Review short title

(reference)

Exercise for CHD

(Heran 2011)

Exercise for HF

(Taylor 2014b)

Psychological for CHD

(Whalley 2011)

Education for CHD

(Brown 2011)

Home vs. centre

(Taylor 2014a)

Uptake and adherence

(Karmali 2014)

Main objective

To determine the effectiveness of exercise‐based CR (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and HRQoL of people with CHD

To determine the effectiveness of exercise‐based interventions compared with usual medical care by focusing on mortality, hospital admission rate, morbidity and HRQoL in people with HF

To determine the independent effects of psychological interventions in people with CHD

To assess the effects of patient education on mortality, morbidity, HRQoL and healthcare costs in people with CHD

To determine the effectiveness of home‐based CR programmes compared with supervised centre‐based CR on mortality and morbidity, HRQoL and modifiable cardiac risk factors in people with CHD

To determine the harms and benefits of interventions to increase patient uptake of, and adherence to, CR

Search time frame

November 2000 to December 2009

2008 to March 2013

2001 to January 2009

1990 to August 2010

2008 to November 2012

2008 to January 2013

Study design

RCTs (follow‐up ≥ 6 months)

RCTs (follow‐up ≥ 6 months)

RCTs (no minimum follow‐up)

RCTs (follow‐up ≥ 6 months)

RCTs (no minimum follow‐up)

RCTs (no minimum follow‐up)

Population

Inclusion

Post‐MI

Post revascularisation

CHD defined by angiography

Exclusion

Heart valve surgery

HF

Heart transplantation

CRT or ICD implant

Inclusion

HF

Exclusion

Previous CR

Inclusion

Post‐MI

Post revascularisation

Angina

CHD defined by angiography

Exclusion

None

Inclusion

Post‐MI

Post revascularisation

Angina

CHD defined by angiography

Inclusion

Post‐MI

Post revascularisation

Angina

HF

Exclusion

Heart transplantation

CRT or CD implant

Previous CR

Inclusion

Post‐MI

Post revascularisation

Angina

HF

CHD

Exclusion

Heart transplantation

CRT or ICD implant

Intervention

Exercise training with or without the addition of psychosocial or educational interventions (or both)

Exercise training with or without the addition of psychosocial or educational interventions (or both)

Psychological interventions delivered by healthcare workers with specific training in psychological techniques

Patient education interventions involving direct contact with a health professional and including structured knowledge transfer about CHD

CR programmes delivered in a home‐based setting

CR plus any intervention with the specific aim of increasing patient uptake of, or adherence to, CR or any of its component parts

Comparator

No exercise training control that could include psychological, educational interventions, standard medical care or a combination

No exercise training control that could include psychological, educational interventions, standard medical care or a combination

No psychological intervention control that could include exercise interventions or standard medical care

No education intervention control that could include exercise interventions or standard medical care

CR programmes delivered in a centre‐based setting

CR programmes without the intervention

Outcomes

• Mortality (total, CV, non‐CV)

• MI (total, fatal, non‐fatal)

• Revascularisations (total, CABG, PTCA, re‐stenting)

• Hospitalisations (total, CV, other)

• HRQoL

• Economic (costs and cost‐effectiveness)

• Mortality (total, HF and sudden death)

• Hospitalisation (total, HF)

• HRQoL

• Economic (costs and cost‐effectiveness)

• Mortality (total and CV)

• Morbidity (non‐fatal MI)

• Revascularisation (CABG and PTCA)

• Psychological well‐being anxiety, depression, stress and Type A

• Behaviour/hostility

• HRQoL

• Mortality (total, CV and non‐CV)

• Total CV events

• MI (fatal or non‐fatal, or both)

• Other fatal or non‐fatal (or both) CV events

• Revascularisations (CABG, PTCA with or without stenting)

• Hospitalisations (cardiac‐related)

• HRQoL

• Withdrawals/drop‐outs

• Economic (healthcare costs and cost‐effectiveness)

• Mortality (total and CV)

• Morbidity (reinfarction, revascularisation, cardiac‐associated hospitalisation)

• Exercise capacity

• Risk factors (smoking behaviour, blood lipid levels, blood pressure)

• HRQoL

• Adverse events (withdrawal from the exercise programme)

• Adherence to rehabilitation

• Economic (health service use, costs and cost‐effectiveness)

Uptake of, or adherence to, CR (primary)

• Mortality (total)

• Morbidity

• Risk factors (smoking behaviour, blood lipid levels, blood pressure)

• HRQoL

• Economic (healthcare costs and cost‐effectiveness)

