1
|
Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2021; 11:CD001800. [PMID: 34741536 PMCID: PMC8571912 DOI: 10.1002/14651858.cd001800.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD. SEARCH METHODS We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease. DATA COLLECTION AND ANALYSIS We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point). MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs). AUTHORS' CONCLUSIONS This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.
Collapse
Affiliation(s)
- Grace Dibben
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - James Faulkner
- Faculty Health and Wellbeing, School of Sport, Health and Community, University of Winchester, Winchester, UK
| | - Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Karen Rees
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Ann-Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| |
Collapse
|
2
|
Chen Z, Ding Z, Chen C, Sun Y, Jiang Y, Liu F, Wang S. Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials. BMC Geriatr 2021; 21:377. [PMID: 34154560 PMCID: PMC8218512 DOI: 10.1186/s12877-021-02319-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) interventions can improve functional ability and reduce mortality in older adults, but the effectiveness of CGA intervention on the quality of life, caregiver burden, and length of hospital stay remains unclear. The study aimed to determine the effectiveness of CGA intervention on the quality of life, length of hospital stay, and caregiver burden in older adults by conducting meta-analyses of randomised controlled trials (RCTs). METHODS A literature search in PubMed, Embase, and Cochrane Library was conducted for papers published before February 29, 2020, based on inclusion criteria. Standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CIs) was calculated using the random-effects model. Subgroup analyses, sensitivity analyses, and publication bias analyses were also conducted. RESULTS A total of 28 RCTs were included. Overall, the intervention components common in different CGA intervention models were interdisciplinary assessments and team meetings. Meta-analyses showed that CGA interventions improved the quality of life of older people (SMD = 0.12; 95% CI = 0.03 to 0.21; P = 0.009) compared to usual care, and subgroup analyses showed that CGA interventions improved the quality of life only in participants' age > 80 years and at follow-up ≤3 months. The change value of quality of life in the CGA intervention group was better than that in the usual care group on six dimensions of the 36-Item Short-Form Health Survey questionnaire (SF-36). Also, compared to usual care, the CGA intervention reduced the caregiver burden (SMD = - 0.56; 95% CI = - 0.97 to - 0.15, P = 0.007), but had no significant effect on the length of hospital stay. CONCLUSIONS CGA intervention was effective in improving the quality of life and reducing caregiver burden, but did not affect the length of hospital stay. It is recommended that future studies apply the SF-36 to evaluate the impact of CGA interventions on the quality of life and provide supportive strategies for caregivers as an essential part of the CGA intervention, to find additional benefits of CGA interventions.
Collapse
Affiliation(s)
- Zhongyi Chen
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
| | | | - Caixia Chen
- Wuxi Tongren Rehabilitation Hospital, Wuxi, China
| | - Yangfan Sun
- Wuxi Tongren Rehabilitation Hospital, Wuxi, China
| | - Yuyu Jiang
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China.
| | - Fenglan Liu
- Medical School, Liaocheng University, Liaocheng, China
| | - Shanshan Wang
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
| |
Collapse
|
3
|
Foccardi G, Vecchiato M, Neunhaeuserer D, Mezzaro M, Quinto G, Battista F, Duregon F, Carlon R, Ermolao A. Effectiveness of Text Messaging as an Incentive to Maintain Physical Activity after Cardiac Rehabilitation: A Randomized Controlled Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126645. [PMID: 34205551 PMCID: PMC8296387 DOI: 10.3390/ijerph18126645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Although the efficacy of cardiac rehabilitation (CR) is proven, the need to improve patients’ adherence has emerged. There are only a few studies that have investigated the effect of sending text messages after a CR period to stimulate subjects’ ongoing engagement in regular physical activity (PA). A randomized controlled pilot trial was conducted after CR, sending a daily PA text message reminder to an intervention group (IG), which was compared with a usual care control group (CG) during three months of follow-up. Thirty-two subjects were assessed pre- and post-study intervention with GPAQ, submaximal iso-watt exercise testing, a 30 s sit-to-stand test, a bilateral arm curl test, and a final survey on a seven-point Likert scale. A statistically significant difference in the increase of moderate PA time (Δ 244.7 (95% CI 189.1, 300.4) minutes, p < 0.001) and in the reduction of sedentary behavior time (Δ −77.5 (95% CI 104.9, −50.1) minutes, p = 0.004) was shown when the IG was compared with the CG. This was associated with an improvement in heart rate, blood pressure, and patients’ Borg rating on the category ratio scale 10 (CR10) in iso-watt exercise testing (all p < 0.05). Furthermore, only the IG did not show a worsening of the strength parameters in the follow-up leading to a change of the 30 s sit-to-stand test with a difference of +2.2 (95% CI 1.23, 3.17) repetitions compared to CG (p = 0.03). The telemedical intervention has been appreciated by the IG, whose willingness to continue with regular PA emerged to be superior compared to the CG. Text messages are an effective and inexpensive adjuvant after phase 2 CR that improves adherence to regular PA. Further studies are needed to confirm these results in a larger patient population and in the long term.
