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Ha WS, Chu MK. Advances in Exercise in the Clinical Trials of Migraine: A Scoping Review. Curr Pain Headache Rep 2024:10.1007/s11916-024-01269-9. [PMID: 38761296 DOI: 10.1007/s11916-024-01269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE OF REVIEW This review aimed to investigate emerging evidence regarding the effectiveness of exercise for migraines, focusing on the results of recent trials. Additionally, it explored the possibility of exercise as a treatment for migraines. RECENT FINDINGS Between 2020 and 2023, five, four, one, and two trials were conducted regarding the effect of aerobic exercise, anaerobic exercise, Tai Chi, and yoga, respectively, on migraine; all studies showed significant effects. Two trials on aerobic exercise showed that high-intensity exercise was similar to or slightly more effective than moderate-intensity exercise as a treatment for migraines. Three trials on anaerobic exercise reported its effectiveness in preventing migraines. Regarding efficacy, side effects, and health benefits, aerobic exercises and yoga are potentially beneficial strategies for the prevention of migraines. Further studies are needed to develop evidence-based exercise programs for the treatment of migraines.
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Affiliation(s)
- Woo-Seok Ha
- Department of Neurology, Severance Hospital Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Hayn D, Sareban M, Höfer S, Wiesmüller F, Mayr K, Mürzl N, Porodko M, Puelacher C, Moser LM, Philippi M, Traninger H, Niebauer J. Effect of digital tools in outpatient cardiac rehabilitation including home training-results of the EPICURE study. Front Digit Health 2023; 5:1150444. [PMID: 37519897 PMCID: PMC10382682 DOI: 10.3389/fdgth.2023.1150444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/03/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Cardiovascular diseases are the leading cause of death worldwide and are partly caused by modifiable risk factors. Cardiac rehabilitation addresses several of these modifiable risk factors, such as physical inactivity and reduced exercise capacity. However, despite its proven short-term merits, long-term adherence to healthy lifestyle changes is disappointing. With regards to exercise training, it has been shown that rehabilitation supplemented by a) home-based exercise training and b) supportive digital tools can improve adherence. Methods In our multi-center study (ClincalTrials.gov Identifier: NCT04458727), we analyzed the effect of supportive digital tools like digital diaries and/or wearables such as smart watches, activity trackers, etc. on exercise capacity during cardiac rehabilitation. Patients after completion of phase III out-patient cardiac rehabilitation, which included a 3 to 6-months lasting home-training phase, were recruited in five cardiac rehabilitation centers in Austria. Retrospective rehabilitation data were analyzed, and additional data were generated via patient questionnaires. Results 107 patients who did not use supportive tools and 50 patients using supportive tools were recruited. Already prior to phase III rehabilitation, patients with supportive tools showed higher exercise capacity (Pmax = 186 ± 53 W) as compared to patients without supportive tools (142 ± 41 W, p < 0.001). Both groups improved their Pmax, significantly during phase III rehabilitation, and despite higher baseline Pmax of patients with supportive tools their Pmax improved significantly more (ΔPmax = 19 ± 18 W) than patients without supportive tools (ΔPmax = 9 ± 17 W, p < 0.005). However, after adjusting for baseline differences, the difference in ΔPmax did no longer reach statistical significance. Discussion Therefore, our data did not support the hypothesis that the additional use of digital tools like digital diaries and/or wearables during home training leads to further improvement in Pmax during and after phase III cardiac rehabilitation. Further studies with larger sample size, follow-up examinations and a randomized, controlled design are required to assess merits of digital interventions during cardiac rehabilitation.
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Affiliation(s)
- Dieter Hayn
- Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Graz, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
| | - Mahdi Sareban
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
| | - Stefan Höfer
- Department of Psychiatry II, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Fabian Wiesmüller
- Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Graz, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
| | - Karl Mayr
- CARDIOMED Kardiologisches Rehabilitationszentrum GmbH, Linz, Austria
| | - Norbert Mürzl
- Institut für Präventiv- und Rehabilitationsmedizin, Cardio Vital Wels, Wels, Austria
| | - Michael Porodko
- Institut für Präventiv- und Rehabilitationsmedizin, Cardio Vital Wels, Wels, Austria
| | | | | | | | - Heimo Traninger
- ZARG Zentrum für ambulante Rehabilitation GmbH, Graz,Austria
| | - Josef Niebauer
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
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Balázs PG, Erdősi D, Zemplényi A, Brodszky V. Time trade-off health state utility values for depression: a systematic review and meta-analysis. Qual Life Res 2023; 32:923-937. [PMID: 36178658 PMCID: PMC10063515 DOI: 10.1007/s11136-022-03253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to systematically review the literature on health utility in depression generated by time trade-off (TTO) method and to compare health state vignettes. METHODS Systematic literature search was conducted following PRISMA guideline in 2020 November (updated in 2022 March) in Pubmed, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews. Random effect meta-analysis was conducted to pool vignette-based utility values of mild, moderate, and severe depression and to compare the preferences of depressed and nondepressed population. RESULTS Overall, 264 records were found, 143 screened by title and abstract after removing duplicates, 18 assessed full text, and 14 original publications included. Majority of the studies (n = 9) used conventional TTO method, and most of the studies (n = 8) applied 10-year timeframe. Eight studies evaluated self-experienced health (own-current depression). Six studies assessed vignette-based health states of remitted, mild, moderate, and severe depression, half of them applied McSad measure based health description. Altogether, 61 different utility values have been cataloged, mean utility of self-experienced depression states (n = 33) ranged between 0.89 (current-own depression) and 0.24 (worst experienced depression). Pooled utility estimates for vignette-based mild, moderate, and severe depression was 0.75, 0.66 and 0.50, respectively. Meta-regression showed that severe depression (β = -0.16) and depressed sample populations (β = -0.13) significantly decrease vignette-based utility scores. CONCLUSION Our review revealed extent heterogeneity both in TTO methodology and health state vignette development. Patient's perception of depression health states was worse than healthy respondents.
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Affiliation(s)
- Péter György Balázs
- Doctoral School of Business and Management, Corvinus University of Budapest, Budapest, Hungary
- Institute of Social and Political Sciences, Department of Health Policy, Corvinus University of Budapest, Budapest, Hungary
| | - Dalma Erdősi
- Center for Health Technology Assessment and Pharmacoeconomic Research, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Antal Zemplényi
- Center for Health Technology Assessment and Pharmacoeconomic Research, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
| | - Valentin Brodszky
- Institute of Social and Political Sciences, Department of Health Policy, Corvinus University of Budapest, Budapest, Hungary
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Dibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J 2023; 44:452-469. [PMID: 36746187 PMCID: PMC9902155 DOI: 10.1093/eurheartj/ehac747] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 10/31/2022] [Accepted: 11/30/2022] [Indexed: 02/08/2023] Open
Abstract
AIMS Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous meta-analyses of randomized controlled trials (RCTs) is questioned. Therefore, a contemporary updated meta-analysis was undertaken. METHODS AND RESULTS Database and trial registry searches were conducted to September 2020, seeking RCTs of exercise-based interventions with ≥6-month follow-up, compared with no-exercise control for adults with myocardial infarction, angina pectoris, or following coronary artery bypass graft, or percutaneous coronary intervention. The outcomes of mortality, recurrent clinical events, and health-related quality of life (HRQoL) were pooled using random-effects meta-analysis, and cost-effectiveness data were narratively synthesized. Meta-regression was used to examine effect modification. Study quality was assessed using the Cochrane risk of bias tool. A total of 85 RCTs involving 23 430 participants with a median 12-month follow-up were included. Overall, exercise-based CR was associated with significant risk reductions in cardiovascular mortality [risk ratio (RR): 0.74, 95% confidence interval (CI): 0.64-0.86, number needed to treat (NNT): 37], hospitalizations (RR: 0.77, 95% CI: 0.67-0.89, NNT: 37), and myocardial infarction (RR: 0.82, 95% CI: 0.70-0.96, NNT: 100). There was some evidence of significantly improved HRQoL with CR participation, and CR is cost-effective. There was no significant impact on overall mortality (RR: 0.96, 95% CI: 0.89-1.04), coronary artery bypass graft (RR: 0.96, 95% CI: 0.80-1.15), or percutaneous coronary intervention (RR: 0.84, 95% CI: 0.69-1.02). No significant difference in effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias. CONCLUSION This review confirms that participation in exercise-based CR by patients with coronary heart disease receiving contemporary medical management reduces cardiovascular mortality, recurrent cardiac events, and hospitalizations and provides additional evidence supporting the improvement in HRQoL and the cost-effectiveness of CR.
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Affiliation(s)
| | - James Faulkner
- School of Sport, Health and Community, Faculty Health and Wellbeing, University of Winchester, Winchester, UK
| | - Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, WI, 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,Department of Cardiology, Odense University Hospital, Odense, Denmark
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Denton F, Waddell A, Kite C, Hesketh K, Atkinson L, Cocks M, Jones H, Randeva H, Davenport N, Powell R, Clark C, Kyrou I, Harwood AE, McGregor G. Remote maintenance cardiac rehabilitation (MAINTAIN): A protocol for a randomised feasibility study. Digit Health 2023; 9:20552076231152176. [PMID: 36818155 PMCID: PMC9936404 DOI: 10.1177/20552076231152176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
Background Long-term adherence to exercise is often poor for people with coronary heart disease (CHD) who have completed supervised, centre-based cardiac rehabilitation. The aim of this study is to assess the feasibility of a remotely prescribed, delivered and monitored cardiac rehabilitation intervention using a wearable device to support long-term adherence to exercise and physical activity during maintenance of cardiac rehabilitation. Methods After completing cardiac rehabilitation, 30 participants with CHD, will be randomised (1:1) to an intervention (n = 15) or a usual care group (n = 15) in a 12-month feasibility randomised controlled trial (RCT). The intervention will comprise of an exercise consultation, personalised exercise prescription delivered via a wearable activity monitor using biometric feedback, regular monitoring via check-ins, and feedback text-messages for 6-months. Participants will be assessed at baseline (following completion of cardiac rehabilitation) and at three-, six-, and 12-months post-randomisation. The primary outcome will be feasibility, including assessment of eligibility, recruitment, adherence, and acceptability. Secondary outcomes will include exercise capacity, physical activity behaviours, cardiovascular disease risk and quality of life. Semi-structured interviews will be conducted at three-, six-, and 12-months post-randomisation (and with those who drop-out) to explore the acceptability of the study intervention and procedures. A questionnaire will be offered to those who decline participation. Discussion The MAINTAIN study will evaluate the feasibility of conducting a future definitive multi-centre RCT testing a remotely prescribed and monitored long-term mHealth maintenance exercise programme, versus usual care, for people with CHD who have completed cardiac rehabilitation. Trial registration number ClinicalTrials.gov, NCT05292287. Registered on 22/03/2022.