• Any beneficial or adverse events

Funding source

NIHR, UK Cochrane Collaboration Programme Grant, UK

None specified

Department of Social Medicine, University of Bristol, UK

Health Services Research Focus, University of Wales College of Medicine, UK

British Heart Foundation, UK

ESCR, UK

NIHR, UK Cochrane Collaboration Heart Programme Grant, UK

NIHR, UK Cochrane Collaboration Programme Grant, UK

NIHR Cochrane Heart Programme grant, UK

Transparency of the National Health System Drug Reimbursement Decisions, Poland, EU

NIHR programme grant, UK

Authors' declarations of interest

Authors were authors of the original Cochrane review. RST was a co‐investigator on a number of CR RCTs

‐

None declared

None declared

RST was a co‐author of the original Cochrane review and was a co‐investigator on a number of CR RCTs

None declared

Review short title

(reference)

Exercise for CHD

(Heran 2011)

Exercise for HF

(Taylor 2014b)

Psychological for CHD

(Whalley 2011)

Education for CHD

(Brown 2011)

Home vs. centre

(Taylor 2014a)

Uptake and adherence

(Karmali 2014)

RCTs (participants)

Number

47 RCTs

(10,794)

33 RCTs

(4740)

24 RCTs

(9296)

13 RCTs

(68,556)

17 RCTs

(2172)

18 RCTs

(2505)

Nature of intervention*

Exercise only

17

21

0

0

6

Interventions aimed at increasing patient uptake of CR (10 RCTs)

Interventions designed to increase adherence to exercise (7 RCTs) or supervised CR (1 RCT)

Psychological only

0

0

14

0

0

Education only

0

0

0

13

0

> 1 intervention

29*

12

10 (psychological and education)

0

11

Sample size

Median (range)

142

(28 to 2304)

54

(19 to 2331)

133

(44 to 2481)

288

(87 to 46,606)

104

(20 to 525)

110

(16 to 597)

Intervention duration [months]

Median (range) months

3 (1 to 30)

6 (1 to 120)

NR

6 (1 to 30)

3 (1.5 to 6)

NR

Publication year (number of RCTs)

1970‐1979

2

0

2

0

0

0

1990‐1999

11

0

4

0

1

2

1990‐1999

20

5

8

4

2

3

2000‐2009

14

20

10

9

11

8

2010+

0

8

0

0

3

5

% male

Median (range)

88 (0 to 100)

80 (36 to 100)

84 (0 to 100)

60 (0 to 100)

80 (60 to 100)

84 (0 to 100)

% white

Median (range)

NR

85 (60 to 100) from 8 RCTs

NR

86 (55 to 97) from 6 RCTs

80 from 1 RCT

79 (43 to 95) from 6 RCTs

Age (years)

Median (range)

55 (49 to 70)

60 (51 to 81)

57 (51 to 62)

62 (51 to 73)

60 (52 to 69)

62 (51 to 77)

Indication (number of RCTs)

MI only

28

0

10

2

4

4

Angina only

1

0

1

1

0

0

Revascularisation only

1

0

4

2

4

0

MI or revascularisation (or both)

4

0

4

1

5

3

MI or angina

4

0

2

0

0

3

Mixed CHD

9

0

2

4

0

7

HF

0

33

0

3 CHD or HF

3

1

Arrhythmia

0

0

1

0

1

0

Study location (number of RCTs (%))

Europe

20 (43)

20 (64)

11 (46)

7 (54)

10 (58)

6 (33)

North America

3 (6)

11 (30)

11 (46)

6 (46)

5 (29)

11 (61)

Asia/Australia

7 (15)

1 (3)

2 (8)

0

1 (6)

1 (6)

Other

‐

1 (3)

0

0

1 (6)

0

NR

17 (36)

0

0

0

0

0

Single centre

Number of RCTs (%)

23 (49)

30 (91)

8 (33)

4 (31)

15 (88)

10/16 (63)**

Follow‐up duration [months]

Median (range)

24 (6 to 120)

6 (6 to 120)

NR

18 (6 to 60)

6 (2 to 72)

3 (1.5 to 12)

Review short title

(reference)

Exercise for CHD

(Heran 2011)

Exercise for HF

(Taylor 2014b)

Psychological for CHD

(Whalley 2011)

Education for CHD

(Brown 2011)

Home vs. centre

(Taylor 2014a)

Uptake and adherence

(Karmali 2014)

1. Was an 'a priori' design provided?

(A) 'a priori' design

Yes

Yes

Yes

Yes

Yes

Yes

(B) Statement of inclusion criteria

Yes

Yes

Yes

Yes

Yes

Yes

(C) PICO/PIPO research question (population, intervention, comparison, prediction, outcome)