Collapse
Affiliation(s)
- Giulia Foccardi
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Marco Vecchiato
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Daniel Neunhaeuserer
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8217456
| | - Michele Mezzaro
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
| | - Giulia Quinto
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Francesca Battista
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Federica Duregon
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
| | - Roberto Carlon
- UOA Cardiology, Rehabilitation Cardiology, ASSL 6 “Euganea”, Cittadella Hospital, 35013 Cittadella, Italy;
| | - Andrea Ermolao
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| |
Collapse
|
4
|
Chair SY, Zou H, Cao X. A systematic review of effects of recorded music listening during exercise on physical activity adherence and health outcomes in patients with coronary heart disease. Ann Phys Rehabil Med 2020; 64:101447. [PMID: 33130038 DOI: 10.1016/j.rehab.2020.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/05/2020] [Accepted: 09/11/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Exercise training is a key facet of cardiac rehabilitation and is associated with irrefutable benefits for individuals with coronary heart disease. However, compliance with and adherence to such interventions are challenging among this population. The incorporation of music into exercise training may be a potential approach to address this issue. OBJECTIVES This study aimed to evaluate the effects of recorded music listening during exercise on adherence to physical activity and health outcomes in individuals with coronary heart disease. METHODS A systematic review was conducted by searching 7 English databases for reports of randomized controlled trials and quasi-experimental studies evaluating the effects of recorded music listening during exercise on adherence to physical activity and physical, psychological, and cognitive outcomes in adults with coronary heart disease. Two reviewers independently screened records for eligibility, extracted data, and assessed the quality of reports by using the Effective Public Health Practice Project Quality Assessment Tool tool. RESULTS We identified 7 studies involving 293 participants (mean age 62.6 to 72 years, men: 57% to 80%). All but one study included relatively small samples (17 to 56). The overall quality was weak for 3 studies, moderate for 2, and strong for 2. Several reviewed studies showed significant effects of music on attendance at exercise-based cardiac rehabilitation (1 of 2 studies), maintenance of physical activity after intervention (1 study), perceived exertion (2 of 3 studies), exercise capacity (1 of 3 studies), heart rate during exercise (1 of 2 studies), male waist circumference (1 of 2 studies), mood (2 of 3 studies), and cognitive function (1 study) as compared with controls. CONCLUSIONS This review provides relatively limited evidence for the potential benefits of recorded music listening during exercise in individuals with coronary heart disease. The findings should be carefully interpreted and generalised. Further rigorous-designed research addressing the limitations of current literature is needed.
Collapse
Affiliation(s)
- Sek Ying Chair
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| | - Huijing Zou
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
| | - Xi Cao
- Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| |
Collapse
|
5
|
Exercise-Based Interventions to Enhance Long-Term Sustainability of Physical Activity in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16142527. [PMID: 31311165 PMCID: PMC6678490 DOI: 10.3390/ijerph16142527] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 01/28/2023]
Abstract
Exercise is a form of physical activity (PA). PA is an important marker of health and quality of life in older adults. The purpose of this study was to conduct a systematic review of the literature to assess the effect of exercise-based interventions on an at least six-month follow up PA measure, and to describe the specific strategies implemented during the intervention to strengthen the sustainability of PA in community-dwelling 65+ year-old adults. We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42017070892) of randomized clinical trials (RCT). We searched three electronic databases during January 2018 to identify RCT assessing any type of exercise-based intervention. Studies had to report a pre-, post-, and at least 6-month post-intervention follow-up. To be included, at least one PA outcome had to be assessed. The effect of exercise-based interventions was assessed compared to active (e.g., a low-intensity type of exercise, such as stretching or toning activities) and non-active (e.g., usual care) control interventions at several time points. Secondary analyses were conducted, restricted to studies that reported specific strategies to enhance the sustainability of PA. The intervention effect was measured on self-reported and objective measures of time spent in PA, by means of standardized mean differences. Standardized mean differences of PA level were pooled. Pooled estimates of effect were computed with the DerSimonian–Laird method, applying a random effects model. The risk of bias was also assessed. We included 12 studies, comparing 18 exercise intervention groups to four active and nine non-active control groups. Nine studies reported specific strategies to enhance the long-term sustainability of PA. The strategies were mostly related to the self-efficacy, self-control, and behavior capability principles based on the social cognitive theory. Exercise interventions compared to active control showed inconclusive and heterogeneous results. When compared to non-active control, exercise interventions improved PA time at the six-months follow up (standardized mean difference (SMD) 0.30; 95%CI 0.15 to 0.44; four studies; 724 participants; I2 0%), but not at the one- or two-years follow-ups. No data were available on the mid- and long-term effect of adding strategies to enhance the sustainability of PA. Exercise interventions have small clinical benefits on PA levels in community-dwelling older adults, with a decline in the observed improvement after six months of the intervention cessation.
