Exercise-based cardiac rehabilitation for adults with stable angina
Linda Long, Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Charlene Bridges, Manish Gandhi, Rod S Taylor, Linda Long, Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Charlene Bridges, Manish Gandhi, Rod S Taylor
Abstract
Background: A previous Cochrane review has shown that exercise-based cardiac rehabilitation (CR) can benefit myocardial infarction and post-revascularisation patients. However, the impact on stable angina remains unclear and guidance is inconsistent. Whilst recommended in the guidelines of American College of Cardiology/American Heart Association and the European Society of Cardiology, in the UK the National Institute for Health and Care Excellence (NICE) states that there is "no evidence to suggest that CR is clinically or cost-effective for managing stable angina".
Objectives: To assess the effects of exercise-based CR compared to usual care for adults with stable angina.
Search methods: We updated searches from the previous Cochrane review 'Exercise-based cardiac rehabilitation for patients with coronary heart disease' by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, DARE, CINAHL and Web of Science on 2 October 2017. We searched two trials registers, and performed reference checking and forward-citation searching of all primary studies and review articles, to identify additional studies.
Selection criteria: We included randomised controlled trials (RCTs) with a follow-up period of at least six months, which compared structured exercise-based CR with usual care for people with stable angina.
Data collection and analysis: Two review authors independently assessed the risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors also independently assessed the quality of the evidence using GRADE principles and we presented this information in a 'Summary of findings' table.
Main results: Seven studies (581 participants) met our inclusion criteria. Trials had an intervention length of 6 weeks to 12 months and follow-up length of 6 to 12 months. The comparison group in all trials was usual care (without any form of structured exercise training or advice) or a no-exercise comparator. The mean age of participants within the trials ranged from 50 to 66 years, the majority of participants being male (range: 74% to 100%). In terms of risk of bias, the majority of studies were unclear about their generation of the randomisation sequence and concealment processes. One study was at high risk of detection bias as it did not blind its participants or outcome assessors, and two studies had a high risk of attrition bias due to the numbers of participants lost to follow-up. Two trials were at high risk of outcome reporting bias. Given the high risk of bias, small number of trials and participants, and concerns about applicability, we downgraded our assessments of the quality of the evidence using the GRADE tool.Due to the very low-quality of the evidence base, we are uncertain about the effect of exercise-based CR on all-cause mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.18 to 5.67; 195 participants; 3 studies; very low-quality evidence), acute myocardial infarction (RR 0.33, 95% CI 0.07 to 1.63; 254 participants; 3 studies; very low-quality evidence) and cardiovascular-related hospital admissions (RR 0.14, 95% CI 0.02 to 1.1; 101 participants; 1 study; very low-quality evidence). We found low-quality evidence that exercise-based CR may result in a small improvement in exercise capacity compared to control (standardised mean difference (SMD) 0.45, 95% CI 0.20 to 0.70; 267 participants; 5 studies, low-quality evidence). We were unable to draw conclusions about the impact of exercise-based CR on quality of life (angina frequency and emotional health-related quality-of-life score) and CR-related adverse events (e.g. skeletomuscular injury, cardiac arrhythmia), due to the very low quality of evidence. No data were reported on return to work.
Authors' conclusions: Due to the small number of trials and their small size, potential risk of bias and concerns about imprecision and lack of applicability, we are uncertain of the effects of exercise-based CR compared to control on mortality, morbidity, cardiovascular hospital admissions, adverse events, return to work and health-related quality of life in people with stable angina. Low-quality evidence indicates that exercise-based CR may result in a small increase in exercise capacity compared to usual care. High-quality, well-reported randomised trials are needed to assess the benefits and harms of exercise-based CR for adults with stable angina. Such trials need to collect patient-relevant outcomes, including clinical events and health-related quality of life. They should also assess cost-effectiveness, and recruit participants that are reflective of the real-world population of people with angina.
Conflict of interest statement
LL declares she has no conflicts of interest.
AD declares she has no conflicts of interest.
JH declares he has no conflicts of interest.
LA is an author on a number of other Cochrane reviews on cardiac rehabilitation (CR).
MG declares she has no conflicts of interest.
RST is an author on a number of other Cochrane reviews on CR and is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based CR intervention for people with heart failure and their carers (NIHR PGfAR RP‐PG‐0611‐12004).
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References
References to studies included in this review Devi 2014 {published data only}
- Devi R, Powell J, Singh S. A web‐based program improves physical activity outcomes in a primary care angina population: Randomized controlled trial. Journal of Medical Internet Research 2014;16(9):e186, 1‐12.
- Hambrecht R, Walther C, Möbius‐Winkler S, Gielen S, Linke A, Conradi K, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004;109(11):1371‐8.
- Jiang X, Sit JW, Wong TKS. A nurse‐led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Journal of Clinical Nursing 2007;16:1886‐97.
