Exercise-based cardiac rehabilitation in patients with heart failure: a meta-analysis of randomised controlled trials between 1999 and 2013.
BACKGROUND
Guidelines recommend exercise-based cardiac rehabilitation (EBCR) for patients with heart failure (HF). However, established research has not investigated the longer-term outcomes including mortality and hospitalisation in light of the contemporary management of HF.


METHODS
This was a systematic review including a meta-analysis of EBCR on all-cause mortality, hospital admission, and standardised exercise capacity using four separate exercise tests in patients with heart failure over a minimum follow-up of six months from January 1999-January 2013. Electronic searches were performed in the databases: Medline, CENTRAL, EMBASE, CINAHL, and PsycINFO constrained to randomised controlled trials (RCTs).


RESULTS
A total of 46 separate RCTs qualified for the meta-analysis, which employed conventional methods for binary and continuous data. The relative risk (RR) ratio for hospital admission (12 studies) was significantly reduced (RR ratio 0.65; 95% confidence interval (CI) 0.50-0.84; p = 0.001), but mortality (21 studies) was not (RR ratio 0.88; 95% CI 0.77-1.02; p = 0.08). The standardised exercise capacity (26 studies) showed a standardised mean difference (SMD) in favour of the exercise group as compared with the controls (SMD 0.98, 95% CI 0.59-1.37; p < 0.001). Women and elderly people were less frequently enrolled in the RCTs independent of the outcomes. Heterogeneity was moderate to high in the analysis of hospital admission and the standardised exercise capacity demonstrated through skewedness in their funnel plots.


CONCLUSIONS
EBCR in patients with HF is associated with significant improvements in exercise capacity and hospital admission over a minimum of six months follow-up, but not in all-cause mortality.
Department of Health Science, University of York, UK Department of Cardiology, University of Copenhagen, Denmark christianlewinter@gmail.com.
Christian
C
Lewinter
Department of Health Science, University of York, UK.
Patrick
P
Doherty
Centre for Epidemiology and Biostatistics, University of Leeds, UK Department of Cardiology, York Teaching Hospital NHS Foundation Trust, UK.
Christopher P
CP
Gale
Department of Health Science, University of York, UK.
Simon
S
Crouch
Centre for Reviews and Dissemination, University of York, UK.
Lisa
L
Stirk
Department of Health Science, University of York, UK.
Robert J
RJ
Lewin
Cardiology Unit, University of Vermont College of Medicine, USA.
Martin M
MM
LeWinter
Cardiology Unit, University of Vermont College of Medicine, USA.
Philip A
PA
Ades
Department of Cardiology, University of Copenhagen, Denmark.
Lars
L
Køber
Department of Health Science, University of York, UK.
John M
JM
Bland
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002317:Cardiovascular Agents / Q000627:therapeutic use; D005081:Exercise Therapy / Q000379:methods*; D017079:Exercise Tolerance; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000534:rehabilitation*; D006801:Humans; D008875:Middle Aged; D016017:Odds Ratio; D010343:Patient Admission; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012307:Risk Factors; D012737:Sex Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
D002317:Cardiovascular Agents
Exercise capacity; cardiac rehabilitation; heart failure; hospital admission; mortality