Exercise-based rehabilitation for coronary heart disease
Open accessAbstract
BACKGROUND: The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Circulatory diseases, including myocardial infarction (MI) and stroke, kill more people than any other disease. Cardiac rehabilitation aims to restore patients who have suffered myocardial infarction to optimal health through exercise only based rehabilitation or comprehensive cardiac rehabilitation (eg. smoking cessation advice, diet and counselling as well as exercise). Data from two published and widely cited meta-analyses (Oldridge 1988, O'Connor 1989) of over 4,000 patients each have demonstrated that patients randomised to exercise-based cardiac rehabilitation after MI have a statistically significant reduction in all-cause and cardiac mortality of about 20 to 25% compared to patients receiving conventional care. However, the trials included were small and often of poor methodological quality. Incomplete literature review methods may have resulted in publication bias thereby resulting in an over-estimate of the benefit of cardiac rehabilitation. The randomised controlled trials used in the reviews have focused almost exclusively on low-risk, middle-aged males post MI, thereby excluding women and the elderly. OBJECTIVES: To determine the effectiveness of exercise only rehabilitation and exercise in addition to other rehabilitation interventions (termed comprehensive cardiac rehabilitation) compared with usual care on the mortality, morbidity, health-related quality of life (HRQoL) and modifiable cardiac risk factors of patients with coronary heart disease. SEARCH STRATEGY: Electronic databases were searched for randomised controlled trials, using standardised trial filters, from the earliest date available to December 31st 1998. SELECTION CRITERIA: Men and women of all ages, in both hospital-based and community-based settings, who have had myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, or who have angina pectoris or coronary artery disease defined by angiography have been included. Studies involving participants following heart transplant, heart valve surgery or heart failure have been excluded. Follow up periods of less than 6 months were excluded. DATA COLLECTION AND ANALYSIS: Studies were selected independently by two reviewers, and data extracted independently. Authors were contacted where possible to obtain missing information. MAIN RESULTS: The current systematic review has allowed analysis of an increased number of patients from approximately 4500 in the earlier meta-analyses to 7683 (2582 in exercise only and 5101 in the comprehensive cardiac rehabilitation group). The quality of reporting overall was poor, with generally high losses to follow up. The pooled effect estimate for total mortality for the exercise only intervention shows a 27% reduction in all cause mortality (random effects model OR 0.73 (0.54, 0.98)). Similarly, comprehensive cardiac rehabilitation reduced all cause mortality compared to usual care, but to a lesser degree (OR 0.87 (0.71, 1.05)). Total cardiac mortality was reduced by 31% (random effects model OR 0.69 (0.51, 0.94)) and 26% (random effects model OR 0.74 (0.57, 0.96)) in the exercise only and comprehensive cardiac rehabilitation intervention groups respectively when compared to usual care. Neither intervention had any effect on the ocurrence of non-fatal myocardial infarction. There was a significant net reduction in total cholesterol in the comprehensive cardiac rehabilitation group (pooled WMD random effects model -0.57 mmol/l (-0.83, -0.31)), but not the exercise only rehabilitation group. Similarly, LDL was significantly reduced in the comprehensive cardiac rehabilitation group (pooled WMD random effects model -0.51 mmol/l (-0.82, -0.19). The effect of exercise only rehabilitation or comprehensive cardiac rehabilitation interventions on revascularisation rates, blood pressure or smoking behaviour could not be determined by this meta-analysis due to the small number of trials reporting these outcomes and heterogeneity between trials. It was not possible to combine the data from studies reporting HRQoL as an outcome. Eighteen different instruments were used to assess HRQoL in the 11 studies reporting it as an outcome. The data are presented qualitatively, only one trial reporting significant improvements with the intervention. REVIEWER'S CONCLUSIONS: Exercise-based cardiac rehabilitation appears to be effective in reducing cardiac deaths but the evidence base is weakened by poor quality trials. It is not clear from this review whether exercise only or a comprehensive cardiac rehabilitation intervention is more beneficial. The population studied in this review is still predominately male, middle aged and low risk. Identification of the ethnic origin of the participants was seldom reported. (ABSTRACT TRUNCATED)
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All studies in that meta-analysis were published before January 1, 1999, and included 8440 patients who were primarily middle-aged, low-risk men.
“All studies were published before January 1, 1999, and included 8440 patients who were primarily middle-aged, low-risk men.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
The Discussion reports 8,440 patients, and “Characteristics of trial participants” describes a predominantly male, middle-aged population whose studies commonly excluded people with comorbidity or heart failure. The Search methods say databases were searched through December 31, 1998, but that does not establish that every included study was published before January 1, 1999; the included-study tables list “Bell 99.” Page numbers were not available for these passages. (LLM, conf=0.88)
Experimental — accuracy not yet measuredRates of sudden cardiac death were not reduced, although only 4 exercise-only and 14 comprehensive rehabilitation trials analyzed this outcome.
