, the pooled effect estimate for total mortality showed a 27% reduction in all cause mortality (random effects model OR 0.73 (0.54–0.98)). Similarly, comprehensive cardiac rehabilitation reduced all cause mortality compared to usual care, but to a lesser, and non-significant, degree (13% OR 0.87 (0.71–1.05)). Total cardiac mortality was reduced by 31% (random effects model OR 0.69 (0.51–0.94)) and 26% (random effects model OR 0.74 (0.57–0.96)) in the exercise only and comprehensive cardiac rehabilitation intervention groups respectively when compared to usual care. There was no significant effect of either intervention on sudden cardiac deaths, non-fatal reinfarctions, or revascularization. Overall for HRQoL, in the RCTs with an exercise only intervention, there were small changes or no change in HRQoL measures. In the RCTs examining comprehensive cardiac rehabilitation intervention, most showed small and variable effects in HRQoL measures.
Grading: 1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
Reference number 2948
Holmback AM;Sawe U;Fagher B;
Training after myocardial infarction: lack of long-term effects on physical capacity and psychological variables
199475Arch Phys Med Rehabilpgs 551 554
Study Type: Randomised Controlled Trial
Patient Characteristics All acute MI patients under 65 years and attending the Hospital Post-MI Clinic. Median age: 55 years. Total age range (years): Intervention group: 38-65, Control group: 43-63. Gender: nearly all males.
Intervention It started weeks post MI and patients trained over a 12 week period for at least 45 min (effective time) twice a week with interval training involving large muscle groups.
Comparisons Received regular medical care with no special emphasis on exercise.
Study Length 1 year post MI.
Outcomes Maximal Physical Capacity (MPC) (after 1 year testing). Mean exercise capacity. Return to work.
Funding The research was supported by Malmohus county council. No commercial party had a direct financial interest in the results of the research.
Effect MPC in intervention group: increased non significantly by an average of 10% or 12W (95% CI: 2 to 22W) over baseline. MPC in control group: increased non significantly by an average of 2% or 1W (CI: −8 to 10W) over baseline. Intervention group difference: not significant. Mean exercise capacity: Interventon group: 172W (SD 33). Control group: 144W (SD 29). Return to work: After 1 year follow up median time of work return: not significant. Interventon group: 16 weeks (interquartile range 12 to 30 weeks). Control group: 12 weeks (interquartile range 9 to 23 weeks). Number of patients that resumed at least part-time work: Intervention group: 23/30 (77%), Control group: 27/32 (84%). There was a weak tendency of earlier return to work in those subjects who were least fit.
Grading:1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias*
Reference number 2950
Stahle A;Lindquist I;Mattsson E;
Important factors for physical activity among elderly patients one year after an acute myocardial infarction
200032Scand J Rehabil Medpgs 111 116
Study Type: Randomised Controlled Trial
Patient Characteristics Post MI patients ≥ 65 years.
Intervention Supervised outpatient training program (50 min, 3x per week for 3 months).
Comparisons Exercise training versus usual care.
Study Length 12 months.
Outcomes Self-motivation, outcome expectation, efficacy expectation, physical activity.
Funding Nat. Asn. Heart & Lung Foundn Swedish Heart & Lung Foundn Swedish Foundn Health Care Sciences Allergy Re-search King Gustaf V & Queen Victoria Foundn Swedish Nat. Center for Research in Sports.
Effect No significant difference for: self-motivation, outcome expectation, efficacy expectation. Reported physical activity at 12 months was significantly higher in the intervention group compared with controls (P < 0.0001). A multiple regression analysis between level of activity at 12 months and age, gender, BMI, support, SMI, activity level before admission, and group (intervention and controls) found that group and activity before admission were the only variables that predicted high activity at 12 months (RR = 0.74, P < 0.001).
Grading: 2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a
Reference number 1020
Dugmore LD;Tipson RJ;Phillips MH;Flint EJ;Stentiford NH;Bone MF;ittler WA;
Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme
199981Heart (British Cardiac Society)pgs 359 366
Study Type: Cohort
Patient Characteristics Post MI patients 36 good prognosis patients & their matched controls (ages 51.6±1.28 & 52.9±1.35 years, respectively). 26 poor prognosis patients & their matched controls (ages 59.6±1.4 & 59.5±1.36 years, respectively).
Intervention Exercise program: 3x per week for a 12 month period-aerobic & local muscular endurance training. Each patient’s training program was individually designed based on results of regular exercise tests.
Comparisons Exercise program for 12 months & no exercise program.
Study Length 12 month then follow up at 5 years.
Outcomes Cardiorespiratory fitness, psychoogical profiles, quality of life scores, mortality, full time employment return, non-fatal reinfarction.
Funding Not listed.
Effect At 12 months, the treatment group had significant improvements compared with matched controls in cardiorespiratory fitness (P < 0.01–0.001), psychological profiles (P < 0.05–0.001) & quality of life scores (P < 0.001) 5 years later by questionnaire and interview. The compliance rate was 95.6% (119 patients). There were 5 attributed deaths in the follow up period: 2 in the treatment group and 3 in the controls. The exercising groups suffered significantly fewer non- fatal reinfarctions (8%) compared with controls (22%) (P < 0.05). Compared with controls, the exercisers visited their general practitioners less frequently (P < 0.01), returned to work earlier (P < 0.05), and reported less angina (P < 0.001).

From: Appendix C, Clinical Evidence Extractions

Cover of Post Myocardial Infarction
Post Myocardial Infarction: Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction [Internet].
NICE Clinical Guidelines, No. 48.
National Collaborating Centre for Primary Care (UK).
Copyright © 2007, National Collaborating Centre for Primary Care.

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