- Manchanda SC, Narang R, Reddy KS, Sachdeva U, Prabhakaran D, Dharmanand S, et al. Retardation of coronary atherosclerosis with yoga lifestyle intervention. The Journal of the Association of Physicians of India 2000;48(7):687‐94.
- Raffo JA, Luksic IY, Kappagoda CT, Mary DA, Whitaker W, Linden RJ. Effects of physical training on myocardial ischaemia in patients with coronary artery disease Effects of physical training on myocardial ischaemia in patients with coronary artery disease. British Heart Journal 1980;43(3):262‐9.
- Niebauer J, Hambrecht R, Marburger C, Hauer K, Velich T, Hodenberg E, et al. Physical exercise and low‐fat diet on collateral vessel formation in stable angina pectoris and angiographically confirmed coronary artery disease. The American Journal of Cardiology 1995;76(11):771‐5.
- Schuler G, Hambrecht R, Schlierf G, Niebauer J, Hauer K, Neumann J, et al. Regular physical exercise and low‐fat diet effects on progression of coronary artery disease. Circulation 1992;86(1):1‐11.
- Todd IC, Bradnam MS, Cooke MB, Ballantyne D. Effects of daily high‐intensity exercise on myocardial perfusion in Angina Pectoris. The American Journal of Cardiology 1991;68(17):1593‐9.
- Back M, Wennerblom B, Wittboldt S, Cider A. Effects of high frequency exercise in patients before and after elective percutaneous coronary intervention. European Journal of Cardiovascular Nursing 2008;7(4):307‐13.
- Byrkjeland R, Njerve IU, Anderssen SH, Arnesen H, Seljeflot I, Solheim S. Effects of exercise training on HbA1c and VO2peak in patients with type 2 diabetes and coronary artery disease: A randomised clinical trial. Diabetes and Vascular Disease Research 2015;12(5):325‐33.
- Jiang YR, Maddison L, Pfaeffli R, Whittaker R, Stewart A, Kerr G, et al. HEART exercise and remote technologies (HEART): A randomized controlled trial. Clinical Trials 2013;10(2):S47‐S48.
- Johnson NA, Lim LLY, Bowe SJ. Multicenter randomized controlled trial of a home walking intervention after outpatient cardiac rehabilitation on health‐related quality of life in women. European Journal of Cardiovascular Prevention and Rehabilitation 2009;16(5):633‐7.
- Kay P, Kittelson J, Stewart RA. Relation between duration and intensity of first exercise and "warm up" in ischaemic heart disease. Heart 2000;83(1):17‐21.
- Linxue LR, Nohara S, Makita R, Hosokawa T, Hata K, Okuda H, et al. Effect of long‐term exercise training on regional myocardial perfusion changes in patients with coronary artery disease. Japanese Circulation Journal 1999;63(2):73‐8.
- Malmborg RO, Isacsson SO, Kallivroussis G. The effect of beta blockade and/or physical training in patients with angina pectoris. Current Therapeutic Research, Clinical & Experimental 1974;16(3):171‐83.
- Menna J, Ferreiros E, Saglietti J. Rehabilitation of different forms of coronary heart disease. A prospective randomized trial and follow up of three groups of patients. Cardiology 1977;62(2):70.
- Michalsen A, Knoblauch TN, Lehmann N, Grossman P, Kerkhoff G, Wilhelm FH, et al. Effects of lifestyle modification on the progression of coronary atherosclerosis, autonomic function, and angina‐‐the role of GNB3 C825T polymorphism. American Heart Journal 2006;151(4):870‐7.
- Myers J, Ahnve S, Froelicher V, Sullivan M, Friis R. Influence of exercise training on spatial R‐wave amplitude in patients with coronary artery disease. Journal of Applied Physiology 1987;62(3):1231‐5.
- Onishi T, Shimada K, Sato H, Seki E, Watanabe Y, Sunayama S, et al. Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease. Circulation Journal 2010;74(4):709‐14.
- Sullivan M, Ahnve S, Froelicher VF, Meyers J. The influence of exercise training on the ventilatory threshold of patients with coronary heart disease. American Heart Journal 1985;109(3):458‐63.
- Wang W, Chan S, He HG. Developing and testing a mobile application programme to support self‐management in patients with stable angina: a feasibility study. Studies in Health Technology & Informatics 2014;201:241‐8.
- Weberg M, Hjermstad MJ, Hilmarsen CW, Oldervoll L. Inpatient cardiac rehabilitation and changes in self‐reported health related quality of life ‐ a pilot study. Annals of Physical and Rehabilitation Medicine 2013;56(5):342‐55.
- NCT00350922. A clinical trial of a self‐management education program for people with chronic stable angina. 2005 (date accessed: 01 Sept 2017).
- Bourke L, Tew GA, Milo M, Crossman DC, Saxton JM, Chico TJ. Study protocol: a randomised controlled trial investigating the effect of exercise training on peripheral blood gene expression in patients with stable angina. BMC Public Health 2010;10:620.
