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DOI:
https://doi.org/10.1002/14651858.CD012264.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 04 abril 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Corazón

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

  • Lindsey Anderson

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Tricia T Nguyen

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Christian H Dall

    Dept. of Cardiology, Dept. of Physical Therapy and IOC Sports Institute Copenhagen, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark

  • Laura Burgess

    Cardiac Rehabilitation, Wythenshawe Hospital, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

  • Charlene Bridges

    Farr Institute of Health Informatics Research, University College London, London, UK

  • Rod S Taylor

    Correspondencia a: Institute of Health Research, University of Exeter Medical School, Exeter, UK

    [email protected]

Contributions of authors

LA undertook study selection, data extraction and risk of bias assessment, led the writing of the review and approved the final manuscript.

TN undertook study selection, data extraction and risk of bias assessment, assisted in the writing of the review and approved the final manuscript.

CD assisted in writing the protocol, provided clinical expertise, edited the review and approved the final manuscript.

LB provided clinical expertise, edited the review and approved the final manuscript.

RST led the statistical analysis, edited the review and approved the final manuscript.

Sources of support

Internal sources

  • University of Exeter Medical School, UK.

External sources

  • NIHR, UK.

    This project was supported by the National Institute for Health Research, via Cochrane Infrastructure 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

LA is an author on a number of other Cochrane cardiac rehabilitation reviews.

CD is an author of several publications on exercise in heart transplant recipients.

TN declares she has no conflicts of interest.

LB declares she has no conflicts of interest.

CB declares she has no conflicts of interest.

RST is an author on a number of other Cochrane cardiac rehabilitation reviews and is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based cardiac rehabilitation intervention for people with heart failure and their carers (PGfAR RP‐PG‐0611‐12004).

Acknowledgements

The authors acknowledge the support of the Cochrane Heart Group editorial team and the template protocol they made available. We would also like to thank Nicole Martin of the Cochrane Heart Group for updating the search strategy. Finally, we would like to thank Dr Felix Gradinger for his translation services and all the authors who provided additional information about their trials.

Version history

Published

Title

Stage

Authors

Version

2017 Apr 04

Exercise‐based cardiac rehabilitation in heart transplant recipients

Review

Lindsey Anderson, Tricia T Nguyen, Christian H Dall, Laura Burgess, Charlene Bridges, Rod S Taylor

https://doi.org/10.1002/14651858.CD012264.pub2

2016 Jun 23

Exercise‐based cardiac rehabilitation in heart transplant recipients

Protocol

Lindsey Anderson, Christian H Dall, Tricia T Nguyen, Laura Burgess, Rod S Taylor

https://doi.org/10.1002/14651858.CD012264

Differences between protocol and review

We conducted this systematic review according to the published protocol (Anderson 2016a).

However, the objectives of this review differ from those described in the protocol. In the review ‘morbidity’ was replaced by ‘adverse events’ and ‘costs’ was added, in order to better reflect the outcome measures being collected.

Also, due to the small number of included studies, we were unable to stratify meta‐analysis of outcomes according to the length of trial duration, or to undertake univariate meta‐regression to explore heterogeneity and examine potential treatment effect modifiers.

In addition to searching CPCI‐S on the Web of Science, as described in the protocol, the search was expanded to the core collection for the purposes of this review.

The protocol states that we would assess the risk of bias of blinding of participants and personnel. However, do to the nature of the intervention, this review assessed blinding of outcome assessors instead.

The protocol states that we would extract data on funding and notable conflicts of interest of trial authors. Instead, we assessed the risk of bias due to funding or conflicts of interest for each study and reported our assessment in the risk of bias tables.

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Summary of selection process
Figuras y tablas -
Figure 1

Summary of selection process

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figuras y tablas -
Figure 2

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
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Funnel plot of comparison: 1 Exercise versus no‐exercise, outcome: 1.1 Exercise capacity (VO2peak)
Figuras y tablas -
Figure 4

Funnel plot of comparison: 1 Exercise versus no‐exercise, outcome: 1.1 Exercise capacity (VO2peak)

Comparison 1 Exercise versus no‐exercise, Outcome 1 Exercise capacity (VO2peak).
Figuras y tablas -
Analysis 1.1

Comparison 1 Exercise versus no‐exercise, Outcome 1 Exercise capacity (VO2peak).

Comparison 1 Exercise versus no‐exercise, Outcome 2 Sensitivity analysis (excluding Kobashigawa 1999).
Figuras y tablas -
Analysis 1.2

Comparison 1 Exercise versus no‐exercise, Outcome 2 Sensitivity analysis (excluding Kobashigawa 1999).

Comparison 1 Exercise versus no‐exercise, Outcome 3 Sensitivity analysis (excluding Wu 2008).
Figuras y tablas -
Analysis 1.3

Comparison 1 Exercise versus no‐exercise, Outcome 3 Sensitivity analysis (excluding Wu 2008).

