The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies – The Cardiac Rehabilitation Outcome Study (CROS)

Background The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event. Design Structured review and meta-analysis. Methods Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later. Results Out of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; rCCS: HR 0.64, 95% CI 0.49–0.84; odds ratio 0.20, 95% CI 0.08–0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54–0.70) and in mixed CAD populations. Conclusions CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

[1]  David R Thompson,et al.  Exercise-based cardiac rehabilitation for coronary heart disease. , 2016, The Cochrane database of systematic reviews.

[2]  Rod S Taylor,et al.  Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. , 2016, Journal of the American College of Cardiology.

[3]  A. Hoes,et al.  2016 European Guidelines on cardiovascular disease prevention in clinical practice. , 2016, Revista espanola de cardiologia.

[4]  J. Slaets,et al.  The association between cardiac rehabilitation and mortality risk for myocardial infarction patients with and without depressive symptoms. , 2015, Journal of affective disorders.

[5]  A. Wienke,et al.  Rehabilitation in Patients With Coronary Heart Disease: Participation and Its Effect on Prognosis. , 2015, Deutsches Arzteblatt international.

[6]  N. Peek,et al.  Cardiac rehabilitation and survival in a large representative community cohort of Dutch patients. , 2015, European heart journal.

[7]  K. Goel,et al.  Cardiac rehabilitation is associated with reduced long-term mortality in patients undergoing combined heart valve and CABG surgery , 2015, European journal of preventive cardiology.

[8]  P. Shekelle,et al.  Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement , 2015, Systematic Reviews.

[9]  H. Katus,et al.  Short-term comprehensive cardiac rehabilitation after AMI is associated with reduced 1-year mortality: results from the OMEGA study , 2014, European journal of preventive cardiology.

[10]  M. Sobolev,et al.  Racial Disparities in Cardiac Rehabilitation Initiation and the Effect on Survival , 2014, PM & R : the journal of injury, function, and rehabilitation.

[11]  M. Monreal,et al.  Cardiac rehabilitation and outcome in stable outpatients with recent myocardial infarction. , 2014, Archives of physical medicine and rehabilitation.

[12]  P. Tugwell,et al.  The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses , 2014 .

[13]  D. Alter,et al.  Outcomes associated with cardiac rehabilitation participation in patients with musculoskeletal comorbidities. , 2013, European journal of physical and rehabilitation medicine.

[14]  Byung Ok Kim,et al.  Regular exercise training reduces coronary restenosis after percutaneous coronary intervention in patients with acute myocardial infarction. , 2013, International journal of cardiology.

[15]  S. Maes,et al.  Lifestyle modification programmes for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials , 2013, European journal of preventive cardiology.

[16]  K. Goel,et al.  Participation in Cardiac Rehabilitation and Survival After Coronary Artery Bypass Graft Surgery: A Community-Based Study , 2013, Circulation.

[17]  P. Tugwell,et al.  Checklists of methodological issues for review authors to consider when including non‐randomized studies in systematic reviews , 2013, Research synthesis methods.

[18]  Jonathan J Deeks,et al.  Issues relating to study design and risk of bias when including non‐randomized studies in systematic reviews on the effects of interventions , 2013, Research synthesis methods.

[19]  B. Murphy,et al.  Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up , 2012, Heart.

[20]  W. Ghali,et al.  Cardiac Rehabilitation Attendance and Outcomes in Coronary Artery Disease Patients , 2012, Circulation.

[21]  K. Werdan,et al.  The importance of genetic variants in TNFα for periodontal disease in a cohort of coronary patients. , 2012, Journal of clinical periodontology.

[22]  Shah Ebrahim,et al.  European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012) , 2012, International Journal of Behavioral Medicine.

[23]  P. Doherty,et al.  Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey , 2012, European journal of preventive cardiology.

[24]  A. Henderson,et al.  Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction , 2011, Heart.

[25]  John Spertus,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. , 2011, Circulation.

[26]  K. Filion,et al.  Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. , 2011, American heart journal.

[27]  S. Ebrahim,et al.  Exercise-based cardiac rehabilitation for coronary heart disease. , 2016, The Cochrane database of systematic reviews.