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Affiliation(s)
- Francesca Denton
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- Francesca Denton, Institute of Health and Wellbeing, Coventry University, Coventry, CV1 2DS, UK.
| | - Alexander Waddell
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
| | - Chris Kite
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- School of Public Health Studies, Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Katie Hesketh
- Research Institute of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Lou Atkinson
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Matthew Cocks
- Research Institute of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Helen Jones
- Research Institute of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Harpal Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nathan Davenport
- UK Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Richard Powell
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- UK Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Cain Clark
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ioannis Kyrou
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham, UK
- Laboratory of Dietetics and Quality of Life, School of Food and Nutritional Sciences, Department of Food Science & Human Nutrition, Agricultural University of Athens, Athens, Greece
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy E Harwood
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
| | - Gordon McGregor
- Institute of Health and Wellbeing, Coventry University, Coventry, UK
- UK Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
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Shen BJ, Tan JJL, Xu Y, Tay HY. Poor Sleep Quality Predicts Decline in Physical Health Functioning in Patients with Coronary Heart Disease and Moderating Role of Social Support. Behav Med 2022; 48:294-304. [PMID: 33750280 DOI: 10.1080/08964289.2021.1895050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although sleep problems are common among patients with coronary heart disease (CHD), there is a lack of prospective research examining its influence on health consequences over time. This study investigated whether poor sleep quality predicted patients' decline in physical health functioning over 6 months and whether social support buffered its detrimental effect. Participants were 185 patients with CHD, who completed measures of sleep, psychosocial characteristics, and physical health functioning at baseline and 6 months. Hierarchical regression analyses were conducted to examine whether global sleep index and its subscales, including sleep efficiency, perceived sleep quality, and daily disturbances (sleep disturbances and daytime dysfunction), predicted the decline of physical health functioning at 6 months. Social support was examined for its moderating effect in buffering the negative influence of poor sleep quality on physical health functioning over 6 months. Findings showed that poorer global sleep index, especially subscales of daily disturbances and lower sleep efficiency, significantly predicted greater decline of physical health functioning at 6 months, even after adjusting for covariates, including baseline functioning and depression. Moreover, social support was found to buffer the detrimental impact of poor sleep quality, especially low sleep efficiency, on 6-month physical health functioning. Findings suggest that improving sleep quality for patients with CHD may be promising to facilitate their long-term health maintenance.
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Affiliation(s)
- Biing-Jiun Shen
- Psychology Program, Nanyang Technological University, Singapore
| | | | - Yue Xu
- Psychology Program, Nanyang Technological University, Singapore
| | - Hung Yong Tay
- Heart Wellness Centre, Singapore Heart Foundation, Singapore
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Liblik K, Théberge E, Gomes Z, Burbidge E, Menon N, Gobran J, Johri AM. Improving Wellbeing After Acute Coronary Syndrome. Curr Probl Cardiol 2022:101201. [DOI: 10.1016/j.cpcardiol.2022.101201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/02/2022] [Indexed: 11/15/2022]
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Fattirolli F, Argirò A, Angelino ME, Balestroni G, Giallauria F, Miani D, Vigorito C, Piccioli L, Genta FT, Höfer S, Marchionni N, Oldridge N. Validation of the Italian HeartQoL: a short health-related quality of life questionnaire for patients with ischemic heart disease. Intern Emerg Med 2022; 17:123-134. [PMID: 34110564 PMCID: PMC8841307 DOI: 10.1007/s11739-021-02780-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/27/2021] [Indexed: 01/16/2023]
Abstract
The psychometric properties of the core disease-specific 14-item Italian HeartQoL health-related quality of life questionnaire have been evaluated in this study. The Italian version of the HeartQoL, the MacNew questionnaire, and the Hospital Anxiety and Depression Scale were completed by 472 patients (angina, N = 183; myocardial infarction, N = 167; or ischemic heart failure, N = 122) who were recruited in five Italian centers (Florence, Veruno, Turin, Udine, and Naples) between 2015 and 2017. Patients with myocardial infarction reported significantly higher HeartQoL scores than patients with angina or ischemic heart failure. Floor and ceiling effects were always minor on the HeartQoL global scale and physical subscale with moderate ceiling effects on the emotional subscale in the total group and in patients with myocardial infarction. The bifactorial structure of the original HeartQoL questionnaire was confirmed with strong physical, emotional, and global scale H coefficients (> 0.50). The HeartQoL scales demonstrated optimal internal consistency (Cronbach's alpha > 0.84). Convergent and divergent validity were confirmed. Discriminative validity was not confirmed for age, largely confirmed for sex, and fully confirmed for anxiety, depression, and distress. The Italian HeartQoL questionnaire demonstrated adequate key psychometric attributes of internal consistency reliability and validity in Italian-speaking patients with ischemic heart disease.
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Affiliation(s)
- Francesco Fattirolli
- Department of Experimental and Clinical Medicine, University of Florence and Cardiothoracovascular Department Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50141, Firenze, Italy.
| | - Alessia Argirò
- Department of Experimental and Clinical Medicine, University of Florence and Cardiothoracovascular Department Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50141, Firenze, Italy
| | | | | | - Francesco Giallauria
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Daniela Miani
- Cardiology Unit, University Hospital S. Maria Della Misericordia, Udine, Italy
| | - Carlo Vigorito
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Lucrezia Piccioli
- Department of Experimental and Clinical Medicine, University of Florence and Cardiothoracovascular Department Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50141, Firenze, Italy
- Psychology Unit, Istituti Clinici Scientifici Maugeri, Turin, Italy
- Psychology Unit, Istituti Clinici Scientifici Maugeri, Veruno, Italy
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Franco Tarro Genta
- Department of Cardiology Istituti Clinici Scientifici Maugeri, Turin, Italy
| | - Stefan Höfer
- Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence and Cardiothoracovascular Department Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50141, Firenze, Italy
| | - Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
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Tully PJ, Ang SY, Lee EJ, Bendig E, Bauereiß N, Bengel J, Baumeister H. Psychological and pharmacological interventions for depression in patients with coronary artery disease. Cochrane Database Syst Rev 2021; 12:CD008012. [PMID: 34910821 PMCID: PMC8673695 DOI: 10.1002/14651858.cd008012.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis. OBJECTIVES To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions. SELECTION CRITERIA We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects. DATA COLLECTION AND ANALYSIS Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes. MAIN RESULTS Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I2 = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I2 = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I2 = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I2 = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I2 = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I2 = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention. AUTHORS' CONCLUSIONS In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.
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Affiliation(s)
- Phillip J Tully
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Ser Yee Ang
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Emily Jl Lee
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Eileen Bendig
- Department of Clinical Psychology and Psychotherapy Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Natalie Bauereiß
- Department of Clinical Psychology and Psychotherapy Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Jürgen Bengel
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy Institute of Psychology and Education, Ulm University, Ulm, Germany
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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: 78] [Impact Index Per Article: 26.0] [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.
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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
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Sadeghi M, Rahiminam H, Amerizadeh A, Masoumi G, Heidari R, Shahabi J, Mansouri M, Roohafza H. Prevalence of Return to Work in Cardiovascular Patients After Cardiac Rehabilitation: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2021; 47:100876. [PMID: 34034921 DOI: 10.1016/j.cpcardiol.2021.100876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 01/11/2023]
Abstract
The present systematic review and meta-analysis aimed to clarify the effects of cardiac rehabilitation (CR) on the prevalence of return to work (RTW) in cardiovascular diseases (CVDs) patients. CR plays a very important role in the management of CVDs and improves the patients' physical activity, quality of life, and a decrease in the cost of healthcare. RTW is the most important goal in the rehabilitation of CVD patients. PubMed, Web of Science, Scopus, and Google scholar were searched systematically from inception up to January 2021 for English published clinical trials and observational studies. In total, 16 studies were analyzed, of them, 8 were controlled studies. Pooled results showed that the mean age of patients was 52.30 (50.04, 54.57). The prevalence of RTW in the CR attending group was 66% (60%, 71%) and in the control group was 58% (47%, 68%). Subgroup analysis showed that the proportion of RTW was higher in white-collars 76% (73%-79%) compared to. blue-collars 63% (56%-70%). Out-patient CR with 72% (61%-81%) RTW was more effective compared to in-patient CR with 62% (44%- 78%) and usual care (control). It can be concluded that CR especially out-patient CR increases the prevalence of RTW but not much. Improved and appropriate CR programs related to each individual's disease and patient condition which follow the valid guidelines might help to increase the effectiveness of CR in terms of RTW.