Comparison 1 Exercise versus no‐exercise, Outcome 4 Sensitivity analysis (excluding Kobashigawa 1999 and Wu 2008).
Figuras y tablas -
Analysis 1.4

Comparison 1 Exercise versus no‐exercise, Outcome 4 Sensitivity analysis (excluding Kobashigawa 1999 and Wu 2008).

Comparison 2 High‐intensity interval training versus continued moderate‐intensity exercise, Outcome 1 Exercise capacity (VO2peak).
Figuras y tablas -
Analysis 2.1

Comparison 2 High‐intensity interval training versus continued moderate‐intensity exercise, Outcome 1 Exercise capacity (VO2peak).

Summary of findings for the main comparison. Exercise versus no exercise for post‐heart transplant recipients

Exercise versus no exercise for post‐heart transplant recipients

Patient or population: Post‐heart transplant recipients
Settings: Home and centre (hospital, cardiac rehabilitation clinic or physiotherapy department)
Intervention: Exercise versus no exercise

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

Exercise versus no exercise

Exercise capacity
(VO2peak)
Follow‐up: median 9 months

The mean exercise capacity in the intervention groups was
2.49 higher (1.63 to 3.36 higher)

284
(9 studies)

⊕⊕⊕⊝
moderate1

Health‐related quality of life
Various HRQoL measures
Follow‐up: median 12 months

HRQoL in comparator > HRQoL in intervention, in 16/19 domains

HRQoL in intervention > HRQoL in comparator, in 3/19 domains

120
(3 studies)

⊕⊕⊕⊝
moderate1

*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; 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, allocation concealment or blinding of outcome assessors were poorly described in 50% or more of included studies.

Figuras y tablas -
Summary of findings for the main comparison. Exercise versus no exercise for post‐heart transplant recipients
Summary of findings 2. High‐intensity versus moderate‐intensity exercise

High‐intensity versus moderate intensity exercise

Patient or population: Post‐heart transplant recipients
Settings: Physiotherapy Department
Intervention: High‐intensity interval training
Comparison: Continued moderate‐intensity exercise

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Moderate intensity exercise

High‐intensity exercise

Exercise capacity
(VO2peak)
Follow‐up: 12 weeks

The mean exercise capacity in the control group was 2.6 mg/kg/min (SD 2.2)

The mean exercise capacity in the intervention group was 4.9 mg/kg/min (SD 2.7)

The mean exercise capacity in the intervention groups was 2.30 higher (0.59 to 4.01 higher)

16
(1 study)

⊕⊕⊕⊝
moderate1

Health‐related quality of life
Follow‐up: 12 weeks

Mental component score = 89.3 (7.4)

Physical component score = 76.4 (11.8)

Mental component score = 90.0 (6.6)

Physical component score = 77.5 (8.9)

HRQoL of patients receiving high‐intensity interval training = HRQoL of patients receiving continued moderate‐intensity exercise

16
(1 study)

⊕⊕⊕⊝
moderate1

*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; RR: risk ratio; RR; HRQoL: health‐related quality of life

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 This evidence is based on the result of only one cross‐over study with just 16 participants, resulting in a lack of precision

Figuras y tablas -
Summary of findings 2. High‐intensity versus moderate‐intensity exercise
Table 1. All‐cause withdrawal/drops out at follow‐up

Study

Number randomised

Number lost at follow‐up*

Notes

Bernardi 2007

Intervention

13

NR

NR

Control

11

NR

NR

Braith 2008

Intervention

10

1

1 withdrew due to illness

Control

10

3

3 participants not included in the final analysis due to non‐compliance with testing regimen

Dall 2014

Intervention

17

1

1 participant had insufficient exercise testing (respiratory exchange ratio (RER) < 0.85) and was an outlier on several parameters, and thus excluded from the main analyses (cross‐over design)

Control

17

1

Haykowsky 2009

Intervention

22

1

1 participant withdrew due to illness

Control

21

2

2 participants requested not to perform the post‐intervention assessments

Hermann 2011

Intervention

15

1

1 participant withdrew due to illness (1 additional participant lost to echo follow‐up)

Control

15

2

1 participant withdrew due to illness; 1 withdrew consent (3 additional participants lost to echo follow‐up)

Kobashigawa 1999

Intervention

14

NR

NR

Control

13

NR

NR

Nytrøen 2012

Intervention

26

2

2 participants withdrew due to illness

Control

26

2

1 participant withdrew due to illness; 1 lost to follow‐up (missing exercise capacity test)

Pascoalino 2015

Intervention

33

2

1 participant withdrew consent; 1 lost to follow‐up

Control

9

0

0 participants were lost to follow‐up

Tegtbur 2003

Intervention

16

8

2 participants declined participation due to personal reasons; 2 were excluded due to illness; 4 dropped out during the intervention due to personal reasons (N = 3) or orthopaedic impairment (N = 1)

Control

15

3

2 participants declined participation due to personal reasons; 1 excluded due to illness

Wu 2008

Intervention

14

2

2 participants dropped out after evaluation. In addition, 4 participants in the exercise group changed over to the control group after randomisation. Analyses conducted using the latter group allocation and not original randomised groups

