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Abraham LN, Sibilitz KL, Berg SK, Tang LH, Risom SS, Lindschou J, Taylor RS, Borregaard B, Zwisler AD. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev 2021; 5:CD010876. [PMID: 33962483 PMCID: PMC8105032 DOI: 10.1002/14651858.cd010876.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The impact of exercise-based cardiac rehabilitation (CR) following heart valve surgery is uncertain. We conducted an update of this systematic review and a meta-analysis to assess randomised controlled trial evidence for the use of exercise-based CR following heart valve surgery. OBJECTIVES To assess the benefits and harms of exercise-based CR compared with no exercise training in adults following heart valve surgery or repair, including both percutaneous and surgical procedures. We considered CR programmes consisting of exercise training with or without another intervention (such as an intervention with a psycho-educational component). SEARCH METHODS We searched the Cochrane Central Register of Clinical Trials (CENTRAL), in the Cochrane Library; MEDLINE (Ovid); Embase (Ovid); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO); PsycINFO (Ovid); Latin American Caribbean Health Sciences Literature (LILACS; Bireme); and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science (Clarivate Analytics) on 10 January 2020. We searched for ongoing trials from ClinicalTrials.gov, Clinical-trials.com, and the World Health Organization International Clinical Trials Registry Platform on 15 May 2020. SELECTION CRITERIA We included randomised controlled trials that compared exercise-based CR interventions with no exercise training. Trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and had received heart valve replacement or heart valve repair. Both percutaneous and surgical procedures were included. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed the risk of systematic errors ('bias') by evaluating risk domains using the 'Risk of bias' (RoB2) tool. We assessed clinical and statistical heterogeneity. We performed meta-analyses using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence for primary outcomes (all-cause mortality, all-cause hospitalisation, and health-related quality of life). MAIN RESULTS We included six trials with a total of 364 participants who have had open or percutaneous heart valve surgery. For this updated review, we identified four additional trials (216 participants). One trial had an overall low risk of bias, and we classified the remaining five trials as having some concerns. Follow-up ranged across included trials from 3 to 24 months. Based on data at longest follow-up, a total of nine participants died: 4 CR versus 5 control (relative risk (RR) 0.83, 95% confidence interval (CI) 0.26 to 2.68; 2 trials, 131 participants; GRADE quality of evidence very low). No trials reported on cardiovascular mortality. One trial reported one cardiac-related hospitalisation in the CR group and none in the control group (RR 2.72, 95% CI 0.11 to 65.56; 1 trial, 122 participants; GRADE quality of evidence very low). We are uncertain about health-related quality of life at completion of the intervention in CR compared to control (Short Form (SF)-12/36 mental component: mean difference (MD) 1.28, 95% CI -1.60 to 4.16; 2 trials, 150 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD 2.99, 95% CI -5.24 to 11.21; 2 trials, 150 participants; GRADE quality of evidence very low), or at longest follow-up (SF-12/36 mental component: MD -1.45, 95% CI -4.70 to 1.80; 2 trials, 139 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD -0.87, 95% CI -3.57 to 1.83; 2 trials, 139 participants; GRADE quality of evidence very low). AUTHORS' CONCLUSIONS: Due to lack of evidence and the very low quality of available evidence, this updated review is uncertain about the impact of exercise-CR in this population in terms of mortality, hospitalisation, and health-related quality of life. High-quality (low risk of bias) evidence on the impact of CR is needed to inform clinical guidelines and routine practice.