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Affiliation(s)
- Masoumeh Sadeghi
- Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Hadis Rahiminam
- Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atefeh Amerizadeh
- Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamreza Masoumi
- Anesthesiology Department, Chamran Cardiovascular Medical and Research Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ramin Heidari
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javad Shahabi
- Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadhadi Mansouri
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Roohafza
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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12
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Physical exercise as an add-on treatment to cognitive behavioural therapy for anxiety: a systematic review. Behav Cogn Psychother 2021; 49:626-640. [PMID: 33678210 DOI: 10.1017/s1352465821000126] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) is currently the treatment of choice for most anxiety disorders. Yet, with recovery rates of approximately 50%, many patients fail to achieve complete remission. This has led to increased efforts to enhance treatment efficacy. Physical exercise (PE) has in recent years been advocated as means to augment the effects of CBT for anxiety disorders. PE appears to reduce anxiety through other mechanisms than CBT, some of which might also have the potential to augment the effects of psychological treatment. AIMS The current review aimed to summarize and discuss the current research status on CBT augmented with PE for anxiety. METHOD A systematic literature search was conducted in the databases PsychInfo, Medline and Web of Science to evaluate the potential augmentative effect of combining PE with CBT for anxiety disorders. These effects were intended to be evaluated in a meta-analysis, but findings from the few and diverse studies were better summarized in a systematic review. RESULTS Eight articles were included in this review, of which two had no control group, while six had from two to four experimental arms. Six of the studies concluded in favour of benefits of add-on PE, while two studies found no added benefits of the combined interventions. CONCLUSIONS The combination of PE and CBT appears feasible. Add-on PE seems to be more beneficial for clinical populations, when administered regularly several times per week, across several weeks. Future studies should investigate further how and for whom to best combine PE and CBT.
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13
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Gao L, Luo W, Tonmukayakul U, Moodie M, Chen G. Mapping MacNew Heart Disease Quality of Life Questionnaire onto country-specific EQ-5D-5L utility scores: a comparison of traditional regression models with a machine learning technique. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:341-350. [PMID: 33438134 DOI: 10.1007/s10198-020-01259-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 12/10/2020] [Indexed: 05/15/2023]
Abstract
BACKGROUND This study aims to derive country-specific EQ-5D-5L health status utility (HSU) from the MacNew Heart Disease Health-related Quality of Life questionnaire (MacNew) using both traditional regression analyses, as well as a machine learning technique. METHODS Data were drawn from the Multi-Instrument Comparison (MIC) survey. The EQ-5D-5L was scored using 4 country-specific tariffs (United States, United Kingdom, Germany, and Canada). The traditional regression techniques, as well as a machine learning technique, deep neural network (DNN), were adopted to directly predict country-specific EQ-5D-5L HSUs (i.e. a direct mapping approach). An indirect response mapping was undertaken additionally. The optimal algorithm was identified based on three goodness-of-fit tests, namely, the mean absolute error (MAE), mean error (ME) and root mean square error (RMSE), with the first being the primary criteria. Internal validation was undertaken. RESULTS Indirect response mapping and direct mapping (via betamix with MacNew items as the key predictors) were found to produce the optimal mapping algorithms with the lowest MAE when EQ-5D-5L were scored using three country-specific tariffs (United Kingdom, Canada, and Germany for the former and United Kingdom, United States, Canada and Germany for the latter approach). DNN approach generated the lowest MAE and RMSE when using the Germany-specific tariff. CONCLUSIONS Among different approaches been explored, there is not a conclusive conclusion regarding the optimal method for developing mapping algorithms. A machine learning approach represents an alternative mapping approach that should be explored further. The reported algorithms from response mapping have the potential to be more widely used; however, the performance needs to be externally validated.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia.
| | - Wei Luo
- School of Information Technology, Deakin University, Geelong, VIC, Australia
| | - Utsana Tonmukayakul
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Gang Chen
- Centre for Health Economics, Monash University, Caulfield East, VIC, Australia
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Thomson P, Angus NJ, Andreis F, Rushworth GF, Mohan AR, Chung ML, Leslie SJ. Longitudinal evaluation of the effects of illness perceptions and beliefs about cardiac rehabilitation on quality of life of patients with coronary artery disease and their caregivers. Health Qual Life Outcomes 2020; 18:158. [PMID: 32460825 PMCID: PMC7254753 DOI: 10.1186/s12955-020-01405-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients' negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients' and caregivers' perceptions of the patient's illness and beliefs about CR at baseline predict their own and their partner's quality of life at 6 months. METHODS In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient's illness and CR. The Short-Form 12 Health Survey was used to assess patients' and caregivers' perceived health status. Dyadic data were analysed using the Actor-Partner Interdependence Model. RESULTS Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient's illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers' poorer mental health at 6 months was predicted by the patient's perceptions of timeline and illness concern (i.e. partner effects). Patient's and caregiver's illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects). CONCLUSIONS Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes).
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Affiliation(s)
- Patricia Thomson
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK94LA, Scotland, UK.
| | - Neil J Angus
- School of Health, Social Care and Life Sciences, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, Scotland, UK
| | - Federico Andreis
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK94LA, Scotland, UK
| | - Gordon F Rushworth
- Highland Pharmacy Education & Research Centre, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, Scotland, UK
| | - Andrea R Mohan
- School of Nursing and Health Sciences, University of Dundee, Dundee, DD1 4HN, Scotland, UK
| | - Misook L Chung
- College of Nursing, University of Kentucky, Lexington, KY, 40506, USA
| | - Stephen J Leslie
- Cardiac Unit, Raigmore Hospital, NHS Highland, Old Perth Road, Inverness, IV2 3UJ, Scotland, UK
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Tsai YJ, Huang WC, Weng TP, Lin KL. Early Phase II Comprehensive Cardiac Rehabilitation after Acute Myocardial Infarction. ACTA CARDIOLOGICA SINICA 2019; 35:425-429. [PMID: 31371904 DOI: 10.6515/acs.201907_35(4).20190330a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Cardiac rehabilitation is beneficial for patients after ST-segment elevation myocardial infarction (STEMI). However, most institutes perform outpatient training phase (phase II) of post-MI cardiac rehabilitation after 2-4 weeks. To evaluate the possibility of performing cardiac rehabilitation with an earlier schedule after STEMI. Methods We conducted a series of early phase II cardiac rehabilitation starting from 5-7 days after STEMI, including the training group (n = 28) and the control group (n = 42). Results The results showed an improved mental component summary of the SF-36 questionnaire after 6 months in the training group. No adverse event was noticed during this early phase II training. Conclusions Cardiac rehabilitation after STEMI might be started earlier than previously thought for clinical use or further research.
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Affiliation(s)
- Yun-Jeng Tsai
- Department of Physical Medicine and Rehabilitation, Kinmen Hospital, Kinmen
| | - Wei-Chun Huang
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital
| | - Tzu-Pin Weng
- Department of Physical Therapy, Fooyin University
| | - Ko-Long Lin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Takura T, Ebata-Kogure N, Goto Y, Kohzuki M, Nagayama M, Oikawa K, Koyama T, Itoh H. Cost-Effectiveness of Cardiac Rehabilitation in Patients with Coronary Artery Disease: A Meta-Analysis. Cardiol Res Pract 2019; 2019:1840894. [PMID: 31275640 PMCID: PMC6589196 DOI: 10.1155/2019/1840894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Medical costs associated with cardiovascular disease are increasing considerably worldwide; therefore, an efficacious, cost-effective therapy which allows the effective use of medical resources is vital. There have been few economic evaluations of cardiac rehabilitation (CR), especially meta-analyses of medical cost versus patient outcome. METHODS The target population in this meta-analysis included convalescent and comprehensive CR patients with coronary artery disease (CAD), the status most commonly observed postmyocardial infarction (MI). Here, we evaluated medical costs, quality-adjusted life year (QALY), cost-effectiveness, mortality, and life year (LY). Regarding cost-effectiveness analysis, we analyzed medical costs per QALY, medical costs per LY, and the incremental cost-utility ratio (ICUR). We then examined the differences in effects for the 2 treatment arms (CR vs. usual care (UC)) using the risk ratio (RR) and standardized mean difference (SMD). RESULTS We reviewed 59 studies and identified 5 studies that matched our selection criteria. In total, 122,485 patients were included in the analysis. Meta-analysis results revealed that the CR arm significantly improved QALY (SMD: -1.78; 95% confidence interval (CI): -2.69, -0.87) compared with UC. Although medical costs tended to be higher in the CR arm compared to the UC arm (SMD: 0.02; 95% CI: -0.08, 0.13), cost/QALY was significantly improved in the CR arm compared with the UC arm (SMD: -0.31; 95% CI: -0.53, -0.09). The ICURs for the studies (4 RCTs and 1 model analysis) were as follows: -48,327.6 USD/QALY; -5,193.8 USD/QALY (dominant, CR is cheaper and more effective than UC); and 4,048.0 USD/QALY, 17,209.4 USD/QALY, and 26,888.7 USD/QALY (<50,000 USD/QALY, CR is costlier but more effective than UC), respectively. Therefore, there were 2 dominant and 3 effective results. CONCLUSIONS While there are some limitations, primarily regarding data sources, our results suggest that CR is potentially cost-effective.
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Affiliation(s)
- Tomoyuki Takura
- Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | | | - Yoichi Goto
- National Cerebral and Cardiovascular Center, Osaka 565-8565, Japan
| | - Masahiro Kohzuki
- Tohoku University Graduate School of Medicine, Miyagi 980-8574, Japan
| | | | - Keiko Oikawa
- Tokai University Hachioji Hospital, Tokyo 192-0032, Japan
| | - Teruyuki Koyama
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo 173-0015, Japan
| | - Haruki Itoh
- Sakakibara Heart Institute, Tokyo 183-0003, Japan
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Cost-Effectiveness of Exercise-Based Cardiac Rehabilitation in Chilean Patients Surviving Acute Coronary Syndrome. J Cardiopulm Rehabil Prev 2019; 39:168-174. [PMID: 31021998 DOI: 10.1097/hcr.0000000000000356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the cost-effectiveness of 3 models of exercise-based cardiac rehabilitation (CR) compared with standard care in survivors of acute coronary syndrome (ACS) within the public health system in Chile. METHODS A Markov model was designed using 5 health states: ACS survivor, second ACS, complications, general mortality, and cardiovascular mortality. The transition probabilities between health states for standard care and corresponding relative risk for CR were calculated from a systematic review. Health benefits were measured with the EuroQol 5-dimensional 3-level (EQ-5D-3L) survey. Costs for each health state were quantified using the national cost verification study. The CR cost was estimated with a microcosting methodology. The time horizon was a lifetime and the discount rate was 3% per year for costs and benefits. Deterministic and probabilistic analyses were performed. Structural uncertainty was managed by designing 3 scenarios: CR as currently delivered in a specific Chilean public health center, CR as recommended by South American guidelines, and CR as proposed for low-resource settings. RESULTS Cardiac rehabilitation versus standard care showed an incremental cost-effectiveness ratio for the standard model of $722, for the South American model of $1247, and for the low-resource model of $666. The tornado diagram showed higher uncertainty in relative risk for the complications state and for the second ACS state. CONCLUSION Considering a cost-effectiveness threshold of 1 unit of gross domestic product per capita (∼$19 000), CR is highly cost-effective for the public health system in Chile.