Yes

Yes

Yes

Yes

Yes

Yes

Score

4

4

4

4

4

4

2. Was there duplicate study selection and data extraction?

(A) There should be at least 2 independent data extractors as stated or implied

Yes

*Yes

*Yes

*Yes

*Yes

Yes

(B) Statement of recognition or awareness of consensus procedure for disagreements

Yes

Yes

Yes

Yes

Yes

Yes

(C) Disagreements among extractors resolved properly as stated or implied

Yes

Yes

Yes

Yes

Yes

Yes

Score

4

4

4

4

4

Yes

3. Was a comprehensive literature search performed?

(A) At least 2 electronic sources should be searched

Yes

Yes

Yes

Yes

Yes

Yes

(B) The report must include years and databases used (e.g. CENTRAL, MEDLINE, EMBASE)

Yes

Yes

Yes

Yes

Yes

Yes

(C) Key words or MESH terms (or both) must be stated AND where feasible the search strategy outline should be provided such that one can trace the filtering process of the included articles

Yes

Yes

Yes

Yes

Yes

Yes

(D) In addition to the electronic databases (PubMed, MEDLINE, EMBASE), all searches should be supplemented by consulting current contents, reviews, textbooks, specialised registers, or experts in the particular field of study, and by reviewing the references in the studies found

No

Yes

Yes

Yes

Yes

No

(E) Journals were "hand‐searched" or "manual searched" (i.e. identifying highly relevant journals and conducting a manual, page‐by‐page search of their entire contents looking for potentially eligible studies)

No

No

No

No

No

No

Score

3

4

4

4

4

3

4. Was the status of publication (i.e. grey literature) used as an inclusion criterion?

(A) The authors should state that they searched for reports regardless of their publication type

*No

*No

No

*No

Yes

*No

(B) The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language, etc.

Yes

Yes

Yes

Yes

Yes

Yes

(C) "Non‐English papers were translated" or readers sufficiently trained in foreign language

Yes

No

Yes

Yes

No

No

(D) No language restriction or recognition of non‐English articles

Yes

Yes

Yes

Yes

Yes

Yes

Score

4

3

4

4

4

3

5. Was a list of studies (included and excluded) provided?

(A) Table/list/figure of included studies, a reference list does not suffice

Yes

Yes

Yes

Yes

Yes

Yes

(B) Table/list/figure of excluded studies, either in the article or in a supplemental source (i.e. online). (Excluded studies refers to those studies seriously considered on the basis of title and/or abstract, but rejected after reading the body of the text)

Yes

Yes

Yes

Yes

Yes

Yes

(C) Author satisfactorily/sufficiently stated the reason for exclusion of the seriously considered studies

Yes

Yes

Yes

Yes

Yes

Yes

(D) Reader was able to retrace the included and the excluded studies anywhere in the article bibliography, reference or supplemental source

Yes

Yes

Yes

Yes

Yes

Yes

Score

4

4

4

4

4

4

6. Were the characteristics of the included studies provided?

(A) In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions AND outcomes

Yes

Yes

Yes

Yes

Yes

Yes

(B) Provide the ranges of relevant characteristics in the studies analysed (e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity or other diseases should be reported)

Yes

Yes

Yes

Yes

Yes

Yes

(C) The information provided appears to be complete and accurate (i.e. there was a tolerable range of subjectivity here. Is the reader left wondering? If so, state the needed information and the reasoning)

Yes

Yes

Yes

Yes

Yes

Yes

Score

4

4

4

4

4

4

7. Was the scientific quality of the included studies assessed and documented?

(A) 'A priori' methods of assessment should be provided (e.g. for effectiveness studies if the author(s) chose to include only randomised, double‐blind, placebo‐controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant

Yes

Yes

Yes

Yes

Yes

Yes

(B) The scientific quality of the included studies appeared to be meaningful

Yes

Yes

Yes

Yes

Yes

Yes

(C) Discussion/recognition/awareness of level of evidence

Yes

Yes

Yes

Yes

Yes

Yes

(D) Quality of evidence should be rated/ranked based on characterised instruments. (Characterised instrument is a created instrument that ranks the level of evidence, e.g. GRADE (Grading of Recommendations Assessment, Development and Evaluation))

No

No

No

No

No

No

Score

3

3

3

3

3

3

8. Was the scientific quality of the included studies used appropriately in formulating conclusions?

(A) The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review

Yes

Yes

Yes

Yes

Yes

Yes

(B) The results of the methodological rigor and scientific quality were explicitly stated in formulating recommendations

No

No

No

No

No

Yes

(C) To have conclusions integrated/drives towards a clinical consensus statement

Yes

Yes

Yes

Yes

Yes

Yes

(D) This clinical consensus statement drives towards revision or confirmation of clinical practice guidelines

No

No

No

Yes

No

No

Score

2

2

2

3

2

3

9. Were the methods used to combine the findings of studies appropriate?

(A) Statement of criteria that were used to decide that the studies analysed were similar enough to be pooled?