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Affiliation(s)
- Lizette N Abraham
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Kirstine L Sibilitz
- Department of Cardiology, Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Selina K Berg
- Department of Cardiology, Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars H Tang
- The research unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Signe S Risom
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- The Heart Centre, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute for Nursing and Nutrition, University College Copenhagen, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Copenhagen University Hospital, Copenhagen, 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
| | - Britt Borregaard
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - 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
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Sibilitz KL, Berg SK, Rasmussen TB, Risom SS, Thygesen LC, Tang L, Hansen TB, Johansen PP, Gluud C, Lindschou J, Schmid JP, Hassager C, Køber L, Taylor RS, Zwisler AD. Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial. Heart 2016; 102:1995-2003. [PMID: 27492941 DOI: 10.1136/heartjnl-2016-309414] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The evidence for cardiac rehabilitation after valve surgery remains sparse. Current recommendations are therefore based on patients with ischaemic heart disease. The aim of this randomised clinical trial was to assess the effects of cardiac rehabilitation versus usual care after heart valve surgery. METHODS The trial was an investigator-initiated, randomised superiority trial (The CopenHeartVR trial, VR; valve replacement or repair). We randomised 147 patients after heart valve surgery 1:1 to 12 weeks of cardiac rehabilitation consisting of physical exercise and monthly psycho-educational consultations (intervention) versus usual care without structured physical exercise or psycho-educational consultations (control). Primary outcome was physical capacity measured by VO2 peak and secondary outcome was self-reported mental health measured by Short Form-36. RESULTS 76% were men, mean age 62 years, with aortic (62%), mitral (36%) or tricuspid/pulmonary valve surgery (2%). Cardiac rehabilitation compared with control had a beneficial effect on VO2 peak at 4 months (24.8 mL/kg/min vs 22.5 mL/kg/min, p=0.045) but did not affect Short Form-36 Mental Component Scale at 6 months (53.7 vs 55.2 points, p=0.40) or the exploratory physical and mental outcomes. Cardiac rehabilitation increased the occurrence of self-reported non-serious adverse events (11/72 vs 3/75, p=0.02). CONCLUSIONS Cardiac rehabilitation after heart valve surgery significantly improves VO2 peak at 4 months but has no effect on mental health and other measures of exercise capacity and self-reported outcomes. Further research is needed to justify cardiac rehabilitation in this patient group. TRIAL REGISTRATION NUMBER NCT01558765, Results.
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Affiliation(s)
- Kirstine L Sibilitz
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Selina K Berg
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Gentofte Hospital, Gentofte, Denmark
| | - Trine B Rasmussen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Gentofte Hospital, Gentofte, Denmark
| | - Signe Stelling Risom
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Bachelor's Degree Programme in Nursing, Metropolitan University College, Copenhagen, Denmark
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Lars Tang
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Technology, Bachelor's Degree Programme in Physiotherapy, Department of Rehabilitation and Nutrition, Metropolitan University College, Copenhagen, Denmark.,CopenRehab, Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Tina B Hansen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Zealand University Hospital, Department of Cardiology, Køgevej 7-13, 4000 Roskilde, Denmark
| | - Pernille Palm Johansen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean Paul Schmid
- Cardiology Clinic, Tiefenau Hospital and University of Bern, Bern, Switzerland
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rod S Taylor
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Institute of Health Research, University of Exeter Medical School, Exeter, England
| | - Ann-Dorthe Zwisler
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Department of Cardiology, Holbaek Sygehus, Holbaek, Denmark.,National Centre of Rehabilitation and Palliation, University of Southern Denmark, and University Hospital of Odense, Odense, Denmark
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Pack QR, Lahr BD, Squires RW, Lopez-Jimenez F, Greason KL, Michelena HI, Goel K, Thomas RJ. Survey Reported Participation in Cardiac Rehabilitation and Survival After Mitral or Aortic Valve Surgery. Am J Cardiol 2016; 117:1985-91. [PMID: 27138188 DOI: 10.1016/j.amjcard.2016.03.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/25/2016] [Accepted: 03/25/2016] [Indexed: 02/04/2023]
Abstract
We sought to measure the impact of cardiac rehabilitation (CR) on mortality in patients with mitral or aortic heart valve surgery (HVS) and nonobstructive coronary artery disease. We surveyed all patients (or a close family member if the patient was deceased) who had HVS without coronary artery bypass in 2006 through 2010 at the Mayo Clinic to assess if they attended CR after their HVS. We performed a propensity-adjusted landmark analysis to test the association between CR attendance and long-term all-cause mortality conditional on surviving the first year after HVS. Survey response rate was 40% (573/1,420), with responders more likely to be older, have longer hospitalizations, and have more aortic valve disease. A total of 547 patients (59% aortic surgery, ejection fraction 64%) with valid survey responses and 1-year follow-up were included in the propensity analysis, of whom 296 (54%) attended CR. There were 100 deaths during a median follow-up of 5.8 years. For all patients, the propensity-adjusted model suggested no impact of CR on mortality (hazard ratio [HR] 1.03, 95% CI 0.66 to 1.62). When stratified by procedure, results suggested a potentially favorable, but nonsignificant, effect in patients with mitral valve surgery (HR 0.49, 95% CI 0.15 to 1.56), but not in patients with aortic valve surgery (HR 1.00, 95% CI 0.61 to 1.64.) In conclusion, we found no survival advantage for patients with normal preoperative ejection fraction who attended CR after surgical "correction" of their severe aortic or mitral valve disease.
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