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Jayawardena R, Sooriyaarachchi P, Punchihewa P, Lokunarangoda N, Pathirana AK. Effects of "plate model" as a part of dietary intervention for rehabilitation following myocardial infarction: a randomized controlled trial. Cardiovasc Diagn Ther 2019; 9:179-188. [PMID: 31143640 DOI: 10.21037/cdt.2019.03.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Reducing body weight by nutritional management is an integral element of cardiac rehabilitation and in secondary prevention of cardiovascular diseases. Administration of a "plate model" is one practical aspect to control calorie intake. The study aimed to evaluate the effectiveness of the plate model as a part of dietary modification in losing excess weight in post-myocardial infarction (MI) patients. Methods An interventional, randomized, single-blinded study with parallel subject allocation was conducted among patients with a history of troponin-positive acute coronary syndrome (ACS). A total of 120 patients were recruited to intervention and control groups. The Intervention cluster was provided with 'plate model' and both groups received standard cardiac rehabilitation care. Anthropometric, clinical and metabolic parameters were measured at recruitment and repeated during 4th and 12th week. Results A sample of 79 patients (the intervention group: 40, the control group: 39) completed the study. At the end of 12 weeks participants in the intervention group exhibited a significant weight loss (-1.27±3.58 vs. -0.26±2.42 kg; P=0.029) and a significant reduction in BMI (-0.48±1.31 vs. -0.10±0.89 kg/m2; P=0.023). Overweight and obese patients (BMI >23 kg/m2) displayed greater weight loss (-2.13±3.46 vs. 0.12±2.62 kg; P=0.013). Many of overweight and obese patients in the test group (35.7%) experienced a weight loss ≥5% compared to the control group (13.04%) which was a nearly significant result (P=0.065). No significant changes observed in other metabolic parameters. Conclusions Plate model is an effective dietary intervention in view of weight reduction in post-MI patients.
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Affiliation(s)
| | | | - Pavani Punchihewa
- Institute of Cardiology, National Hospital of Sri Lanka, Colombo, Sri Lanka
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Hegewald J, Wegewitz UE, Euler U, van Dijk JL, Adams J, Fishta A, Heinrich P, Seidler A. Interventions to support return to work for people with coronary heart disease. Cochrane Database Syst Rev 2019; 3:CD010748. [PMID: 30869157 PMCID: PMC6416827 DOI: 10.1002/14651858.cd010748.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work. OBJECTIVES To assess the effects of person- and work-directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention. SEARCH METHODS We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return-to-work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements. DATA COLLECTION AND ANALYSIS Two review authors extracted data and independently assessed the risk of bias. We conducted meta-analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health-related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work. MAIN RESULTS We found 39 RCTs (including one cluster- and four three-armed RCTs). We included the return-to-work results of 34 studies in the meta-analyses.Person-directed, psychological counselling versus usual careWe included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta-analysis. Most interventions used some form of counselling to address participants' disease-related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low-certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low-certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low-certainty evidence).Person-directed, work-directed counselling versus usual careFour studies examined work-directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co-workers' fears and misconceptions regarding CHD. Work-directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD -7.52 days, 95% CI -20.07 to 5.03 days; four studies; low-certainty evidence). Work-directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate-certainty evidence).Person-directed, physical conditioning interventions versus usual careNine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low-certainty evidence). Physical conditioning interventions may result in little to no difference in return-to-work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low-certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low-certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD -7.86 days, 95% CI -29.46 to 13.74 days; four studies; low-certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate-certainty evidence).Person-directed, combined interventions versus usual careWe included 13 studies considering return to work following combined interventions in the meta-analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low-certainty evidence), and may have little to no difference on return-to-work rates at six to 12 months' follow-up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low-certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low-certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low-certainty evidence). Combined interventions probably shortened the time needed until return to work (MD -40.77, 95% CI -67.19 to -14.35; two studies; moderate-certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate-certainty evidence).Work-directed, interventionsWe found no studies exclusively examining strictly work-directed interventions at the workplace. AUTHORS' CONCLUSIONS Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person-directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work-directed interventions, health-related quality of life within the return-to-work process, and adverse effects.
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Affiliation(s)
- Janice Hegewald
- Faculty of Medicine Carl Gustav Carus, TU DresdenInstitute and Policlinic of Occupational and Social MedicineFetscherstrasse 74DresdenGermany01307
| | - Uta E Wegewitz
- Federal Institute for Occupational Safety and Health (BAuA)Division 3: Work and HealthNöldnerstr. 40‐42BerlinGermanyD‐10317
| | - Ulrike Euler
- Faculty of Medicine Carl Gustav Carus, TU DresdenInstitute and Policlinic of Occupational and Social MedicineFetscherstrasse 74DresdenGermany01307
| | - Jaap L van Dijk
- Dutch Institute of Clinical Occupational MedicineHilversumNetherlands
| | - Jenny Adams
- Baylor Hamilton Heart and Vascular HospitalCardiac Rehabilitation Unit411 N Washington, Suite 3100DallasTexasUSA75218
| | - Alba Fishta
- Federal Institute for Occupational Safety and Health (BAuA)Evidence Based Medicine, OH ManagementNöldnerstr. 40‐42BerlinGermanyD‐10317
| | - Philipp Heinrich
- Faculty of Medicine Carl Gustav Carus, TU DresdenInstitute and Policlinic of Occupational and Social MedicineFetscherstrasse 74DresdenGermany01307
| | - Andreas Seidler
- Faculty of Medicine Carl Gustav Carus, TU DresdenInstitute and Policlinic of Occupational and Social MedicineFetscherstrasse 74DresdenGermany01307
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Goodman JM, Marzolini S. Adding Life to Years in Cardiac Rehabilitation: Importance of Measuring Quality of Life. Can J Cardiol 2019; 35:235-237. [PMID: 30825946 DOI: 10.1016/j.cjca.2018.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jack M Goodman
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada; University Health Network/Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program, Toronto, Ontario, Canada.
| | - Susan Marzolini
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada; University Health Network/Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program, Toronto, Ontario, Canada
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Measuring subjective wellbeing in patients with heart disease: relationship and comparison between health-related quality of life instruments. Qual Life Res 2019; 28:1017-1028. [DOI: 10.1007/s11136-018-2094-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2018] [Indexed: 11/25/2022]
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Uhlmann DB, Alexandre NMC, Rodrigues RCM, São-João TM. Retorno ao trabalho de pacientes com Síndrome Coronariana Aguda. REVISTA BRASILEIRA DE SAÚDE OCUPACIONAL 2019. [DOI: 10.1590/2317-6369000019518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Introdução: as doenças cardiovasculares representam grande impacto de morbimortalidade para a sociedade brasileira. Objetivo: verificar o tempo para retorno ao trabalho de pacientes com Síndrome Coronária Aguda (SCA); identificar e correlacionar variáveis sociodemográficas, clínicas, psicossociais e ocupacionais que podem influenciar nesse período e no desempenho no trabalho. Métodos: estudo transversal correlacional desenvolvido em 2015-2016 com 65 pacientes com SCA que retornaram ao trabalho. Instrumentos utilizados: Questionário de Caracterização; Questionário de Avaliação do Desempenho no Trabalho; Veterans Specific Activity Questionnaire; MacNew Heart Disease Health-related Quality of Life; Escala Hospitalar de Ansiedade e Depressão; e Impacto da Doença no Cotidiano do Valvopata. Foram aplicados: o teste de Mann-Whitney; pós-teste de Dunn; e coeficiente de correlação de Spearman. Resultados: o tempo médio para retorno ao trabalho foi de 7,3 meses. Os participantes que exerciam trabalho manual apresentaram tempo maior para retorno ao trabalho. O desempenho no trabalho foi fortemente correlacionado com a qualidade de vida e inversamente com ansiedade e depressão. Conclusão: os dados apontam a necessidade de desenvolvimento de estratégias a fim de promover o retorno ao trabalho de pacientes com SCA.