Yes

Yes

No

Yes

Yes

Yes

(B) For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi² test for homogeneity, I² statistic)

Yes

Yes

Yes

Yes

Yes

NA

(C) Is there a recognition of heterogeneity or lack of thereof

Yes

Yes

Yes

Yes

Yes

Yes

(D) If heterogeneity exists a "random‐effects model" should be used or the rationale (i.e. clinical appropriateness) of combining should be taken into consideration (i.e. is it sensible to combine?), or stated explicitly (or both)

Yes

Yes

Yes

Yes

Yes

NA

(E) If homogeneity exists, author should state a rationale or a statistical test

Yes

Yes

NA

NA

Yes

NA

Score

4

4

3

4

4

2

10. Was the likelihood of publication bias (a.k.a. "file drawer" effect) assessed?

(A) Recognition of publication bias or file‐drawer effect

Yes

Yes

Yes

Yes

Yes

Yes

(B) An assessment of publication bias should include graphical aids (e.g. funnel plot, other available tests)

Yes

Yes

Yes

Yes

Yes

No

(C) Statistical tests (e.g. Egger regression test)

Yes

Yes

Yes

Yes

Yes

No

Score

4

4

4

4

4

2

11. Was the conflict of interest stated?

(A) Statement of sources of support

Yes

Yes

Yes

Yes

Yes

Yes

(B) No conflict of interest. This is subjective and may require some deduction or searching

Yes

Yes

Yes

Yes

Yes

Yes

(C) An awareness/statement of support or conflict of interest in the primary inclusion studies

No

No

No

No

No

No

Score

3

3

3

3

3

3

Total score (n/44)

39

39

39

41

40

35

Review short title

(reference)

Exercise for CHD

(Heran 2011)

Exercise for HF

(Taylor 2014b)

Psychological for CHD

(Whalley 2011)

Education for CHD

(Brown 2011)

Home vs. centre

(Taylor 2014a)

Uptake and adherence

(Karmali 2014)

Total

Number of RCTs with low risk of bias (%)

Random sequence generation

8 (17)

10 (30)

7 (29)

9 (69)

4 (24)

9 (50)

47 (31)

Allocation concealment

7 (15)

6 (18)

7 (29)

7 (54)

7 (41)

8 (44)

41 (27)

Groups balanced at baseline

^a27 (57)

32 (97)

^a10 (42)

12 (92)

14 (82)

^ab9 (56)

103 (68)

Outcome blinding

4 (9)

11 (33)

5 (21)

4 (31)

7 (41)

5 (28)

36 (24)

Selective reporting

0 (0)

31 (94)

16 (67)

12 (92)

16 (94)

15 (83)

90 (59)

Loss to follow‐up < 20%

33 (70)

29 (88)

13 (54)

10 (77)

11 (65)

4 (22)

99 (65)

Intention‐to‐treat analysis

^a19 (40)

29 (88)

22 (92)

11 (85)

14 (82)

^ab7 (44)

101 (66)

Groups received same treatment apart from intervention*

^a21 (45)

21 (64)

^a16 (67)

11 (85)

15 (88)

^ab15 (94)

100 (66)

Exercise‐based cardiac rehabilitation for coronary heart disease

Patient or population: people with CHD
Settings:
Intervention: exercise‐based CR

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Exercise‐based CR

Total mortality
Follow‐up: 6‐12 months

Study population

RR 0.82
(0.67 to 1.01)

6000
(19 studies)

⊕⊕⊝⊝
low^1,2

‐

65 per 1000

53 per 1000
(43 to 65)

Moderate

‐

‐

Total mortality
Follow‐up: 12‐120 months

Study population

RR 0.87
(0.75 to 0.99)

5790
(16 studies)

⊕⊕⊕⊝
moderate¹

‐

126 per 1000

109 per 1000
(94 to 125)

Moderate

‐

‐

Cardiovascular mortality
Follow‐up: 6‐12 months

Study population

RR 0.93
(0.71 to 1.21)

4130
(9 studies)

⊕⊕⊝⊝
low^1,2

‐

51 per 1000

48 per 1000
(36 to 62)

Moderate

‐

‐

Cardiovascular mortality
Follow‐up: 12‐120 months

Study population

RR 0.74
(0.63 to 0.87)

4757
(12 studies)

⊕⊕⊕⊝
moderate¹

‐

129 per 1000

96 per 1000
(81 to 112)