Collapse
|
6
|
Bailly L, Mossé P, Diagana S, Fournier M, d'Arripe-Longueville F, Diagana O, Gal J, Grebet J, Moncada M, Domerego JJ, Radel R, Fabre R, Fuch A, Pradier C. "As du Coeur" study: a randomized controlled trial on quality of life impact and cost effectiveness of a physical activity program in patients with cardiovascular disease. BMC Cardiovasc Disord 2018; 18:225. [PMID: 30522438 PMCID: PMC6284296 DOI: 10.1186/s12872-018-0973-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 11/28/2018] [Indexed: 12/30/2022] Open
Abstract
Background Physical activity programs (PAP) in patients with cardiovascular disease require evidence of cost-utility. To assess improvement in health-related quality of life (QoL) and reduction of health care consumption of patients following PAP, a randomized trial was used. Methods Patients from a health insurance company who had experienced coronary artery disease or moderate heart failure were invited to participate (N = 1891). Positive responders (N = 50) were randomly assigned to a progressively autonomous physical activity (PAPA) program or to a standard supervised physical activity (SPA) program. The SPA group had two supervised sessions per week over 5 months. PAPA group had one session per week and support to aid habit formation (written tips, exercise program, phone call). To measure health-related quality of life EQ-5D utility score were used, before intervention, 6 months (T6) and 1 year later. Health care costs were provided from reimbursement databases. Results Mobility, usual activities and discomfort improved significantly in both group (T6). One year later, EQ-5D utility score was improved in the PAPA group only. Total health care consumption in the intervention group decreased, from a mean of 4097 euros per year before intervention to 2877 euros per year after (p = 0.05), compared to a health care consumption of 4087 euros and 4180 euros per year, in the total population of patients (N = 1891) from the health insurance company. The incremental cost effectiveness ratio was 10,928 euros per QALYs. Conclusion A physical activity program is cost-effective in providing a better quality of life and reducing health care consumption in cardiovascular patients. Trial registration ISRCTN77313697, retrospectively registered on 20 November 2015. Electronic supplementary material The online version of this article (10.1186/s12872-018-0973-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laurent Bailly
- Département de Santé Publique, Centre Hospitalier Universitaire de Nice (Public Health Department University Hospital of Nice), F-06202, Nice, France. .,Université Côte d'Azur, LAMHESS, Nice, France. .,Département de Santé Publique, CHU Nice, Hôpital Archet 1. Niveau1 151 Route Saint Antoine de Ginestière CS 23079, 06202, Nice Cedex 3, France.
| | - Philippe Mossé
- LEST, Aix-Marseille Université, CNRS, Aix en Provence, France
| | | | | | | | - Odile Diagana
- Diagana Sport Santé, Nice, France.,Azur Sport Santé, Nice, France
| | - Jocelyn Gal
- Epidemiology and Biostatistics Unit, Centre Antoine Lacassagne, Nice, France
| | - Jean Grebet
- Sécurité Sociale des Indépendants, Nice, France
| | | | | | - Rémi Radel
- Université Côte d'Azur, LAMHESS, Nice, France
| | - Roxane Fabre
- Département de Santé Publique, Centre Hospitalier Universitaire de Nice (Public Health Department University Hospital of Nice), F-06202, Nice, France.,EA Cobtek, University of Nice Sophia-Antipolis, Nice, France
| | - Alain Fuch
- Azur Sport Santé, Nice, France.,Sécurité Sociale des Indépendants, Nice, France
| | - Christian Pradier
- Département de Santé Publique, Centre Hospitalier Universitaire de Nice (Public Health Department University Hospital of Nice), F-06202, Nice, France.,Université Côte d'Azur, LAMHESS, Nice, France
| |
Collapse
|
7
|
Abell B, Glasziou P, Hoffmann T. The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression. SPORTS MEDICINE - OPEN 2017; 3:19. [PMID: 28477308 PMCID: PMC5419959 DOI: 10.1186/s40798-017-0086-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 04/27/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND While the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease. METHODS In this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome. RESULTS Sixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy (I 2 = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047). CONCLUSIONS Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention.
Collapse
Affiliation(s)
- Bridget Abell
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, 4229, Australia.