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Zheng X, Zheng Y, Ma J, Zhang M, Zhang Y, Liu X, Chen L, Yang Q, Sun Y, Wu J, Yu B. Effect of exercise-based cardiac rehabilitation on anxiety and depression in patients with myocardial infarction: A systematic review and meta-analysis. Heart Lung 2019; 48:1-7. [DOI: 10.1016/j.hrtlng.2018.09.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/02/2018] [Accepted: 09/22/2018] [Indexed: 10/28/2022]
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Calkins TE, Darrith B, Okroj KT, Drabchuk R, Culvern C, Della Valle CJ. Utilizing the Time Trade-Off, Standard Gamble, and Willingness to Pay Utility Measures to Evaluate Health-Related Quality of Life Prior to Knee or Hip Arthroplasty. J Arthroplasty 2019; 34:9-14. [PMID: 30245123 DOI: 10.1016/j.arth.2018.08.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/21/2018] [Accepted: 08/28/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Time trade-off, standard gamble, and willingness to pay assess the number of years, risk of death, and income a patient would give up for perfect health. These questions were used to evaluate the impact knee arthritis, hip arthritis, or failed total knee (TKA) or hip arthroplasty (THA) has on patients' health-related quality of life prior to surgery. METHODS Three hundred sixty patients including 176 undergoing primary TKA, 127 undergoing primary THA, 31 undergoing revision TKA, and 26 undergoing revision THA were assessed. Time trade-off and standard gamble were converted to utility scores with 1.0 suggesting perfect health and 0 suggesting preference for death rather than living in current state. Willingness to pay is the percentage of yearly income that a patient would pay for perfect health. RESULTS The mean time trade-off, standard gamble, and willingness to pay scores were 0.74, 0.83, and 0.32 without significant difference between procedures with the numbers available for study (P = .16, .31, and 0.41, respectively). Increasing body mass index was correlated with decreasing time trade-off scores (P = .014). CONCLUSION Patients scheduled for primary or revision THA and TKA would accept an average 17% risk of death, lose 2.6 years of an additional 10-year life expectancy, and pay 32% of their income for perfect health. The time trade-off (0.74) was similar to patients with history of acute myocardial infarction (0.74) or minor stroke (0.72) and worse than those with chronic hepatitis C (0.83) or human immunodeficiency virus/acquired immunodeficiency syndrome infection (0.86). These data highlight the high value that patients place on adult reconstructive procedures.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian Darrith
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Kamil T Okroj
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Roman Drabchuk
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Chris Culvern
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Kabboul NN, Tomlinson G, Francis TA, Grace SL, Chaves G, Rac V, Daou-Kabboul T, Bielecki JM, Alter DA, Krahn M. Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis. J Clin Med 2018; 7:E514. [PMID: 30518047 PMCID: PMC6306907 DOI: 10.3390/jcm7120514] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 01/12/2023] Open
Abstract
A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.
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Affiliation(s)
- Nader N Kabboul
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - George Tomlinson
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
| | - Troy A Francis
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - Sherry L Grace
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2, Canada.
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, ON M3J 1P3, Canada.
| | - Gabriela Chaves
- Department of Physical Therapy, Federal University of Minas Gerais, Av. Pres. Antônio Carlos, 6627-Pampulha, Belo Horizonte, MG 31270-901, Brazil.
| | - Valeria Rac
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - Tamara Daou-Kabboul
- Human Nutrition, Bridgeport University, 126 Park Ave, Bridgeport, CT 06604, USA.
| | - Joanna M Bielecki
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - David A Alter
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2, Canada.
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
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Xia TL, Huang FY, Peng Y, Huang BT, Pu XB, Yang Y, Chai H, Chen M. Efficacy of Different Types of Exercise-Based Cardiac Rehabilitation on Coronary Heart Disease: a Network Meta-analysis. J Gen Intern Med 2018; 33:2201-2209. [PMID: 30215179 PMCID: PMC6258639 DOI: 10.1007/s11606-018-4636-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 10/16/2017] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Exercise-based cardiac rehabilitation (CR) has been recognized as an essential component of the treatment for coronary heart disease (CHD). Determining the efficacy of modern alternative treatment methods is the key to developing exercise-based CR programs. METHODS Studies published through June 6, 2016, were identified using MEDLINE, EMBASE, and the Cochrane Library. English-language articles regarding the efficacy of different modes of CR in patients with CHD were included in this analysis. Two investigators independently reviewed abstracts and full-text articles and extracted data from the studies. According to the categories described by prior Cochrane reviews, exercise-based CR was classified into center-based CR, home-based CR, tele-based CR, and combined CR for this analysis. Outcomes included all-cause mortality, cardiovascular death, recurrent fatal and/or nonfatal myocardial infarction, recurrent cardiac artery bypass grafting, recurrent percutaneous coronary intervention (PCI), and hospital readmissions. RESULTS Sixty randomized clinical trials (n = 19,411) were included in the analysis. Network meta-analysis (NMA) demonstrated that only center-based CR significantly reduced all-cause mortality (center-based: RR = 0.76 [95% CI 0.64-0.90], p = 0.002) compared to usual care. Other modes of CR were not significantly different from usual care with regard to their ability to reduce mortality. Treatment ranking indicated that combined CR exhibited the highest probability (86.9%) of being the most effective mode, but this finding was not statistically significant due to the small sample size (combined: RR = 0.50 [95% CI 0.20-1.27], p = 0.146). CONCLUSIONS Current evidence suggests that center-based CR is acceptable for patients with CHD. As home- and tele-based CR can save time, money, effort, and resources and may be preferred by patients, their efficacy should be investigated further in subsequent studies.
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Affiliation(s)
- Tian-Li Xia
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Xiao-Bo Pu
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Yong Yang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Hua Chai
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China.
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Houchen-Wolloff L, Gardiner N, Devi R, Robertson N, Jolly K, Marshall T, Furze G, Doherty P, Szczepura A, Powell J, Singh S. Web-based cardiac REhabilitatio N alternative for those declining or dropping out of conventional rehabilitation: results of the WREN feasibility randomised controlled trial. Open Heart 2018; 5:e000860. [PMID: 30364405 PMCID: PMC6196944 DOI: 10.1136/openhrt-2018-000860] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/02/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023] Open
Abstract
Introduction Cardiac rehabilitation (CR) is typically delivered in hospital-based classes and is recommended to help people reduce their risk of further cardiac events. However, many eligible people are not completing the programme. This study aimed to assess the feasibility of delivering a web-based CR intervention for those who decline/drop out from usual CR. Intervention A web-based CR programme for 6 months, facilitated with remote support. Methods Two-centre, randomised controlled feasibility trial. Patients were randomly allocated to web-based CR/usual care for 6 months. Data were collected to inform the design of a larger study: recruitment rates, quality of life (MacNew), exercise capacity (incremental shuttle walk test) and mood (Hospital Anxiety and Depression Scale). Feasibility of health utility collection was also evaluated. Results 60 patients were randomised (90% male, mean age 62±9 years, 26% of those eligible). 82% completed all three assessment visits. 78% of the web group completed the programme. Quality of life improved in the web group by a clinically meaningful amount (0.5±1.1 units vs 0.2±0.7 units: control). Exercise capacity improved in both groups but mood did not change in either group. It was feasible to collect health utility data. Conclusions It was feasible to recruit and retention to the end of the study was good. The web group reported important improvements in quality of life. This intervention has the opportunity to increase access to CR for patients who would otherwise not attend. Promising outcomes and recruitment suggest feasibility for a full-scale trial. Trial registration number 10726798.
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Affiliation(s)
- Linzy Houchen-Wolloff
- Centre for Exercise and Rehabilitation Science (CERS), NIHR Leicester Biomedical Research Centre (BRC)- Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nikki Gardiner
- Centre for Exercise and Rehabilitation Science (CERS), NIHR Leicester Biomedical Research Centre (BRC)- Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Reena Devi
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Noelle Robertson
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gill Furze
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | | | - Ala Szczepura
- Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | - John Powell
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Sally Singh
- Centre for Exercise and Rehabilitation Science (CERS), NIHR Leicester Biomedical Research Centre (BRC)- Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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Effect of Psychosocial and Vocational Interventions on Return-to-Work Rates Post–Acute Myocardial Infarction. J Cardiopulm Rehabil Prev 2018; 38:215-223. [DOI: 10.1097/hcr.0000000000000261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Farquhar JM, Stonerock GL, Blumenthal JA. Treatment of Anxiety in Patients With Coronary Heart Disease: A Systematic Review. PSYCHOSOMATICS 2018; 59:318-332. [PMID: 29735242 PMCID: PMC6015539 DOI: 10.1016/j.psym.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/14/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Anxiety is common in patients with coronary heart disease (CHD) and is associated with an increased risk for adverse outcomes. There has been a relative paucity of studies concerning treatment of anxiety in patients with CHD. OBJECTIVE We conducted a systematic review to organize and assess research into the treatment of anxiety in patients with CHD. METHODS We searched CCTR/CENTRAL, MEDLINE, EMBASE, PsycINFO, and CINAHL for randomized clinical trials conducted before October 2016 that measured anxiety before and after an intervention for patients with CHD. RESULTS A total of 475 articles were subjected to full text review, yielding 112 publications that met inclusion criteria plus an additional 7 studies from reference lists and published reviews, yielding 119 studies. Sample size, country of origin, study quality, and demographics varied widely among studies. Most studies were conducted with nonanxious patients. The Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were the most frequently used instruments to assess anxiety. Interventions included pharmacological, counseling, relaxation-based, educational, or "alternative" therapies. Forty (33% of total) studies reported that the interventions reduced anxiety; treatment efficacy varied by study and type of intervention. Elevated anxiety was an inclusion criterion in only 4 studies, with inconsistent results. CONCLUSION Although there have been a number of randomized clinical trials of patients with CHD that assessed anxiety, in most cases anxiety was a secondary outcome, and only one-third found that symptoms of anxiety were reduced with treatment. Future studies need to target anxious patients and evaluate the effects of treatment on anxiety and relevant clinical endpoints.
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Affiliation(s)
- Julia M Farquhar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
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Abstract
Accumulating research in rodents and humans indicates that exercise benefits brain function and may prevent or delay onset of neurodegenerative conditions. In particular, exercise modifies the structure and function of the hippocampus, a brain area important for learning and memory. This review addresses the central and peripheral mechanisms underlying the beneficial effects of exercise on the hippocampus. We focus on running-induced changes in adult hippocampal neurogenesis, neural circuitry, neurotrophins, synaptic plasticity, neurotransmitters, and vasculature. The role of peripheral factors in hippocampal plasticity is also highlighted. We discuss recent evidence that systemic factors released from peripheral organs such as muscle (myokines), liver (hepatokines), and adipose tissue (adipokines) during exercise contribute to hippocampal neurotrophin and neurogenesis levels, and memory function. A comprehensive understanding of the body-brain axis is needed to elucidate how exercise improves hippocampal plasticity and cognition.