Moderate

‐

‐

Hospitalisations
Follow‐up: 6‐12 months

Study population

RR 0.69
(0.51 to 0.93)

463
(4 studies)

⊕⊕⊕⊝
moderate¹

‐

324 per 1000

224 per 1000
(165 to 302)

Moderate

‐

‐

Hospitalisations
Follow‐up: 12‐48 months

Study population

RR 0.98
(0.87 to 1.11)

2009
(7 studies)

⊕⊕⊝⊝
low^1,3

‐

342 per 1000

335 per 1000
(297 to 379)

Moderate

‐

‐

MI
Follow‐up: 6‐12 months

Study population

RR 0.92
(0.7 to 1.22)

4216
(12 studies)

⊕⊝⊝⊝
very low^1,2,4

‐

45 per 1000

41 per 1000
(32 to 55)

Moderate

‐

‐

MI
Follow‐up: 12‐120 months

Study population

RR 0.97
(0.82 to 1.15)

5682
(16 studies)

⊕⊕⊝⊝
low^1,4

‐

89 per 1000

87 per 1000
(73 to 103)

Moderate

‐

‐

CABG
Follow‐up: 6‐12 months

Study population

RR 0.91
(0.67 to 1.24)

2312
(14 studies)

⊕⊕⊝⊝
low^1,2

‐

67 per 1000

61 per 1000
(45 to 83)

Moderate

‐

‐

CABG
Follow‐up: 12‐120 months

Study population

RR 0.93
(0.68 to 1.27)

2189
(9 studies)

⊕⊕⊝⊝
low^1,2

‐

69 per 1000

64 per 1000
(47 to 88)

Moderate

‐

‐

PTCA
Follow‐up: 6‐12 months

Study population

RR 1.02
(0.69 to 1.5)

1328
(7 studies)

⊕⊕⊝⊝
low^1,2

‐

69 per 1000

71 per 1000
(48 to 104)

Moderate

‐

‐

PTCA
Follow‐up: 12‐48 months

Study population

RR 0.89
(0.66 to 1.19)

1322
(6 studies)

⊕⊕⊝⊝
low^1,2

‐

124 per 1000

110 per 1000
(82 to 147)

Moderate

‐

‐

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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).
CABG: coronary artery bypass graft; CHD: coronary heart disease; CI: confidence interval; CR: cardiac rehabilitation; MI: myocardial infarction; PTCA: percutaneous transluminal coronary angioplasty; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

¹ Random sequence generation and allocation concealment were poorly described; bias likely.
² The 95% CIs include both no effect and appreciable benefit or harm (i.e. RR < 0.75 or > 1.25).
³ Moderate heterogeneity (I² > 50%).
⁴ Funnel plots or Egger test (or both) suggest evidence of asymmetry.

Exercise‐based cardiac rehabilitation for heart failure

Patient or population: people with HF

Settings:
Intervention: exercise‐based CR

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Exercise‐based CR

Total mortality
Follow‐up: 6‐12 months

Study population

RR 0.93
(0.69 to 1.27)

1871
(25 studies)

⊕⊕⊝⊝
low^1,2

‐

75 per 1000

70 per 1000
(52 to 96)

Moderate

‐

‐

Total mortality
Follow‐up: 12‐120 months

Study population

RR 0.88
(0.75 to 1.02)

2845
(6 studies)

⊕⊕⊝⊝
low^1,2

‐

196 per 1000

173 per 1000
(147 to 200)

Moderate

‐

‐

Hospitalisations
Follow‐up: 6‐12 months

Study population

RR 0.75
(0.62 to 0.92)

1328
(15 studies)

⊕⊕⊕⊝
moderate¹

‐

227 per 1000

170 per 1000
(141 to 209)

Moderate

‐

‐

Hospitalisations
Follow‐up: 12‐74 months

Study population

RR 0.92
(0.66 to 1.29)

2722
(5 studies)

⊕⊝⊝⊝
very low^1,2,3

‐

604 per 1000

556 per 1000
(399 to 779)

Moderate

‐

‐

Hospitalisations (HF‐specific admissions)
Follow‐up: 12‐120 months

Study population

RR 0.61
(0.46 to 0.8)

1036
(12 studies)

⊕⊕⊕⊝
moderate^1,2

‐

182 per 1000

111 per 1000
(84 to 145)

Moderate

‐

‐

HRQoL
MLWHF score
Follow‐up: 6‐12 months

‐

The mean HRQoL in the intervention groups was
5.8 lower
(9.21 to 2.44 lower)

‐

1270
(13 studies)

⊕⊝⊝⊝
very low^1,3,4

‐

HRQoL
All HRQoL measures
Follow‐up: 12‐120 months

‐

The mean HRQoL in the intervention groups was
0.46 lower
(0.66 to 0.26 lower)

