Exercise‐based cardiac rehabilitation for adults with stable angina
Information
- DOI:
- https://doi.org/10.1002/14651858.CD012786.pub2Copy DOI
- Database:
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- Cochrane Database of Systematic Reviews
- Version published:
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- 02 February 2018see what's new
- Type:
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- Intervention
- Stage:
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- Review
- Cochrane Editorial Group:
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Cochrane Heart Group
- Copyright:
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- Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Authors
Contributions of authors
LL contributed to writing the protocol, undertook the 'Risk of bias' assessment, conducted the GRADE analysis and led the writing of the final review manuscript.
LA led writing of the protocol, undertook study selection and data extraction and contributed to writing the final review manuscript.
AD contributed to writing the protocol and manuscript, undertook study selection, data extraction and 'Risk of bias' assessment, and approved the final review manuscript.
JH provided clinical expertise, assisted in writing the protocol, undertook study selection, data extraction and 'Risk of bias' assessment.
MG contributed to writing the protocol and provided clinical expertise.
RST led the statistical analysis, conducted the GRADE analysis, edited the review and contributed to writing the final review manuscript.
All authors approved the final review.
Sources of support
Internal sources
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University of Exeter Medical School, UK.
External sources
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The Cochrane Heart Group US Satellite is supported by intramural support from the Northwestern University Feinberg School of Medicine and the Northwestern University Clinical and Translational Science (NUCATS) Institute (UL1TR000150)., USA.
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This project was supported by the National Institute for Health Research, via Cochrane Incentive funding to the Heart Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health, UK.
Declarations of interest
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).
Acknowledgements
The review authors thank the Cochrane Heart editorial team for their support. The review authors would also like to express their sincere thanks for the professional and timely handling of the review process by Helen Wakeford and Cochrane Fast‐Track team.
Version history
| Published | Title | Stage | Authors | Version |
| 2018 Feb 02 | Exercise‐based cardiac rehabilitation for adults with stable angina | Review | Linda Long, Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Charlene Bridges, Manish Gandhi, Rod S Taylor | |
| 2017 Sep 25 | Exercise‐based cardiac rehabilitation for patients with stable angina | Protocol | Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Manish Gandhi, Rod S Taylor, Linda Long | |
Differences between protocol and review
In addition to the outcomes stated in the protocol, we took the decision to extract data for one additional outcome measure, adverse events associated with exercise, as we decided that this is an outcome important to patients.
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Aged; Female; Humans; Male; Middle Aged;
PICOs
PRISMA flow diagram of trial selection
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1 Exercise versus no exercise for stable angina, Outcome 1 All‐cause mortality.
Comparison 1 Exercise versus no exercise for stable angina, Outcome 2 Acute myocardial infarction (AMI).
Comparison 1 Exercise versus no exercise for stable angina, Outcome 3 Revascularisation procedure (CABG or PCI).
Comparison 1 Exercise versus no exercise for stable angina, Outcome 4 Exercise capacity.
Comparison 1 Exercise versus no exercise for stable angina, Outcome 5 Cardiovascular‐related hospital admissions.
| Exercise‐based cardiac rehabilitation (CR) compared to usual care for patients with stable angina | ||||||
| Patient or population: adults with stable angina | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | Comments | |
| Risk with usual care | Risk with exercise‐based cardiac rehabilitation | |||||
| All‐cause mortality Follow‐up: 12 months | Study population | RR 1.01 | 195 | ⊕⊝⊝⊝ | We are uncertain about the effect of exercise‐based CR on all‐cause mortality compared to usual care. | |
| 20 per 1,000 | 21 per 1,000 | |||||
| Acute myocardial infarction (AMI) Follow‐up: 12 months | Study population | RR 0.33 | 254 | ⊕⊝⊝⊝ | We are uncertain about the effect of exercise‐based CR on AMI compared to usual care. | |
| 39 per 1,000 | 13 per 1,000 | |||||
| Exercise capacity (assessed using a variety of outcomes including VO2 max and duration of exercise) Follow‐up: range 6 to 12 months | The mean exercise capacity in the intervention groups was 0.45 standard deviations higher | 267 | ⊕⊕⊝⊝ | Using Cohen's rule of thumb a SMD of 0.2 represents a small effect, 0.5 a moderate effect and 0.8 a large effect between groups (Cohen 1988). Exercise‐based CR may slightly improve exercise capacity compared to usual care. | ||
| Cardiovascular‐related hospital admissions Follow‐up: 12 months | Study population | RR 0.14 (0.02 to 1.1) | 101 | ⊕⊝⊝⊝ | We are uncertain about the effect of exercise‐based CR on cardiovascular‐related hospital admissions compared to usual care. | |
| 140 per 1000 | 20 per 1000 (2 to 154) | |||||
| Health‐related quality of life (assessed with: Seattle Angina Questionnaire and The MacNew Questionnaire) | One study showed improvement in emotional score at 6‐week follow up, and benefits in angina frequency and social HRQL score at 6 months follow‐up. | Not estimable | 94 (1 RCT) | ⊕⊝⊝⊝ | We are uncertain about the effect of exercise‐based CR on quality of life compared to usual care. | |
| Return to work | No studies were found that looked at return to work. | |||||
| Adverse events (e.g. skeletomuscular injury) Follow‐up: 12 months | Only one study looked at adverse events and reported that there were no adverse events during the exercise‐based CR. | Not estimable | 101 (1 RCT) | ⊕⊝⊝⊝ | We are uncertain about the effect of exercise‐based CR on adverse events compared to usual care. | |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 Some concerns with random sequence generation, allocation concealment, blinding of outcome assessment and selective reporting; bias likely, therefore quality of evidence downgraded by one level 2 Some concern with applicability to review question as participants in all studies were limited to middle‐aged men, therefore quality of evidence downgraded by one level 3 Imprecise due to small number of participants (less than 300) and confidence intervals including potential for important harm or benefit as 95% CI crosses RR of 0.75 and 1.25, therefore quality of evidence downgraded by two levels 4 Some concerns with random sequence generation, allocation concealment, blinding of outcome assessment, selective reporting and unbalanced groups at baseline; bias likely, therefore quality of evidence downgraded by one level 5 Some concern with random sequence generation, allocation concealment, blinding of outcome assessment, high loss to follow‐up, selective reporting and unbalanced groups at baseline; serious bias likely, therefore quality of evidence downgraded by two levels 6 Imprecise due to small number of participants (less than 300) therefore quality of evidence downgraded by one level 7 Some concerns with random sequence generation, allocation concealment and selective reporting; bias likely, therefore quality of evidence downgraded by one level 8 Some concerns with blinding of outcome assessment, selective reporting and groups not receiving comparable care; bias likely, therefore quality of evidence downgraded by one level 9 Imprecise due to very small number of participants therefore quality of evidence downgraded by two levels | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 All‐cause mortality Show forest plot | 3 | 195 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.01 [0.18, 5.67] |
| 2 Acute myocardial infarction (AMI) Show forest plot | 3 | 254 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.33 [0.07, 1.63] |
| 3 Revascularisation procedure (CABG or PCI) Show forest plot | 3 | 256 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.27 [0.11, 0.64] |
| 4 Exercise capacity Show forest plot | 5 | 267 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.45 [0.20, 0.70] |
| 5 Cardiovascular‐related hospital admissions Show forest plot | 1 | 101 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.14 [0.02, 1.10] |