- 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]
- 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]
- British Association for Cardiovascular Prevention and Rehabilitation. The BACPR standards and core components for cardiovascular disease prevention and rehabilitation, 2nd edition. (accessed 20 April 2016).
- Beswick AD, Rees K, Griebsch I, Taylor FC, Burke M, West RR, et al. Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under‐represented groups. Health Technology Assessment 2004;8(iii–iv,ix–x):1‐152.
- British Heart Foundation. Cardiovascular Disease Statistics 2014. British Heart Foundation Centre on Population Approaches for Non‑Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford 2014.
- 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]
- Chan AW, Tetzlaff JM, Altman DG, Laupacis A, Gøtzsche PC, Krleža‐Jerić K, et al. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Annals of internal medicine 2013;158(3):200‐7.
- Clark AM, King‐Shier KM, Thompson DR, Spaling MA, Duncan AS, Stone JA, et al. A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral. American Heart Journal 2012;164(6):835‐45.
- Clausen JP, Trap‐Jensen J. Heart rate and arterial blood pressure during exercise in patients with angina pectoris: effects of exercise training and of nitroglycerin. Circulation 1976;53:436–42.
- Cohen J. Statistical power analysis in the behavioural sciences. 2nd Edition. Hillsdale, New Jersey: Lawrence Erlbaum Associates Inc, 1988.
- Crea F, Pupita G, Galassi AR, El‐Tamimi H, Kaski JC, Davies G, et al. Role of adenosine in pathogenesis of angina pain. Circulation 1990;81:164‐72.
- Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta‐analysis detected by a simple, graphical test. BMJ 1997;315:629‐34.
- Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP. ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Journal of American College of Cardiologists 2012;60(24):e44‐e164.
- Foreman RD. Mechanisms of cardiac pain. Annual Review of Physiology 1999;61:143.
- GRADEpro GTD: GRADEpro Guideline Development Tool [software]. McMaster University, 2015 (developed by Evidence Prime, Inc). Available from .
- Hambrecht R, Wolff A, Gielen S, Linke A, Hofer J, Erbs S, et al. Effect of exercise on coronary endothelial function in patients with coronary artery disease. New England Journal of Medicine 2000;342:454–60.
- Hemingway H, McCallum A, Shipley M, Manderbacka K, Martikainen P, Keskimaki I. Incidence and prognostic implications of stable angina pectoris among women and men. Journal of the American Medical Association 2006;295:1404–11.
- Heran BS, Wong MM, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD003823.pub2]
- Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin receptor blockers for primary hypertension. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD003822.pub2]
- Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011] The Cochrane Collaboration. Available from . The Cochrane Collaboration, 2011.
- Karmali KN, Davies P, Taylor F, Beswick A, Martin N, Ebrahim S. Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database of Systematic Reviews 2014, Issue 6. [DOI: 10.1002/14651858.CD007131.pub3]
- Lavie CJ, Milani RV, O’Keefe JH, Lavie TJ. Impact of exercise training on psychological risk factors. Progress in Cardiovascular Diseases 2011;53:464–70.
- Lavie CJ, Arena R, Swift DL, Johannsen NM, Sui X, Lee DC, et al. Exercise and the cardiovascular system: clinical science and cardiovascular outcomes. Circulation Research 2015;117(2):207‐19.
- Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S editor(s). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐.
- Lewin RJP, Petre C, Morton V, Onion N, Mortzou G. The National Audit of Cardiac Rehabilitation: 4th Annual Statistical Report 2010. British Heart Foundation, London 2010.
- Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease. European Heart Journal 2013;34(38):2949‐3003.
- British Heart Foundation. The National Audit of Cardiac Rehabilitation; Annual Statistical Report. 2016 (accessed 01 June 2017).
- National Heart, Lung and Blood Institute. 2012 NHLBI Morbidity and Mortality Chart Book. Bethesda, MD 2012.
- National institute for Health and Clinical Excellence. CG126: Stable Angina (Full Guideline). National Clinical Guidelines Centre, London 2011.
- Pavy B, Iliou MC, Meurin P, Tabet JY, Corone S. Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation. Arch Intern Med 2006;166:2329‐34.
- The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre: The Cochrane Collaboration, 2014.
- Schünemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziou P, et al. Chapter 12: Interpreting results and drawing conclusions. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions. Available from www.cochrane‐.
- 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]
- Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. Journal of the American college of cardiology 2011;58(23):2432‐46.
- StataCorp. Stata Statistical Software: Release 13. College Station, TX: StataCorp, 2013.
- Taylor RS, Unal B, Critchley JA, Capewell S. Mortality reductions in patients receiving exercise‐based cardiac rehabilitation: How much can be attributed to cardiovascular risk factors improvements?. European Journal of Cardiopulmonary Rehabilitation 2006;136:369‐74.
- Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home‐based versus centre‐based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD007130.pub2]
- 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]
- 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]
- Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA 1986;256:1160‐3.
- Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2163‐96.
- World Health Organization. The top 10 causes of death. Fact sheet No. 310. Updated Jan 2017.
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