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, 4229, Australia
| | - Tammy Hoffmann
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, 4229, Australia
| |
Collapse
|
8
|
Anderson L, Thompson DR, Oldridge N, Zwisler A, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016; 2016:CD001800. [PMID: 26730878 PMCID: PMC6491180 DOI: 10.1002/14651858.cd001800.pub3] [Citation(s) in RCA: 307] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane systematic review previously published in 2011. OBJECTIVES To assess the effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with usual care on mortality, morbidity and HRQL in patients with CHD.To explore the potential study level predictors of the effectiveness of exercise-based CR in patients with CHD. SEARCH METHODS We updated searches from the previous Cochrane review, by searching Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 6, 2014) from December 2009 to July 2014. We also searched MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Science Citation Index Expanded (December 2009 to July 2014). SELECTION CRITERIA We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with a no exercise control. The study population comprised men and women of all ages who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or who have angina pectoris, or coronary artery disease. We included RCTs that reported at least one of the following outcomes: mortality, MI, revascularisations, hospitalisations, health-related quality of life (HRQL), or costs. DATA COLLECTION AND ANALYSIS Two review authors independently screened all identified references for inclusion based on the above inclusion and exclusion criteria. One author extracted data from the included trials and assessed their risk of bias; a second review author checked data. We stratified meta-analysis by the duration of follow up of trials, i.e. short-term: 6 to 12 months, medium-term: 13 to 36 months, and long-term: > 3 years. MAIN RESULTS This review included 63 trials which randomised 14,486 people with CHD. This latest update identified 16 new trials (3872 participants). The population included predominantly post-MI and post-revascularisation patients and the mean age of patients within the trials ranged from 47.5 to 71.0 years. Women accounted for fewer than 15% of the patients recruited. Overall trial reporting was poor, although there was evidence of an improvement in quality of reporting in more recent trials.As we found no significant difference in the impact of exercise-based CR on clinical outcomes across follow-up, we focused on reporting findings pooled across all trials at their longest follow-up (median 12 months). Exercise-based CR reduced cardiovascular mortality compared with no exercise control (27 trials; risk ratio (RR) 0.74, 95% CI 0.64 to 0.86). There was no reduction in total mortality with CR (47 trials, RR 0.96, 95% CI 0.88 to 1.04). The overall risk of hospital admissions was reduced with CR (15 trials; RR 0.82, 95% CI 0.70 to 0.96) but there was no significant impact on the risk of MI (36 trials; RR 0.90, 95% CI 0.79 to 1.04), CABG (29 trials; RR 0.96, 95% CI 0.80 to 1.16) or PCI (18 trials; RR 0.85, 95% CI 0.70 to 1.04).There was little evidence of statistical heterogeneity across trials for all event outcomes, and there was evidence of small study bias for MI and hospitalisation, but no other outcome. Predictors of clinical outcomes were examined across the longest follow-up of studies using univariate meta-regression. Results show that benefits in outcomes were independent of participants' CHD case mix (proportion of patients with MI), type of CR (exercise only vs comprehensive rehabilitation) dose of exercise, length of follow-up, trial publication date, setting (centre vs home-based), study location (continent), sample size or risk of bias.Given the heterogeneity in outcome measures and reporting methods, meta-analysis was not undertaken for HRQL. In five out of 20 trials reporting HRQL using validated measures, there was evidence of significant improvement in most or all of the sub-scales with exercise-based CR compared to control at follow-up. Four trial-based economic evaluation studies indicated exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years.The quality of the evidence for outcomes reported in the review was rated using the GRADE method. The quality of the evidence varied widely by outcome and ranged from low to moderate. AUTHORS' CONCLUSIONS This updated Cochrane review supports the conclusions of the previous version of this review that, compared with no exercise control, exercise-based CR reduces the risk of cardiovascular mortality but not total mortality. We saw a significant reduction in the risk of hospitalisation with CR but not in the risk of MI or revascularisation. We identified further evidence supporting improved HRQL with exercise-based CR. More recent trials were more likely to be well reported and include older and female patients. However, the population studied in this review still consists predominantly of lower risk individuals following MI or revascularisation. Further well conducted RCTs are needed to assess the impact of exercise-based CR in higher risk CHD groups and also those presenting with stable angina. These trials should include validated HRQL outcome measures, explicitly report clinical event outcomes including mortality and hospital admissions, and assess costs and cost-effectiveness.
Collapse
Affiliation(s)
- Lindsey Anderson
- University of Exeter Medical SchoolInstitute of Health ResearchVeysey Building, Salmon Pool LaneExeterUKEX2 4SG
| | - David R Thompson
- University of MelbourneDepartment of PsychiatrySt Vincent's HospitalMelbourneVictoriaAustraliaVIC 3000
| | - Neil Oldridge
- Aurora Sinai/Aurora St. Luke's Medical CenterUniversity of Wisconsin School of Medicine & Public Health and Aurora Cardiovascular ServicesMilwaukeeWisconsinUSA
| | - Ann‐Dorthe Zwisler
- Copenhagen University Hospital, RigshospitaletDepartment of Cardiology, The Heart CentreBlegsdamsvej 9CopenhagenDenmark2100
| | - Karen Rees
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Rod S Taylor
- University of Exeter Medical SchoolInstitute of Health ResearchVeysey Building, Salmon Pool LaneExeterUKEX2 4SG
- University of Southern DenmarkNational Institute of Public HealthCopenhagenDenmark
| | | |
Collapse
|
9
|
Bulamu NB, Kaambwa B, Ratcliffe J. A systematic review of instruments for measuring outcomes in economic evaluation within aged care. Health Qual Life Outcomes 2015; 13:179. [PMID: 26553129 PMCID: PMC4640110 DOI: 10.1186/s12955-015-0372-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/22/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector. METHODS Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000. RESULTS The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care. CONCLUSION In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.