‐

3240
(13 studies)

⊕⊝⊝⊝
very low^1,2,3,4

‐

HRQoL
MLWHF
Follow‐up: 6‐120 months

‐

The mean HRQoL in the intervention groups was
9.49 lower
(17.48 to 1.5 lower)

‐

329
(20 studies)

⊕⊝⊝⊝
very low^1,2,3,4

‐

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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).
CI: confidence interval; CR: cardiac rehabilitation; HF: heart failure; HRQoL: health‐related quality of life; MLWHF: Minnesota Living with Heart Failure questionnaire; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

¹ Random sequence generation and allocation concealment were poorly described; bias likely.
² The 95% CIs include both no effect and appreciable benefit or harm (i.e. RR < 0.75 or > 1.25).
³ Moderate heterogeneity (I² > 50%).
⁴ Funnel plots or Egger test (or both) suggest evidence of asymmetry.

Psychological‐based interventions for coronary heart disease

Patient or population: people with CHD
Settings:
Intervention: psychological‐based interventions

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Psychological‐based interventions

Total mortality
Follow‐up: 6‐12 months

Study population

RR 0.89
(0.75 to 1.05)

6852
(17 studies)

⊕⊕⊝⊝
low^1,2

‐

93 per 1000

83 per 1000
(70 to 98)

Moderate

‐

‐

Cardiovascular mortality
Follow‐up: 6‐15 months

Study population

RR 0.80
(0.64 to 1)

3893
(5 studies)

⊕⊕⊝⊝
low^1,2

‐

85 per 1000

68 per 1000
(55 to 85)

Moderate

‐

‐

MI (non‐fatal)
Follow‐up: 6‐15 months

Study population

RR 0.87
(0.67 to 1.13)

7534
(12 studies)

⊕⊕⊝⊝
low^1,2

‐

83 per 1000

72 per 1000
(55 to 94)

Moderate

Revascularisation (CABG and PTCA combined)
Follow‐up: 6‐15 months

Study population

RR 0.95
(0.8 to 1.13)

6670
(12 studies)

⊕⊕⊕⊝
moderate¹

‐

121 per 1000

115 per 1000
(97 to 137)

Moderate

‐

‐

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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).
CABG: coronary artery bypass graft; CHD: coronary heart disease; CI: confidence interval; MI: myocardial infarction; PTCA: percutaneous transluminal coronary angioplasty; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

¹ Random sequence generation and allocation concealment were poorly described; bias likely.
² The 95% CIs include both no effect and appreciable benefit or harm (i.e. RR < 0.75 or > 1.25).

Education‐based interventions forcoronary heart disease

Patient or population: people with CHD
Settings:
Intervention: education‐based interventions

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Education‐based interventions

Total mortality
deaths
Follow‐up: median 18 months

Study population

RR 0.79
(0.55 to 1.13)

2330
(6 studies)

⊕⊕⊕⊝
moderate¹

‐

96 per 1000

76 per 1000
(53 to 108)

Moderate

‐

‐

Hospitalisations

Study population

RR 0.83
(0.65 to 1.07)

12,905
(4 studies)

⊕⊕⊕⊝
moderate¹

‐

64 per 1000

53 per 1000
(41 to 68)

Moderate

‐

‐

MI

Study population

RR 0.63
(0.26 to 1.48)

209
(2 studies)

⊕⊝⊝⊝
very low²

‐

118 per 1000

74 per 1000
(31 to 174)

Moderate

‐

‐

CABG

Study population

RR 0.58
(0.19 to 1.71)

209
(2 studies)

⊕⊕⊝⊝
low²

‐

78 per 1000

45 per 1000
(15 to 134)

Moderate

‐

‐

All‐cause withdrawal

Study population

RR 1.03
(0.83 to 1.27)

2862
(8 studies)

⊕⊕⊕⊝
moderate¹

‐

181 per 1000

186 per 1000
(150 to 230)

Moderate

‐

‐

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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).
CABG: coronary artery bypass graft; CHD: coronary heart disease; CI: confidence interval; MI: myocardial infarction; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

¹ The 95% CIs include both no effect and appreciable benefit or harm (i.e. RR < 0.75 or > 1.25).
² The 95% CIs include both no effect and substantial benefit or harm (i.e. RR < 0.50 or > 1.50).