Control

23

4

4 participants dropped out: 2 due to renal problem/anaemia; 2 for personal reasons

Combined results

Intervention

180

18

10.0%

Control

160

17

10.6%

* All causes of drop out from follow‐up included (including mortality)
NR = not reported

Figuras y tablas -
Table 1. All‐cause withdrawal/drops out at follow‐up
Table 2. Summary of health‐related quality of life (HRQoL) scores at follow‐up

Measure of HRQoL

Mean (SD) outcome values at follow‐up

P value

Difference between groups

High‐intensity interval training

Continued moderate‐intensity training

Dall 2014

SF‐36 at 3 months follow‐up

Physical functioning

83.1 (15.9)

83.1 (15.5)

NS

HIIT = CON

Physical performance

84.4 (25.6)

83.1 (15.5)

NS

HIIT = CON

Bodily pain

85.2 (17.0)

83.1 (18.2)

NS

HIIT = CON

General health

65.6 (16.4)

65.5 (12.7)

NS

HIIT = CON

Vitality

77.2 (15.5)

78.4 (12.6)

NS

HIIT = CON

Social functioning

95.3 (11.1)

96.1 (7.5)

NS

HIIT = CON

Emotional performance

89.6 (20.1)

91.7 (22.8)

NS

HIIT = CON

Mental health

89.3 (7.4)

89.3 (5.8)

NS

HIIT = CON

Mental component

89.3 (7.4)

90.0 (6.6)

NS

HIIT = CON

Physical component

76.4 (11.8)

77.5 (8.9)

NS

HIIT = CON

Measure of HRQoL

Mean (SD) outcome values at follow‐up

P value

Difference between groups

Exercise

Usual care

Nytrøen 2012

SF‐36 at 6 months follow‐up

Physical functioning

NR

NR

*NS

Exercise = Comparator

Physical performance

NR

NR

*NS

Exercise = Comparator

Bodily pain

NR

NR

*NS

Exercise = Comparator

General health

54

49

P < 0.05

Exercise > Comparator

Vitality

NR

NR

*NS

Exercise = Comparator

Social functioning

NR

NR

*NS

Exercise = Comparator

Emotional performance

NR

NR

*NS

Exercise = Comparator

Mental health

NR

NR

*NS

Exercise = Comparator

Mental component

NR

NR

*NS

Exercise = Comparator

Physical component

NR

NR

*NS

Exercise = Comparator

Tegtbur 2003

**Profile of quality of life in the chronically ill (PLC)

Physical function

NR

NR

P < 0.05

Exercise > Comparator

Psychological function

NR

NR

NS

Exercise = Comparator

Positive mood

NR

NR

NS

Exercise = Comparator

Negative mood

NR

NR

NS

Exercise = Comparator

Social function

NR

NR

NS

Exercise = Comparator

Social well being

NR

NR

NS

Exercise = Comparator

Physical well being

NR

NR

P < 0.01

Exercise > Comparator

Wu 2008

World Health Organization Quality of Life (WHOQoL) ‐ BREF

Physical domain

13.84 (1.78)

13.64 (2.11)

NS

Exercise = Usual care

Psychological domain

13.33 (1.85)

14.00 (2.45)

NS

Exercise = Usual care

Social relationship domain

13.90 (2.49)

14.55 (1.88)

NS

Exercise = Usual care

Environment domain

14.00 (2.30)

14.30 (2.10)

NS

Exercise = Usual care

CON = continued moderate‐intensity exercise
HIIT = high‐intensity interval training
NR = not reported
NS = Not significant
* There were no significant changes in any of the sum‐scores (data not shown)
** Values reported graphically, with higher values indicating a better self‐assessment of quality of life

Figuras y tablas -
Table 2. Summary of health‐related quality of life (HRQoL) scores at follow‐up
Comparison 1. Exercise versus no‐exercise

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Exercise capacity (VO2peak) Show forest plot

9

284

Mean Difference (IV, Fixed, 95% CI)

2.49 [1.63, 3.36]

2 Sensitivity analysis (excluding Kobashigawa 1999) Show forest plot

8

257

Mean Difference (IV, Fixed, 95% CI)

2.59 [1.69, 3.49]

3 Sensitivity analysis (excluding Wu 2008) Show forest plot

8

247

Mean Difference (IV, Fixed, 95% CI)

2.99 [1.93, 4.05]

4 Sensitivity analysis (excluding Kobashigawa 1999 and Wu 2008) Show forest plot

7

220

Mean Difference (IV, Fixed, 95% CI)

3.20 [2.08, 4.33]

Figuras y tablas -
Comparison 1. Exercise versus no‐exercise
Comparison 2. High‐intensity interval training versus continued moderate‐intensity exercise

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Exercise capacity (VO2peak) Show forest plot

1

32

Mean Difference (IV, Fixed, 95% CI)

2.30 [0.59, 4.01]

Figuras y tablas -
Comparison 2. High‐intensity interval training versus continued moderate‐intensity exercise