Collapse
Affiliation(s)
- Norma B Bulamu
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Billingsley Kaambwa
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Julie Ratcliffe
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| |
Collapse
|
10
|
Kim SS, Lee S, Kim G, Kang SM, Ahn JA. Effects of a comprehensive cardiac rehabilitation program in patients with coronary heart disease in Korea. Nurs Health Sci 2014; 16:476-82. [DOI: 10.1111/nhs.12155] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 03/30/2014] [Accepted: 05/13/2014] [Indexed: 12/21/2022]
Affiliation(s)
- So-Sun Kim
- College of Nursing; Nursing Policy Research Institute; Yonsei University; Seoul Korea
| | - Sunhee Lee
- College of Nursing; The Catholic University of Korea; Seoul Korea
| | - GiYon Kim
- Department of Nursing; Yonsei University, Wonju College of Medicine; Wonju Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, College of Medicine; Yonsei University; Seoul Korea
| | - Jeong-Ah Ahn
- School of Nursing; Bouvé College of Health Sciences, Northeastern University; Boston Massachusetts USA
| |
Collapse
|
11
|
Levin LÅ, Wallentin L, Bernfort L, Andersson D, Storey RF, Bergström G, Lamm CJ, Janzon M, Kaul P. Health-related quality of life of ticagrelor versus clopidogrel in patients with acute coronary syndromes-results from the PLATO trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:574-580. [PMID: 23796291 DOI: 10.1016/j.jval.2013.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 01/26/2013] [Accepted: 01/29/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the effects of ticagrelor versus clopidogrel on health-related quality of life in the PLATelet inhibition and patient Outcomes (PLATO) trial. BACKGROUND The PLATO trial showed that ticagrelor was superior to clopidogrel for the prevention of cardiovascular death, myocardial infarction, or stroke in a broad population of patients with acute coronary syndromes. METHODS HRQOL in the PLATO study was measured at hospital discharge, 6-month visit, and end of treatment (anticipated at 12 months) by using the EuroQol five-dimensional (EQ-5D) questionnaire. All patients who had an EQ-5D questionnaire assessment at discharge from the index hospitalization (n = 15,212) were included in the study. Patients who died prior to the end-of-treatment visit were assigned an EQ-5D questionnaire value of 0. RESULTS The EQ-5D questionnaire value at discharge among 7631 patients assigned to ticagrelor was 0.847 and among 7581 patients assigned to clopidogrel was 0.846 (P = 0.71). At 12 months, the mean EQ-5D questionnaire value was 0.840 for ticagrelor and 0.832 for clopidogrel (P = 0.046). Excluding patients who died resulted in mean EQ-5D questionnaire values of 0.864 among ticagrelor patients and 0.863 among clopidogrel patients (P = 0.69). CONCLUSIONS In patients hospitalized with acute coronary syndromes with or without ST-segment elevation, treatment with ticagrelor was associated with a lower mortality but otherwise no difference in quality of life relative to treatment with clopidogrel. The improved survival and reduction in cardiovascular events with ticagrelor are therefore obtained with no loss in quality of life.
Collapse
Affiliation(s)
- Lars-Åke Levin
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Shepherd CW, While AE. Cardiac rehabilitation and quality of life: a systematic review. Int J Nurs Stud 2011; 49:755-71. [PMID: 22197653 DOI: 10.1016/j.ijnurstu.2011.11.019] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 11/29/2011] [Accepted: 11/30/2011] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objective of this systematic review was to explore the effects of cardiac rehabilitation interventions on the quality of life of patients with coronary heart disease with a specific focus on interventions that could be delivered within the context of a publicly funded health service. DESIGN Systematic review of trials reporting quality of life data as an outcome measure. Electronic databases (CINAHL, MEDLINE and PsycINFO) were searched from 1 January 1999 to 25 November 2010 in the English language. Inclusion criteria were: randomised controlled trials of cardiac rehabilitation as configured for a publicly funded health service. Data were extracted by one reviewer and checked by a second reviewer. RESULTS The 16 papers reported RCTs conducted in nine countries. Fifteen measurement instruments were utilised to measure quality of life across the different studies precluding a meta-analysis. Four themes emerged from the thematic analysis of the selected papers: physical well-being (including fitness and symptoms); psychological well-being (including anxiety and depression); social well-being (including family life and relationships); and functional status (including return to work and previous life style). Physical domain outcomes suggest that cardiac rehabilitation may improve physical well-being and levels of physical activity and thereby improved levels of physical fitness. Both physical and psychological domain outcomes suggest that home-based interventions are at least as effective as centre-based interventions. Relatively few trials reported on quality of life within the social domain and any difference between centre-based and home-based interventions appeared to favour the home-based intervention. CONCLUSIONS This review indicates that cardiac rehabilitation improves the quality of life for coronary heart disease patients and that quality of life improvements have a bi-directional relationship with increased physical activity and vocational status. Further research is needed to explore the relationship of quality of life outcomes to cardiac mortality, the relationship between improved physical well-being and anxiety, and the quality of life and mortality effects of cardiac rehabilitation in older people.