Home‐based cardiac rehabilitation compared with centre‐based cardiac rehabilitation for heart disease

Patient or population: people with heart disease
Settings:
Intervention: home‐based CR
Comparison: centre‐based CR

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Centre‐based CR

Home‐based CR

Total mortality
Follow‐up: 3‐12 months

Study population

RR 0.79
(0.43 to 1.47)

1166
(7 studies)

⊕⊕⊝⊝
low^1,2

‐

27 per 1000

22 per 1000
(12 to 40)

Moderate

‐

‐

All‐cause withdrawal
Follow‐up: median 6 months

Study population

RR 1.04
(1.01 to 1.07)

1984
(18 studies)

⊕⊕⊕⊝
moderate¹

‐

874 per 1000

909 per 1000
(883 to 936)

Moderate

‐

‐

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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).
CI: confidence interval; CR: cardiac rehabilitation; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

¹ Random sequence generation and allocation concealment were poorly described; bias likely.
² The 95% CIs include both no effect and appreciable benefit or harm (i.e. RR < 0.75 or > 1.25).

Review short title

(reference)

Exercise for CHD

(Heran 2011)

Exercise for HF

(Taylor 2014b)

Psychological for CHD

(Whalley 2011)

Education for CHD

(Brown 2011)

Home vs. centre

(Taylor 2014a)

Uptake and adherence

(Karmali 2014)

Total mortality

Follow‐up < 12 months

19 RCTs (6000 participants),

RR 0.82; 95% CI 0.67 to 1.01

I² = 0%

Follow‐up > 12 months

16 RCTs (5790 participants)

RR 0.87; 95% CI 0.75 to 0.99

I² = 0%

Follow‐up < 12 months

25 RCTs (1871 participants)

RR 0.93; 95% CI 0.697 to 1.27

I² = 0%

Follow‐up > 12 months

6 RCTs (2845 participants)

RR 0.88; 95% CI 0.75 to 1.02

I² = 34%

17 RCTs (6852 participants)

RR 0.89; 95% CI 0.75 to 1.05

I² = 2%

6 RCTs (2330 participants)

RR 0.79; 95% CI 0.55 to 1.13

I² = 16%

Follow‐up < 12 months

7 RCTs (1166 participants)

RR 0.79; 95% CI 0.43 to 1.47

I² = 0%

Follow‐up > 12 months

1 RCT (525 participants)

RR 1.99; 95% CI 0.50 to 7.88

3 RCTs (211 participants)

0/3 RCTs reported a significant difference between intervention and control groups

(no pooling of data)

Cardiovascular mortality

Follow‐up < 12 months

9 RCTs (4130 participants)

RR 0.93; 95% CI 0.71 to 1.21

I² = 0.0%

Follow‐up > 12 months

12 RCTs (4757)

RR 0.74; 95% CI 0.63 to 0.87

I² = 0%

"Studies did not consistently report deaths due to heart failure or sudden death"

5 RCTs (3893 participants)

RR 0.80; 95% CI 0.6 to 1.00

I² = 0.0%

NR

NR

NR

Hospitalisation

Follow‐up < 12 months

4 RCTs (463 participants)

RR 0.69; 95% CI 0.51 to 0.93

I² = 12%

Follow‐up > 12 months

7 RCTs (2009 participants)

RR 0.98; 95% CI 0.87 to 1.11

I² = 56%

Follow‐up < 12 months

15 RCTs (1328 participants)

RR 0.75; 95% CI 0.62 to 0.92

I² = 0%

Follow‐up > 12 months

5 RCTs (2722 participants)

RR 0.92; 95% CI 0.66 to 1.29

I² = 63%

NR

At end of follow‐up period

4 RCTs (12,905 participants)

RR 0.83; 95% CI 0.65 to 1.07

I² = 32%

1 RCT

No difference between home‐based and centre‐based CR

3 RCTs (numbers NR)

No significant difference between intervention and control groups

(no pooling of data)

HF‐specific admissions

NR

Follow‐up > 12 months

12 RCTs (1036 participants)

RR 0.61; 95% CI 0.46 to 0.80

I² = 34%

NR

1 RCT

Participants in the intervention group had 41% fewer (P value = 0.05) and 61% fewer heart‐related inpatient days

(P value = 0.02) than in the control group

NR

NR

Events

MI

Fatal or non‐fatal(or both) MI

Follow‐up < 12 months

12 RCTs (4216 participants)

RR 0.92; 95% CI 0.70 to 1.22

I² = 19%

Follow‐up > 12 months

16 RCTs (5682 participants)

RR 0.97; 95% CI 0.82 to 1.15

I² = 25%

NR

Non‐fatal MI

12 RCTs (7534 participants)

RR 0.87; 95% CI 0.67 to 1.13

I² = 31%

MI at the end of the follow‐up period

2 RCTs (209 participants)

RR 0.63; 95% CI 0.26 to 1.48

I² = 0%

2 RCTs

No difference between home‐based and centre‐based CR (no pooling of data performed)