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Affiliation(s)
- C'iana Cooper
- Neuroplasticity and Behavior Unit, Laboratory of Neurosciences, National Institute on Aging, National Institutes of Health, Biomedical Research Center, Baltimore, Maryland 21224
| | - Hyo Youl Moon
- Neuroplasticity and Behavior Unit, Laboratory of Neurosciences, National Institute on Aging, National Institutes of Health, Biomedical Research Center, Baltimore, Maryland 21224
- Institute of Sport Science, Seoul National University, Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Henriette van Praag
- Neuroplasticity and Behavior Unit, Laboratory of Neurosciences, National Institute on Aging, National Institutes of Health, Biomedical Research Center, Baltimore, Maryland 21224
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Short- and Longer-Term Association Between Body Mass Index and Health Status in Cardiac Rehabilitation Patients. J Cardiopulm Rehabil Prev 2018; 38:85-91. [DOI: 10.1097/hcr.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The effect of exercise therapy on depressive and anxious symptoms in patients with ischemic heart disease: A systematic review. J Psychosom Res 2018; 105:80-91. [PMID: 29332638 DOI: 10.1016/j.jpsychores.2017.11.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/13/2017] [Accepted: 11/29/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Depressive and anxiety symptoms are associated with Ischemic Heart Disease (IHD). Exercise interventions might improve both depressive and anxiety symptoms, but an overview of the evidence is lacking. Therefore, we systematically reviewed the existing literature on the effectiveness of exercise therapy to reduce depression and anxiety symptoms specifically in patients with IHD. METHODS MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials were searched until January 2016. The effectiveness of exercise was assessed within two groups: a) patients selected for study with severe depression or anxiety; and b) studies that did not exclusively targeted patients with increased levels of depression or anxiety. Secondary outcomes were mortality, cardiac events, re-hospitalizations and cardiovascular risk factors. RESULTS We included fourteen studies. Clinical and methodological heterogeneity precluded meta-analysis. Three studies specifically included patients with high levels of depression or anxiety and eleven studies selected patients with unclear levels of depression or anxiety. Some RCTs showed that exercise was effective in lowering severe depressive symptoms (short and long term follow-up), but for the group with unclear depressive symptoms the results were non-conclusive. In the group with elevated anxiety symptoms, exercise had a positive effect on the short term follow-up. In the group with unclear anxiety symptoms the results were inconsistent (short and long term follow-up). No differences were found regarding the secondary outcomes. CONCLUSIONS There is a general paucity of data on the effect of exercise, precluding firm conclusions about the effectiveness of exercise for depressive and anxiety symptoms in IHD patients.
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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.
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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
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Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL. Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis. Mayo Clin Proc 2017; 92:1644-1659. [PMID: 29101934 DOI: 10.1016/j.mayocp.2017.07.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/17/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To ascertain the effect of cardiac rehabilitation (CR) dose (ie, duration × frequency/wk; categorized as low [<12 sessions], medium [12-35 sessions], or high [≥36 sessions]) on mortality and morbidity. METHODS The Cochrane, CINAHL, EMBASE, PsycINFO, and MEDLINE databases were systematically searched from inception through November 30, 2015. Inclusion criteria included randomized or nonrandomized studies with a minimum CR dose of 4 or higher and presence of a control/comparison group. Citations were considered for inclusion, and data were extracted in included studies independently by 2 investigators. Studies were pooled using random-effects meta-analysis and meta-regression where warranted (covariates included study quality, country, publication year, and diagnosis). RESULTS Of 4630 unique citations, 33 trials were included comparing CR to usual care (ie, no dose). In meta-regression, greater dose was significantly related to lower all-cause mortality (high: -0.77; SE, 0.22; P<.001; medium: -0.80; SE, 0.21; P<.001) when compared with low dose. With regard to morbidity, meta-analysis revealed that dose was significantly associated with fewer percutaneous coronary interventions (high: relative risk, 0.65; 95% CI, 0.50-0.84; medium/low: relative risk, 1.04; 95% CI, 0.74-1.48; between subgroup difference P=.03). This reduction was also significant in meta-regression (high vs medium/low: -0.73; SE, 0.20; P<.001). Publication bias was not evident. No dose-response association was found for cardiovascular mortality, all-cause hospitalization, coronary artery bypass graft surgery, or myocardial infarction. CONCLUSION A minimum of 36 CR sessions may be needed to reduce percutaneous coronary interventions. Future studies should examine the effect of actual dose of CR, and trials are needed comparing different doses. PROSPERO REGISTRATION CRD42016036029.
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Affiliation(s)
| | - Susan Marzolini
- University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Maureen Pakosh
- University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Sherry L Grace
- York University, School of Kinesiology and Health Science, Toronto, Ontario, Canada; University Health Network-University of Toronto, Toronto, Ontario, Canada.
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Edwards K, Jones N, Newton J, Foster C, Judge A, Jackson K, Arden NK, Pinedo-Villanueva R. The cost-effectiveness of exercise-based cardiac rehabilitation: a systematic review of the characteristics and methodological quality of published literature. HEALTH ECONOMICS REVIEW 2017; 7:37. [PMID: 29052044 PMCID: PMC5648728 DOI: 10.1186/s13561-017-0173-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/29/2017] [Indexed: 05/25/2023]
Abstract
AIM This descriptive review aimed to assess the characteristics and methodological quality of economic evaluations of cardiac rehabilitation (CR) programs according to updated economic guidelines for healthcare interventions. Recommendations will be made to inform future research addressing the impact of a physical exercise component on cost-effectiveness. METHODS Electronic databases were searched for economic evaluations of exercise-based CR programs published in English between 2000 and 2014. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement was used to review the methodological quality of included economic evaluations. RESULTS Fifteen economic evaluations met the review inclusion criteria. Assessed study characteristics exhibited wide variability, particularly in their economic perspective, time horizon, setting, comparators and included costs, with significant heterogeneity in exercise dose across interventions. Ten evaluations were based on randomised controlled trials (RCTs) spanning 6-24 months but often with weak or inconclusive results; two were modelling studies; and the final three utilised longer time horizons of 3.5-5 years from which findings suggest that long-term exercise-based CR results in lower costs, reduced hospitalisations and a longer cumulative patient lifetime. None of the 15 articles met all the CHEERS quality criteria, with the majority either fully or partially meeting a selection of the assessed variables. CONCLUSION Evidence exists supporting the cost-effectiveness of exercise-based CR for cardiovascular disease patients. However, variability in CR program delivery and weak consistency between study perspective and design limits study comparability and therefore the accumulation of evidence in support of a particular exercise regime. The generalisability of study findings was limited due to the exclusion of patients with comorbidities as would typically be found in a real-world setting. The use of longer time-horizons would be more comparable with a chronic condition and enable economic assessments of the long-term effects of CR. As none of the articles met recent reporting standards for the economic assessment of healthcare interventions, it is recommended that future studies adhere to such guidelines.
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Affiliation(s)
- Katherine Edwards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Natasha Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Sport and Exercise Medicine, Edinburgh, UK
- Nuffield Orthopaedic Centre, Oxford, UK
| | - Julia Newton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, University of Oxford, Oxford, UK
| | - Charlie Foster
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiological Unit, University of Southampton, Southampton, UK
| | - Kate Jackson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel K. Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiological Unit, University of Southampton, Southampton, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiological Unit, University of Southampton, Southampton, UK
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Kureshi F, Kennedy KF, Jones PG, Thomas RJ, Arnold SV, Sharma P, Fendler T, Buchanan DM, Qintar M, Ho PM, Nallamothu BK, Oldridge NB, Spertus JA. Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction. JAMA Cardiol 2016; 1:980-988. [PMID: 27760269 DOI: 10.1001/jamacardio.2016.3458] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Cardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients' health status (eg, quality of life, symptoms, and functional status) is poorly defined. Objective To examine the association of participation in CR with health status outcomes after AMI. Design, Setting, and Participants A retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015. Exposures Participation in at least 1 CR session within 6 months of hospital discharge. Main Outcomes and Measures Patient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality. Results After successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was -0.76 (95% CI, -2.05 to 0.52) for the SAQ quality of life score, -1.53 (95% CI, -2.57 to -0.49) for the SAQ angina frequency score, 0.38 (95% CI, -0.51 to 1.27) for the SAQ treatment satisfaction score, -0.42 (95% CI, -1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, -0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, -0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was -0.89 (95% CI, -2.20 to 0.43) for the SAQ quality of life score, -1.05 (95% CI, -2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, -0.54 to 1.29) for the SAQ treatment satisfaction score, -0.14 (95% CI, -1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, -0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, -0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75). Conclusions and Relevance In a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.
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Affiliation(s)
- Faraz Kureshi
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - Kevin F Kennedy
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Philip G Jones
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Randal J Thomas
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Suzanne V Arnold
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - Praneet Sharma
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - Timothy Fendler
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - Donna M Buchanan
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - Mohammed Qintar
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
| | - P Michael Ho
- Division of Cardiovascular Diseases, University of Colorado-Denver
| | | | - Neil B Oldridge
- University of Wisconsin School of Medicine and Public Health, Milwaukee7Aurora Cardiovascular Services, Milwaukee, Wisconsin
| | - John A Spertus
- Division of Cardiovascular Diseases and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri2School of Medicine, University of Missouri-Kansas City
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Benedek T, Maurovich-Horváth P, Ferdinandy P, Merkely B. The Use of Biomarkers for the Early Detection of Vulnerable Atherosclerotic Plaques and Vulnerable Patients. A Review. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2016. [DOI: 10.1515/jce-2016-0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
Acute coronary syndromes represent the most severe consequences of atherosclerosis, most often triggered by the rupture of a coronary plaque, which, for various reasons, has become unstable. In many cases, these rupture-prone vulnerable plaques are difficult to diagnose, because they do not always cause significant obstruction noticeable by coronary angiography. Therefore, new methods and tools for the identification of vulnerable plaques have been proposed, many of which are currently under study. Various biomarkers have been suggested as predictors of a vulnerable plaque, as well as indicators of an increased inflammatory status associated with higher patient susceptibility for plaque rupture. Integration of such biomarkers into multiple biomarker platforms has been suggested to identify superior diagnostic algorithms for the early detection of the high-risk condition associated with an unstable plaque. The aim of this review is to summarize recent research related to biomarkers used for the early detection of vulnerable plaques and vulnerable patients.