Collapse
Affiliation(s)
- Colin W Shepherd
- Barts and the London NHS Trust, London Chest Hospital, London E2 9JX, United Kingdom
| | | |
Collapse
|
13
|
Du H, Everett B, Newton PJ, Salamonson Y, Davidson PM. Self-efficacy: a useful construct to promote physical activity in people with stable chronic heart failure. J Clin Nurs 2011; 21:301-10. [PMID: 22175249 DOI: 10.1111/j.1365-2702.2011.03983.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and propose a model of intervention. BACKGROUND The benefits of physical activity in reducing cardiovascular risk have led to evidence-based recommendations for patients with heart disease, including those with chronic heart failure. However, adherence to best practice recommendations is often suboptimal, particularly in those individuals who experience high symptom burden and feel less confident to undertake physical activity. Self-efficacy is the degree of confidence an individual has in his/her ability to perform behaviour under several specific circumstances. Four factors influence an individual's level of self-efficacy: (1) past performance, (2) vicarious experience, (3) verbal persuasion and (4) physiological arousal. DESIGN Discursive. METHODS Using the method of a discursive paper, this article seeks to explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and proposes a model of intervention, the Home-Heart-Walk, to promote physical activity and monitor functional status. CONCLUSIONS Implementing effective interventions to promote physical activities require appreciation of factors impacting on behaviour change. Addressing concepts relating to self-efficacy in physical activity interventions may promote participation and adherence in the longer term. RELEVANCE TO CLINICAL PRACTICE The increasing burden of chronic disease and the emphasis on self-management strategies underscore the importance of promoting adherence to recommendations, such as physical activity.
Collapse
Affiliation(s)
- HuiYun Du
- Curtin Health Innovation Research Institute, School of Nursing and Midwifery, Curtin University, Perth, WA, Australia.
| | | | | | | | | |
Collapse
|
14
|
Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011:CD001800. [PMID: 21735386 PMCID: PMC4229995 DOI: 10.1002/14651858.cd001800.pub2] [Citation(s) in RCA: 449] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health. OBJECTIVES To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD. SEARCH STRATEGY RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009). SELECTION CRITERIA Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography. DATA COLLECTION AND ANALYSIS Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information. MAIN RESULTS This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care. AUTHORS' CONCLUSIONS Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.
Collapse
Affiliation(s)
- Balraj S Heran
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Jenny MH Chen
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Tiffany Moxham
- Wimberly Library, Florida Atlantic University, Boca Raton, Florida, USA
| | - Neil Oldridge
- University of Wisconsin School of Medicine & Public Health and Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin, USA
| | - Karen Rees
- Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - David R Thompson
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - Rod S Taylor
- Peninsula College of Medicine and Dentistry, Universities of Exeter & Plymouth, Exeter, UK
| |
Collapse
|
15
|
Effectiveness of nonpharmacological secondary prevention of coronary heart disease. ACTA ACUST UNITED AC 2010; 17:688-700. [DOI: 10.1097/hjr.0b013e32833a1c95] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Dyer MTD, Goldsmith KA, Sharples LS, Buxton MJ. A review of health utilities using the EQ-5D in studies of cardiovascular disease. Health Qual Life Outcomes 2010; 8:13. [PMID: 20109189 PMCID: PMC2824714 DOI: 10.1186/1477-7525-8-13] [Citation(s) in RCA: 278] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 01/28/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease. METHODS A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included. RESULTS Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients. CONCLUSIONS The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.
Collapse
Affiliation(s)
- Matthew TD Dyer
- Health Economics Research Group, Brunel University, Uxbridge, UK
- National Collaborating Centre for Mental Health, The Royal College of Psychiatrists, London, UK
| | - Kimberley A Goldsmith
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Linda S Sharples
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Martin J Buxton
- Health Economics Research Group, Brunel University, Uxbridge, UK
| |
Collapse
|
17
|
Tolmie EP, Lindsay GM, Kelly T, Tolson D, Baxter S, Belcher PR. Are older patients' cardiac rehabilitation needs being met? J Clin Nurs 2009; 18:1878-88. [PMID: 19638048 PMCID: PMC3787784 DOI: 10.1111/j.1365-2702.2009.02798.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aims. The primary aim of this study was to examine the needs of older people in relation to cardiac rehabilitation and to determine if these were currently being met. A secondary aim was to compare illness representations, quality of life and anxiety and depression in groups with different levels of attendance at a cardiac rehabilitation programme. Background. Coronary heart disease accounted for over seven million cardiovascular deaths globally in 2001. Associated deaths increase with age and are highest in those older than 65. Effective cardiac rehabilitation can assist independent function and maintain health but programme uptake rates are low. We have, therefore, focussed specifically on the older patient to determine reasons for the low uptake. Design. Mixed methods. Methods. A purposive sample of 31 older men and women (≥65 years) completed three questionnaires to determine illness representations, quality of life and anxiety and depression. They then underwent a brief clinical assessment and participated in a face-to-face audio-taped interview. Results.Quantitative: Older adults, who did not attend a cardiac rehabilitation programme, had significantly poorer personal control and depression scores (p < 0·01) and lower quality of life scores than those who had attended. Few achieved recommended risk factor reduction targets. Qualitative: The three main themes identified as reflecting the views and experiences of and attendance at the cardiac rehabilitation programme were: ‘The sensible thing to do’, ‘Assessing the impact’ and ‘Nothing to gain’. Conclusions. Irrespective of level of attendance, cardiac rehabilitation programmes are not meeting the needs of many older people either in terms of risk factor reduction or programme uptake. More appropriate programmes are needed. Relevance to clinical practice. Cardiac rehabilitation nurses are ideally placed to identify the rehabilitation needs of older people. Identifying these from the older person’s perspective could help guide more appropriate intervention strategies.