CHD event rates

3 RCTs (414 participants)

2/3 RCTs reported no difference between intervention and control groups

1 RCT (228 participants)

RR 1.66, P value < 0.01

CABG

Follow‐up < 12 months

14 RCTs (2312 participants)

RR 0.91; 95% CI 0.67 to 1.24

I² = 0%

Follow‐up > 12 months

9 RCTs (2189 participants)

RR 0.93; 95% CI 0.68 to 1.27

I² = 0%

NR

Revascularisation (CABG and PTCA combined)

12 RCTs (6670 participants)

RR 0.95; 95% CI 0.80 to 1.13

I² = 13%

At end of follow‐up period

2 RCTs (209 participants)

RR 0.58; 95% CI 0.19 to 1.71

I² = 0%

Not reported by RCTs

‐

PTCA

Follow‐up < 12 months

7 RCTs (1328 participants)

RR 1.02; 95% CI 0.69 to 1.50

I² = 12%

Follow‐up > 12 months

6 RCTs (1322 participants)

RR 0.89; 95% CI 0.66 to 1.19

I² = 20%

NR

Revascularisation (CABG and PTCA combined)

12 RCTs (6670 participants)

RR 0.95; 95% CI 0.80 to 1.13

I² = 13%

Not reported by RCTs

Not reported by RCTs

‐

HRQoL

10 RCTs

7/10 RCTs reported evidence of a significantly higher level of HRQoL with intervention at follow‐up

20 RCTs

Follow‐up < 12 months

13 RCTs (1270 participants)

MLWHF score: MD ‐5.8; 95% CI ‐9.2 to ‐2.4

I² = 70%

Follow up > 12 months

3 RCTs (329 participants)

MD ‐9.5; 95% CI ‐17.54 to ‐1.5

I² = 73%

All HRQoL measures pooled

20 RCTs (3240 participants)

SMD ‐0.5; 95% CI ‐0.7 to ‐0.3

I² = 79%

7 RCTs

1/7 RCTs reported evidence of a significantly higher level of HRQoL with intervention at follow‐up

Across 11 RCTs, 81 HRQoL outcome scores/sub‐scores reported:

14/81 in favour of intervention compared to control

67/81 no significant difference between intervention and control

5/11 RCTs reported evidence of a significantly higher level of some HRQoL domains with intervention at follow‐up

No consistent difference in HRQoL total or domain score at follow‐up between intervention and control

10 RCTs

8/10 RCTs reported improvements in HRQoL at follow‐up with both home‐based and centre‐based CR compared with baseline

No strong evidence of difference in overall HRQoL outcomes or domain score at follow up between home‐based and centre‐based CR

2 RCTs

1/2 RCTs reported improvement in HRQoL with intervention (not significant)

1/2 RCTs reported improvement in both groups but no significant difference between intervention and control

Economics

Costs

Cost‐effectiveness

Costs

3 RCTs

2/3 studies reported total healthcare costs were not statistically significantly different between groups

Cost‐effectiveness

1 RCT

Authors concluded that rehabilitation was an efficient use of healthcare resources and may be economically justified

3 RCTs

2 studies undertook a cost effectiveness analysis and 1 reported costs

There was no evidence of significantly different costs or outcomes

NR

5 RCTs reported healthcare utilisation costs

2/5 RCTs reported an overall mean net saving of USD965 per participant at 6 months follow‐up and USD1420 per participant at 24 months follow‐up

1/5 RCTs reported an increase in mean net costs of USD52 per participant

2/5 RCTs reported no difference between groups

No RCTs reported cost‐effectiveness

3/4 RCTs reported healthcare costs associated with CR were lower for the home‐based than centre‐based programmes

1/4 RCTs reported that home‐based CR was more costly than centre‐based CR but costs would be the same if participant travel costs and travel time were included

8 studies reported different aspects of consumption of healthcare resources

No significant between group differences were seen

NR

All‐cause withdrawal /drop‐out at follow‐up

NR

NR

NR

At follow‐up

8 RCTs (2862 participants)

RR 1.03; 95% CI 0.83 to 1.27

I² = 34%

At follow‐up

18 (1894 participants)

RR 1.04; 95% CI 1.00 to 1.08

I² = 44%

NR

Uptake

NR

NR

NR

NR

NR

10 RCTs (1338 participants)

8/10 RCTs reported uptake was significantly higher in intervention group

Adherence

NR

NR

NR

NR

14 RCTs

*3/14 RCTs reported adherence was significantly higher in home‐based CR

8 RCTs (1150 participants)

3/8 RCTs reported adherence was significantly higher in intervention group