“Additionally, rates of sudden cardiac death were not reduced, although only 4 exercise-only and 14 comprehensive rehabilitation trials analyzed this outcome.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
The Effects of interventions section reports no significant effect on sudden cardiac deaths and says that only 4 exercise-only trials and 14 comprehensive rehabilitation trials reported this outcome. The trial counts match, but 'rates were not reduced' states a stronger conclusion than the paper's finding of no statistically significant effect. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe most recent and comprehensive meta-analysis identified 51 randomized controlled trials of exercise-based cardiac rehabilitation.
“The most recent and comprehensive meta-analysis identified 51 randomized controlled trials of exercise-based cardiac rehabilitation.25”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
The Effects of interventions section reports 36 exercise-based cardiac rehabilitation trials found and 32 included. Subdividing some included trials produced 51 separate studies, not 51 randomized controlled trials. The Discussion describes this review as including more trials and patients than earlier meta-analyses. (LLM, conf=0.90)
Experimental — accuracy not yet measuredIn contrast to prior analyses, recent results suggest that the exercise component is a critical aspect of the rehabilitation process.
“In contrast to the prior analyses, however, these recent results suggest that the exercise component is a critical aspect of the rehabilitation process.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
Cardiac mortality was reduced 31% (P<0.05) and 26% (P<0.05) for the exercise-only and comprehensive programs, respectively.
“Cardiac mortality was reduced 31% (PϽ0.05) and 26% (PϽ0.05) for the exercise-only and comprehensive programs, respectively.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
Total mortality was reduced 27% (P<0.05) with the exercise-only intervention and 13% (P=NS) with comprehensive rehabilitation.
“Total mortality was reduced 27% (PϽ0.05) with the exercise-only intervention and 13% (PϭNS) with comprehensive rehabilitation (Table).”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
Neither the exercise-only program nor the comprehensive intervention significantly reduced the rate of nonfatal myocardial infarction.
“Neither the exercise-only program nor the comprehensive intervention significantly reduced the rate of nonfatal myocardial infarction.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
This review adds approximately 4000 patients to prior meta-analyses and confirms that exercise-based cardiac rehabilitation reduces cardiac mortality but does not reduce the risk of recurrent myocardial infarction.
“This review 25 adds Ϸ4000 patients to the prior, widely cited meta-analyses of cardiac rehabilitation 23,24 and confirms that exercise-based cardiac rehabilitation reduces cardiac mortality but does not reduce the risk of recurrent myocardial infarction.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
Only 5 exercise-only trials and 10 comprehensive trials examined the rate of coronary artery bypass grafting.
“Similarly, only 5 exercise-only trials and 10 comprehensive trials examined the rate of coronary artery bypass grafting.”
From Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) (2003) · cites this paper as [25]
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- Authors
- Jolliffe, J., Rees, K., Taylor, R. R., Thompson, D. R., Oldridge, N., & Ebrahim, S.
- Affiliations
- University of Exeter (GB)
- University of Bristol (GB)
- University of York (GB)
- Center for Urban Population Health (US)
- London School of Hygiene & Tropical Medicine (GB)
- Venue
- The Cochrane Database of Systematic Reviews
- Publisher
- John Wiley & Sons, Ltd
- Published
- 2001-01-22
- Issue
- 1
- Pages
- CD001800-CD001800
- OpenAlex
- W1817200870
- Cited by
- 963
- References
- 4
- Citations by year
- 2026: 3 · 2025: 11 · 2024: 11 · 2023: 18 · 2022: 13 · 2021: 23 · 2020: 21 · 2019: 28 · 2018: 24 · 2017: 27 · 2016: 37 · 2015: 38 · 2014: 40 · 2013: 67 · 2012: 77
- Type
- reference entry
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (submittedVersion, cc-by-sa)
- Research Portal (Queen's University Belfast) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Keywords
- exercise-based cardiac rehabilitation, coronary artery disease, exercise therapy, comprehensive cardiac rehabilitation, all-cause mortality, cardiac mortality, myocardial infarction, health-related quality of life, cholesterol, LDL cholesterol, cardiovascular risk factors, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, angina pectoris
- MeSH terms
- Coronary Disease, Exercise Therapy, Female, Humans, Male, Myocardial Infarction, Quality of Life, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care
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