Collapse
|
18
|
Peterson JJ, Lowe JB, Peterson NA, Janz KF. The relationship between active living and health-related quality of life: income as a moderator. HEALTH EDUCATION RESEARCH 2006; 21:146-56. [PMID: 16087691 DOI: 10.1093/her/cyh050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This study used a moderator model to examine the relationship between active living and the physical components of health-related quality of life [i.e. overall physical component of quality of life (PQOL), physical functioning and ability to fulfill physical role] among a randomly selected sample of rural residents (n = 407) from the Midwestern US. Results showed that active living was associated with greater increases in health-related quality of life for those reporting lower income. The effect size of the relationship between active living and the PQOL for the low-income group was over 2 times the effect size for the high-income group. For physical functioning, the effect size of active living for the low-income group was greater than 3 times the effect size for the high-income group. Although active living behaviors have been demonstrated to be less prevalent among those of low socioeconomic status, this group may have the most to gain from these activities. Findings highlight the need for increased and specifically targeted promotion of active living interventions.
Collapse
Affiliation(s)
- Jana J Peterson
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 1215 Westlawn, Iowa City, 52242, USA.
| | | | | | | |
Collapse
|
19
|
Thomas RJ, Witt BJ, Lopez-Jimenez F, King ML, Squires RW. Quality Indicators in Cardiovascular Care. ACTA ACUST UNITED AC 2005; 25:249-56. [PMID: 16217225 DOI: 10.1097/00008483-200509000-00003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Randal J Thomas
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn 55905, USA.
| | | | | | | | | |
Collapse
|
20
|
Izawa KP, Watanabe S, Omiya K, Hirano Y, Oka K, Osada N, Iijima S. Effect of the self-monitoring approach on exercise maintenance during cardiac rehabilitation: a randomized, controlled trial. Am J Phys Med Rehabil 2005; 84:313-21. [PMID: 15829777 DOI: 10.1097/01.phm.0000156901.95289.09] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of the self-monitoring approach (SMA) on self-efficacy for physical activity (SEPA), exercise maintenance, and objective physical activity level over a 6-mo period after a supervised 6-mo cardiac rehabilitation (CR) program. DESIGN We conducted a randomized, controlled trial with 45 myocardial infarction patients (38 men, seven women; mean age, 64.2 yrs) recruited after completion of an acute-phase, exercise-based CR program. Patients were randomly assigned to an SMA group (n = 24) or control group (n = 21). Along with CR, the subjects in the SMA group self-monitored their weight and physical activity for 6 mos. The SMA used in this study was based on Bandura's self-efficacy theory and was designed to enhance confidence for exercise maintenance. The control group participated in CR only. All patients were evaluated with the SEPA assessment tool. Exercise maintenance, SEPA scores, and objective physical activity (average steps per week) as a caloric expenditure were assessed at baseline and during a 6-mo period after the supervised CR program. RESULTS Mean period from myocardial infarction onset did not differ significantly between the SMA and control groups (12.1 +/- 1.3 vs. 12.2 +/- 1.2 mos, P = 0.692). All patients maintained their exercise routine in the SMA group. Mean SEPA score (90.5 vs. 72.7 points, P < 0.001) and mean objective physical activity (10,458.7 vs. 6922.5 steps/wk, P < 0.001) at 12 mos after myocardial infarction onset were significantly higher in the SMA than control group. SEPA showed significant positive correlation with objective physical activity (r = 0.642, P < 0.001). CONCLUSIONS SMA during supervised CR may effectively increase exercise maintenance, SEPA, and objective physical activity at 12 mos after myocardial infarction onset.
Collapse
Affiliation(s)
- Kazuhiro P Izawa
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | | | | | | | | | | | | |
Collapse
|
21
|
Boesch C, Myers J, Habersaat A, Ilarraza H, Kottman W, Dubach P. Maintenance of Exercise Capacity and Physical Activity Patterns 2 Years After Cardiac Rehabilitation. ACTA ACUST UNITED AC 2005; 25:14-21; quiz 22-3. [PMID: 15714106 DOI: 10.1097/00008483-200501000-00004] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The benefits of exercise training for postmyocardial infarction and postcoronary artery bypass surgery patients are well established, but little is known about the effects of rehabilitation in the months or years following the program. The purpose of this study was to assess exercise capacity, blood lipids, and physical activity patterns 2 years after completing a concentrated residential rehabilitation program in Switzerland. METHODS Seventy-eight patients (86% males, mean age = 56 +/- 10, mean ejection fraction = 64% +/- 12%) were referred to a residential rehabilitation program after a myocardial infarction or coronary artery bypass surgery between January 2001 and June 2001. Patients lived at the center for 1 month, during which time they underwent educational sessions, consumed a low-fat diet, and exercised 2 hours daily. Two years after completing the program, patients returned to the hospital and underwent a maximal exercise test, an assessment of recent and adulthood physical activity patterns, and evaluation of blood lipids. RESULTS During the 2-year follow-up period, there were 5 deaths, and 70 of the remaining 73 patients returned for repeat testing. Mean exercise capacity increased 27% during the rehabilitation program (P < .01). Gains in exercise capacity during rehabilitation were maintained after the follow-up period; mean exercise capacity after 2 years was 34% higher compared with that at baseline (P < .01). At the 2-year evaluation, patients were expending a mean of 3127 +/- 1689 kcals/wk during recreational activities compared with 977 +/- 842 kcals/wk during adulthood prior to their cardiac event (P < .001). Between the completion of rehabilitation and the 2-year follow-up, total cholesterol, total cholesterol/high-density lipoprotein ratio, and triglycerides increased significantly. CONCLUSIONS Two years after a cardiac event and participation in a concentrated residential rehabilitation program, patients maintained their exercise capacity and engaged in physical activities that exceed the levels recommended by guidelines for cardiovascular health. These observations suggest that a relatively intensive rehabilitation program provided a catalyst to maintain physical activity patterns and exercise tolerance in the 2 years following a cardiac event.