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Affiliation(s)
- Theodora Benedek
- Department of Cardiology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
| | - Pál Maurovich-Horváth
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Pharmahungary Group, Szeged, Hungary
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Zwisler ADO, Traeden UI, Videbaek J, Madsend M. Cardiac rehabilitation services in Denmark: Still room for expansion. Scand J Public Health 2016; 33:376-83. [PMID: 16265807 DOI: 10.1080/14034940510005824] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: European cardiologists agree that cardiac rehabilitation (CR) should be offered as an integrated part of cardiac care, and CR guidelines have been published. The authors aimed to ascertain the potential for expanding CR coverage at hospitals in Denmark. Method: A cross-sectional questionnaire study was conducted among all hospitals receiving acute cardiac patients (n=67). The response rate was 79%, with no differences according to catchment area, number of beds, or geographical location. The hospitals were classified as having full CR if all core components (physical training, psychosocial support, dietary counselling, smoking cessation, and pharmaceutical risk factor management) were available during each of three phases: (I) in hospital; (II) outpatient; and (II) community-based services. Results: Many hospitals offered one or more of the CR components during phases I and II: physical training (77%; 77%), psychosocial support (89%; 79%), dietary counselling (85%; 89%), smoking cessation (94%; 68%), and clinical control by a physician (100%; 93%). The content varied greatly. Full phase I CR was offered at 57% (95% confidence interval (95% CI): 44—70%) of the hospitals and 47% (95% CI: 34—60%) offered full phase II CR. Phase III CR was very rare (2% (95% CI: 0—6%). The numbers of patients receiving CR was not registered. Conclusion: Marked progress was made in the 1990s in implementing CR; nevertheless, the services are far from fully expanded. Denmark has great potential for improving CR services, as do most other European countries. CR activities need to be registered at Danish hospitals.
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Affiliation(s)
- Ann-Dorthe O Zwisler
- Unit of Cardiac Rehabilitation, Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark.
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Worcester MUC, Murphy BM, Mee VK, Roberts SB, Goble AJ. Cardiac rehabilitation programmes: predictors of non-attendance and drop-out. ACTA ACUST UNITED AC 2016; 11:328-35. [PMID: 15292767 DOI: 10.1097/01.hjr.0000137083.20844.54] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite evidence of its benefits, attendance at cardiac rehabilitation (CR) programmes is poor. Past studies to identify predictors of non-attendance have been limited by their small sample size, particularly for female patients. The present study was designed to identify socio-demographic and clinical predictors of non-attendance and drop-out separately for men and women automatically referred to CR programmes. METHOD AND SUBJECTS Prospective study of CR programme attendance amongst 808 patients consecutively admitted over an 11-month period to one of two hospitals in Melbourne, Australia, after acute myocardial infarction (AMI), or to undergo coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI). RESULTS Of the 652 eligible patients, 573 (88%) were successfully tracked at 4 months. Of these, 284 (49.6%) had attended a CR programme, while 272 (47.5%) had not. Using logistic regression, the significant predictors of programme non-attendance among men were having had a PCI, being a non-driver, and being aged 70 or more. The only factor predictive of non-attendance for women was being aged 70 or more. Amongst attenders, 67 (23.6%) patients discontinued the programme. Being a smoker, having diabetes and being unemployed at the time of hospital admission were predictive of programme drop-out by men. Being physically inactive at admission was predictive of programme drop-out by women. CONCLUSIONS The present study demonstrated a relatively high rate of CR programme attendance. Special attention needs to be directed towards males who are older, PCI patients, smokers, unemployed or non-drivers, and females who are older or inactive.
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Le Grande MR, Murphy BM, Higgins RO, Worcester MUC, Parkinson A, Brown SL, Elliott PC, Goble AJ. Physical activity and negative emotional response after percutaneous coronary intervention. ACTA ACUST UNITED AC 2016; 13:254-60. [PMID: 16575281 DOI: 10.1097/01.hjr.0000189808.22224.b0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aims of this study were to investigate the association between negative emotional response (NER) and physical activity levels in percutaneous coronary intervention (PCI) patients, and to examine the extent to which physical activity levels were influenced by factors such as the patients' age, sex, and attendance at a cardiac rehabilitation (CR) programme. METHODS A consecutive series of 200 PCI patients [mean age 59.0 (+/-10.1) years] completed telephone interviews 2 weeks and 6 months after their procedure. NER was assessed using 12 items addressing patients' perceptions and concerns regarding symptoms, diagnosis and prognosis. Physical activity was assessed by asking four questions relating to the frequency and duration of walking and of moderate activity. CR attendance, medical history and sociodemographic data were also collected. Hierarchical linear regression was used to assess the association between NER and physical activity over time. RESULTS After controlling for baseline levels of moderate activity and other covariates, NER significantly predicted change in moderate activity over 6 months. Only baseline walking levels predicted the duration and frequency of walking at 6 months. CONCLUSION NER can be considered an inhibitive factor towards increased moderate activity uptake after PCI. Walking after PCI does not appear to be affected by NER. These findings highlight the need to focus on improving the emotional aspects of patients' recovery.
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Clark AM, Hartling L, Vandermeer B, Lissel SL, McAlister FA. Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions. ACTA ACUST UNITED AC 2016; 14:538-46. [PMID: 17667645 DOI: 10.1097/hjr.0b013e328013f11a] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The aim of this study was to determine which programme characteristics influence the effectiveness of secondary prevention programmes for Coronary Heart Disease. Design The study follows a meta-regression design. Methods We conducted a meta-regression within a systematic review of randomized trials comparing secondary prevention programmes versus usual care. The primary outcome was all-cause mortality. Studies were identified by searching multiple electronic databases, bibliographies of published studies, contact with experts, and references provided by the United States Centers for Medicare and Medicaid Services. Primary authors of all relevant trials were surveyed for detailed information on programme characteristics. Forty-six unique trials were identified (18 821 patients). The pooled all-cause mortality risk ratio (RR) for programmes was 0.87 [95% confidence interval (CI) 0.79-0.97]. Programmes containing less than 10 h of patient contact with health professionals reduced all-cause mortality (RR 0.80, 95% CI 0.68-0.95) as effectively as programmes with more contact time. Programmes provided in general practice settings were effective at reducing all-cause mortality (RR 0.76, 95% CI 0.63-0.92) and compared favourably with the effectiveness of hospital-based programmes. Other characteristics, including specialist versus generalist provision, did not appreciably impact programme effectiveness. Conclusions Shorter secondary prevention programmes, those based in general practice, and those staffed by generalists are at least as effective in reducing all cause mortality in patients with coronary heart disease as longer programmes, hospital-based programmes, and programmes staffed by specialists.
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Affiliation(s)
- Alexander M Clark
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Dröes RM, Boelens-Van Der Knoop EC, Bos J, Meihuizen L, Ettema TP, Gerritsen DL, Hoogeveen F, De Lange J, SchöLzel-Dorenbos CJ. Quality of life in dementia in perspective. DEMENTIA 2016. [DOI: 10.1177/1471301206069929] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many different definitions of the concept of quality of life (QOL) are found in the literature. This raises the question as to which domains are viewed as really important by people with dementia and which are possibly based on views of others, such as (in)formal carers, or theoretical models. An explorative study was carried out among people with dementia living in the community and in nursing homes. Their opinions were compared to those of professional carers and to the current theoretical models and instruments for QOL in dementia. Data were gathered by means of interviews, focus groups and literature study. Most QOL domains mentioned as important by the persons with dementia were also acknowledged by the carers and in the literature. A few, however, were not mentioned by the carers (i.e. ‘sense of aesthetics in living environment’,‘financial situation’ and ‘being of use/giving meaning to life’), and not selected in the measuring instruments (‘security and privacy’, and ‘self-determination and freedom’). This indicates differences in perspectives on quality of life between persons with dementia, their carers and theoretical models. Further research is recommended on this point.
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Affiliation(s)
| | | | - Joke Bos
- Amsterdam Meeting Centre De Pijp,Amsterdam, The Netherlands
| | | | - Teake P. Ettema
- Institute for Research in Extramural Medicine,VU Medical Centre,
Amsterdam/Trimbos Institute Utrecht,The Netherlands
| | | | | | - Jacomine De Lange
- Trimbos Institute,The Netherlands Institute of Mental Health and
Addiction,Utrecht, The Netherlands
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Worcester MUC, Stojcevski Z, Murphy B, Goble AJ. Factors Associated with Non-Attendance at a Secondary Prevention Clinic for Cardiac Patients. Eur J Cardiovasc Nurs 2016; 2:151-7. [PMID: 14622640 DOI: 10.1016/s1474-5151(03)00031-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: A randomised controlled trial was undertaken to test the effectiveness of a secondary prevention clinic. Secondary prevention programs can improve prognosis after an acute cardiac illness. It is therefore important to encourage high participation rates. Aim: The present study was a post-hoc analysis to identify factors associated with patients’ non-attendance at the clinic. Methods: We compared the baseline socio-demographic and clinical characteristics of 83 (73.5% male) non-attending patients and a random sample of 96 (85.4% male) attending patients. Self-reported data were gathered during interviews conducted on an average of 30 months after hospital admission to investigate long-term outcomes of the clinic. Results: Using logistic regression analysis, we found that non-attendance was significantly and independently associated with being female, being under 60 years of age, having no history of high cholesterol and having no angina prior to the event. In bivariate analyses, non-attendance was also associated with being born overseas and not having private health insurance. Conclusions: Likely non-attending patients should be identified early and more effective strategies should be devised to facilitate their participation in secondary prevention programs.