[28]  Chul Kim,et al.  Prognostic Influences of Cardiac Rehabilitation in Korean Acute Myocardial Infarction Patients , 2011, Annals of rehabilitation medicine.

[29]  D. Stewart,et al.  Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. , 2011, Archives of internal medicine.

[30]  H. Raspe,et al.  In-patient cardiac rehabilitation versus medical care – a prospective multicentre controlled 12 months follow-up in patients with coronary heart disease , 2011, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[31]  K. Goel,et al.  Impact of Cardiac Rehabilitation on Mortality and Cardiovascular Events After Percutaneous Coronary Intervention in the Community , 2010, Circulation.

[32]  M. Cupples,et al.  Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease , 2010, Cardiology research and practice.

[33]  G. Steinbeck,et al.  OMEGA, a Randomized, Placebo-Controlled Trial to Test the Effect of Highly Purified Omega-3 Fatty Acids on Top of Modern Guideline-Adjusted Therapy After Myocardial Infarction , 2010, Circulation.

[34]  H. McGee,et al.  Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey , 2010, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[35]  G. Rauch,et al.  Effect of early short-term cardiac rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality , 2010, Current medical research and opinion.

[36]  R. Meeusen,et al.  Reduction of cardiovascular event rate: different effects of cardiac rehabilitation in CABG and PCI patients , 2009, Acta cardiologica.

[37]  J. Bisbe,et al.  Body mass index and outcome in patients with coronary, cerebrovascular, or peripheral artery disease: findings from the FRENA registry , 2009, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[38]  S. Normand,et al.  Cardiac rehabilitation and survival in older coronary patients. , 2009, Journal of the American College of Cardiology.

[39]  D. Alter,et al.  Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system , 2009, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[40]  L. Tavazzi,et al.  Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. , 2008, Archives of internal medicine.

[41]  O. Faergeman,et al.  Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend. , 2008, European journal of public health.

[42]  A. Zwisler,et al.  Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. , 2008, American heart journal.

[43]  H. Raspe,et al.  The TeleGuard trial of additional telemedicine care in CAD patients. 2 Morbidity and mortality after 12 months , 2008, Journal of telemedicine and telecare.

[44]  C. Lavie,et al.  Impact of cardiac rehabilitation on depression and its associated mortality. , 2007, The American journal of medicine.

[45]  B. Bjarnason-Wehrens,et al.  Cardiac rehabilitation in Germany , 2007, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[46]  H. Crijns,et al.  Decreased impact of post-myocardial infarction depression on cardiac prognosis? , 2006, Journal of psychosomatic research.

[47]  Yijian Huang,et al.  Cardiac rehabilitation and survival of dialysis patients after coronary bypass. , 2006, Journal of the American Society of Nephrology : JASN.

[48]  W. Ghali,et al.  Referral rate and outcomes of cardiac rehabilitation after cardiac catheterization in a large Canadian city. , 2004, Journal of cardiopulmonary rehabilitation.

[49]  B. Murphy,et al.  Cardiac rehabilitation programmes: predictors of non-attendance and drop-out , 2004, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[50]  G. Montalescot,et al.  Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction. , 2004, Heart.

[51]  P. Boulay,et al.  Health-care consumption and recurrent myocardial infarction after 1 year of conventional treatment versus short- and long-term cardiac rehabilitation. , 2004, Preventive medicine.

[52]  D. Atar,et al.  JOINT ESC GUIDELINES 2016 European Guidelines on cardiovascular disease prevention in clinical practice – Web Addenda , 2016 .

[53]  M. Symons,et al.  Hazard rate ratio and prospective epidemiological studies. , 2002, Journal of clinical epidemiology.

[54]  A. Schene,et al.  Treatment of depression after myocardial infarction and the effects on cardiac prognosis and quality of life: rationale and outline of the Myocardial INfarction and Depression-Intervention Trial (MIND-IT). , 2002, American heart journal.

[55]  I. Olkin,et al.  Meta-analysis of observational studies in epidemiology - A proposal for reporting , 2000 .

[56]  David Moher,et al.  Meta-analysis of Observational Studies in Epidemiology , 2000 .

[57]  M. Johannesson,et al.  Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. , 1997, The New England journal of medicine.

[58]  R. Mulcahy,et al.  Rehabilitation of patients with coronary heart disease. , 1972, British heart journal.