Collapse
|
22
|
Izawa KP, Yamada S, Oka K, Watanabe S, Omiya K, Iijima S, Hirano Y, Kobayashi T, Kasahara Y, Samejima H, Osada N. Long-Term Exercise Maintenance, Physical Activity, and Health-Related Quality of Life After Cardiac Rehabilitation. Am J Phys Med Rehabil 2004; 83:884-92. [PMID: 15624566 DOI: 10.1097/01.phm.0000143404.59050.11] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to determine exercise maintenance rate, leisure-time objective physical activity level, and health-related quality of life in relation to exercise maintenance over the 6-mo period after a supervised 5-mo recovery-phase cardiac rehabilitation program in acute myocardial infarction patients. The study also investigated whether exercise maintenance resulted in reproducible health-related quality-of-life outcomes comparable with those of the Japanese normal population. DESIGN This observational study comprised 109 acute myocardial infarction patients (89 men, 20 women; mean age, 63.5 +/- 10.1 yrs). Physiologic outcomes (peak oxygen uptake, handgrip, and knee-extension strength) measured at 1 and 6 mos after acute myocardial infarction onset were compared. Completed exercise maintenance and health-related quality-of-life questionnaires and results of electronic pedometer recordings to evaluate leisure-time objective physical activity level were assessed 6 mos after cardiac rehabilitation. RESULTS The mean period from acute myocardial infarction to evaluation of outcomes was 18.8 +/- 3.4 mos. Ninety of 109 patients (82.6%) continued exercise for >6 mos after cardiac rehabilitation (exercise group); 19 patients (17.4%) quit exercise after cardiac rehabilitation (nonexercise group). Improvement in physiologic outcomes was noted at 6 mos vs. those at 1 mo, but outcomes were not significantly different between groups. The exercise group performed significantly better than the nonexercise group for leisure-time objective physical activity level and scored significantly higher than the nonexercise group for seven of eight health-related quality of life measures, attaining scores similar to those of the Japanese normal population. CONCLUSIONS At >18 mos after acute myocardial infarction, the exercise maintenance rate in our patients remains high, and exercise maintenance may be one of the factors contributing to improvement of health-related quality of life and leisure-time objective physical activity level.
Collapse
Affiliation(s)
- Kazuhiro P Izawa
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Kanagawa, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Deaton C, Bennett JA, Riegel B. State of the science for care of older adults with heart disease. Nurs Clin North Am 2004; 39:495-528. [PMID: 15331299 DOI: 10.1016/j.cnur.2004.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.
Collapse
Affiliation(s)
- Christi Deaton
- School of Nursing, Midwifery & Health Visiting, University of Manchester, Coupland 3, Coupland Street, Manchester M13 9PL, United Kingdom.
| | | | | |
Collapse
|
24
|
Abstract
Successful aging includes the ability to perform functional tasks. This ability to perform functional tasks, or functional ability, is influenced by musculoskeletal and cardiovascular functioning and the presence and severity of symptoms of chronic disease. Empirical evidence indicates that musculoskleletal and cardiovascular functioning and symptoms of chronic disease in later life are strongly related to lifestyle choices involving physical activity and nutritional intake. Previous researchers have demonstrated that increases in physical activity and appropriate changes in nutritional intake can be effective interventions to prevent and treat symptoms of chronic disease and improve musculoskeletal and cardiovascular functioning. As a result of this evidence, several organizations have developed physical activity and nutritional intake recommendations aimed at maintaining or increasing the functional ability of older adults. These physical activity recommendations include engaging in cardiorespiratory, flexibility, strength, and balance training 3 to 5 days per week. Broad nutritional recommendations for older adults include a low-fat, plant-based diet including fruits, vegetables, whole grains, 8 glasses of water per day, and a vitamin and mineral supplement.
Collapse
Affiliation(s)
- Robert Topp
- School of Nursing, University of Louisville 555 South Floyd Street, Louisville, KY 40292, USA.
| | | | | |
Collapse
|