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Blumenthal JA, Feger BJ, Smith PJ, Watkins LL, Jiang W, Davidson J, Hoffman BM, Ashworth M, Mabe SK, Babyak MA, Kraus WE, Hinderliter A, Sherwood A. Treatment of anxiety in patients with coronary heart disease: Rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial. Am Heart J 2016; 176:53-62. [PMID: 27264220 PMCID: PMC4900181 DOI: 10.1016/j.ahj.2016.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/04/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anxiety is highly prevalent among patients with coronary heart disease (CHD), and there is growing evidence that high levels of anxiety are associated with worse prognosis. However, few studies have evaluated the efficacy of treating anxiety in CHD patients for reducing symptoms and improving clinical outcomes. Exercise and selective serotonin reuptake inhibitors have been shown to be effective in treating patients with depression, but have not been studied in cardiac patients with high anxiety. METHODS The UNWIND trial is a randomized clinical trial of patients with CHD who are at increased risk for adverse events because of comorbid anxiety. One hundred fifty participants with CHD and elevated anxiety symptoms and/or with a diagnosed anxiety disorder will be randomly assigned to 12 weeks of aerobic exercise (3×/wk, 35 min, 70%-85% VO2peak), escitalopram (5-20 mg qd), or placebo. Before and after 12 weeks of treatment, participants will undergo assessments of anxiety symptoms and CHD biomarkers of risk, including measures of inflammation, lipids, hemoglobin A1c, heart rate variability, and vascular endothelial function. Primary outcomes include post-intervention effects on symptoms of anxiety and CHD biomarkers. Secondary outcomes include clinical outcomes (cardiovascular hospitalizations and all-cause death) and measures of quality of life. CONCLUSIONS The UNWIND trial (ClinicalTrials.gov NCT02516332) will evaluate the efficacy of aerobic exercise and escitalopram for improving anxiety symptoms and reducing risk for adverse clinical events in anxious CHD patients.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
| | - Bryan J Feger
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Lana L Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Wei Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Jonathan Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Benson M Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Megan Ashworth
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Stephanie K Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Michael A Babyak
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - William E Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
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Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol 2016; 67:1-12. [PMID: 26764059 DOI: 10.1016/j.jacc.2015.10.044] [Citation(s) in RCA: 1036] [Impact Index Per Article: 129.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/12/2015] [Accepted: 10/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although recommended in guidelines for the management of coronary heart disease (CHD), concerns have been raised about the applicability of evidence from existing meta-analyses of exercise-based cardiac rehabilitation (CR). OBJECTIVES The goal of this study is to update the Cochrane systematic review and meta-analysis of exercise-based CR for CHD. METHODS The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Science Citation Index Expanded were searched to July 2014. Retrieved papers, systematic reviews, and trial registries were hand-searched. We included randomized controlled trials with at least 6 months of follow-up, comparing CR to no-exercise controls following myocardial infarction or revascularization, or with a diagnosis of angina pectoris or CHD defined by angiography. Two authors screened titles for inclusion, extracted data, and assessed risk of bias. Studies were pooled using random effects meta-analysis, and stratified analyses were undertaken to examine potential treatment effect modifiers. RESULTS A total of 63 studies with 14,486 participants with median follow-up of 12 months were included. Overall, CR led to a reduction in cardiovascular mortality (relative risk: 0.74; 95% confidence interval: 0.64 to 0.86) and the risk of hospital admissions (relative risk: 0.82; 95% confidence interval: 0.70 to 0.96). There was no significant effect on total mortality, myocardial infarction, or revascularization. The majority of studies (14 of 20) showed higher levels of health-related quality of life in 1 or more domains following exercise-based CR compared with control subjects. CONCLUSIONS This study confirms that exercise-based CR reduces cardiovascular mortality and provides important data showing reductions in hospital admissions and improvements in quality of life. These benefits appear to be consistent across patients and intervention types and were independent of study quality, setting, and publication date.
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Affiliation(s)
- Lindsey Anderson
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - Neil Oldridge
- College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin
| | - David R Thompson
- Centre for the Heart and Mind, Australian Catholic University, Melbourne, Australia
| | - Ann-Dorthe Zwisler
- National Centre of Rehabilitation and Palliation, University Hospital Odense, and University of Southern Denmark, Odense, Denmark
| | - Karen Rees
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Nicole Martin
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom.
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Stonerock GL, Hoffman BM, Smith PJ, Blumenthal JA. Exercise as Treatment for Anxiety: Systematic Review and Analysis. Ann Behav Med 2016; 49:542-56. [PMID: 25697132 DOI: 10.1007/s12160-014-9685-9] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Exercise has been shown to reduce symptoms of anxiety, but few studies have studied exercise in individuals preselected because of their high anxiety. PURPOSE The objective of this study is to review and critically evaluate studies of exercise training in adults with either high levels of anxiety or an anxiety disorder. METHODS We conducted a systematic review of randomized clinical trials (RCTs) in which anxious adults were randomized to an exercise or nonexercise control condition. Data were extracted concerning anxiety outcomes and study design. Existing meta-analyses were also reviewed. RESULTS Evidence from 12 RCTs suggested benefits of exercise, for select groups, similar to established treatments and greater than placebo. However, most studies had significant methodological limitations, including small sample sizes, concurrent therapies, and inadequate assessment of adherence and fitness levels. CONCLUSIONS Exercise may be a useful treatment for anxiety, but lack of data from rigorous, methodologically sound RCTs precludes any definitive conclusions about its effectiveness.
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Affiliation(s)
- Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3119, Durham, NC, 27710, USA,
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Thompson DR, Ski CF, Garside J, Astin F. A review of health-related quality of life patient-reported outcome measures in cardiovascular nursing. Eur J Cardiovasc Nurs 2016; 15:114-25. [DOI: 10.1177/1474515116637980] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 02/18/2016] [Indexed: 12/22/2022]
Affiliation(s)
- David R Thompson
- Centre for the Heart and Mind, Australian Catholic University, Melbourne, Australia
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chantal F Ski
- Centre for the Heart and Mind, Australian Catholic University, Melbourne, Australia
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Joanne Garside
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Felicity Astin
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
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Seneviwickrama KLMD, Samaranayake DBDL, Fonseka P, Galappaththy GNL, Höfer S, Oldridge NB. Psychometric evaluation of the Sinhalese version of MacNew Heart Disease Health Related Quality of Life Questionnaire in patients with stable angina. Health Qual Life Outcomes 2016; 14:44. [PMID: 26980077 PMCID: PMC4791756 DOI: 10.1186/s12955-016-0448-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 03/09/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A Sinhalese version of a validated, disease-specific patient-reported heart disease health related quality of life instrument is lacking. The purpose of this study was to validate the interviewer-administered Sinhalese version of the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients with clinically diagnosed stable angina. METHODS The Sinhalese translation of the MacNew was carried using standard forward- backward translation technique. In this validation study, the MacNew was administered to 200 patients with stable angina. Reliability was assessed by internal consistency and test-retest reliability. Construct validity was explored by exploratory factor analysis using principal component analysis and confirmed by confirmatory factor analysis using the robust maximum likelihood method and known group comparison. The correlation between compatible domain scores of MacNew and the World Health Organization's quality of life -brief questionnaire was used to assess concurrent validity. RESULTS The original 3-factor model (Physical, Emotional and Social) of the MacNew with cross-loadings was confirmed: principal component analysis with 53.42 % of the explained variance and confirmatory factor analysis with adequate fit for each of the three model fit criteria considered [root mean square error of approximation = 0.044 (90 % CI = 0.031 to 0.056); comparative fit index = 0.99; χ(2)/df = 1.39]. Internal consistency of the MacNew was acceptable with Cronbach's α of 0.92 on the Global scale and on the domain scales ranging from 0.85-0.91. Test-retest reliability was also found to be satisfactory with intraclass correlation coefficients of >0.9 for total and domain scores. A satisfactory level of concurrent validity was demonstrated with statistically significant correlations between compatible domain scores of MacNew and the World Health Organization's quality of life questionnaire (Pearson correlation ranging from 0.36-0.79). CONCLUSIONS The interviewer-administered Sinhalese MacNew is a valid and reliable patient-reported outcome measure to assess disease specific health-related quality of life among Sinhalese patients with stable angina.
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Affiliation(s)
| | | | - P. Fonseka
- />Department of Community Medicine, University of Sri Jayawardhenepura, Nugegoda, Sri Lanka
| | - G. N. L. Galappaththy
- />Emergency Response to Artemisinin Resistance (ERAR) and other Vector Borne & Parasitic Diseases, World Health Organization, Hà Nội, Viet Nam
| | - S. Höfer
- />Department of Medical Psychology, Innsbruck Medical University, Innsbruck, Austria
| | - N. B. Oldridge
- />College of Health Sciences, University of Wisconsin-Milwaukee, Milwaukee, USA
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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.
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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
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Whittaker F, Wade V. The costs and benefits of technology-enabled, home-based cardiac rehabilitation measured in a randomised controlled trial. J Telemed Telecare 2015; 20:419-22. [PMID: 25400004 DOI: 10.1177/1357633x14552376] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We conducted a cost benefit analysis of a home telehealth-based cardiac rehabilitation programme compared to the standard hospital-based programme. A total of 120 participants were enrolled in a trial, with 60 randomised to the telehealth group and 60 randomised to usual care. Participants in the telehealth group received a mobile phone, Wellness Diary and a Wellness web portal, with daily text messaging. Participants in the usual care group received the standard 6-week hospital-based outpatient cardiac rehabilitation programme, including gym sessions. The cost of delivery by telehealth was slightly lower than for patients attending a rehabilitation service in person. From the provider's perspective, the telehealth intervention could be delivered for $1633 per patient, compared to $1845 for the usual care group. From the participant's perspective, patient travel costs for home rehabilitation were substantially less than for hospital attendance ($80 vs $400). Cardiac rehabilitation by telehealth offers obvious advantages and the option should be available to all patients who are eligible for cardiac rehabilitation.
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Affiliation(s)
| | - Victoria Wade
- Discipline of General Practice, University of Adelaide, South Australia, Australia
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