Exercise-Based Cardiac Rehabilitation for Adults With Heart Failure

Does exercise-based cardiac rehabilitation improve mortality rates, hospital admission rates, and health-related quality of life in adults who have heart failure (HF) with reduced or preserved ejection fraction?

Exercise-based cardiac rehabilitation likely reduces the risk of all-cause hospital admission in adults who have HF with reduced or preserved ejection fraction.¹ (Strength of Recommendation [SOR]: A, consistent, good-quality patient-oriented evidence.) Exercise-based cardiac rehabilitation likely improves short-term health-related quality of life in adults with HF with reduced or preserved ejection fraction. (SOR: A, consistent, good-quality patient-oriented evidence.) Exercise-based cardiac rehabilitation does not decrease short-term (up to 12 months) all-cause mortality compared with usual care in adults who have HF with reduced or preserved ejection fraction. (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

HF is a common condition affecting more than 60 million people worldwide.^1,2 HF is a clinical syndrome with signs and/or symptoms caused by structural and/or functional cardiac abnormalities.³ In this Cochrane review, patients who had HF with preserved ejection fraction (HFpEF) were defined as having an ejection fraction of 45% or greater, and patients with HF with reduced ejection fraction (HFrEF) were defined as having an ejection fraction of less than 45%.¹ Patients with HF often experience a significant reduction in exercise capacity, which can negatively affect quality of life. Exercise-based cardiac rehabilitation is an underused treatment for cardiovascular disease to improve HF symptoms and related outcomes.⁴ Exercise-based cardiac rehabilitation always includes formal exercise training but may also include education on lifestyle and risk factor modification, counseling, and psychosocial support.^1,4 It typically is conducted in person but also may be implemented through home-based models or technology-based models, which may increase access to this intervention.⁴

The authors of this Cochrane review sought to determine the effectiveness of exercise-based cardiac rehabilitation in adults (older than 18 years) with HF on all-cause mortality, mortality due to HF, all-cause hospital admission, HF-related hospital admission, and health-related quality of life.¹ This updated a 2018 review and included 60 randomized controlled trials (n = 8,728) with a median follow-up time of 6 months. Most patients had HFrEF, but an increasing proportion of patients in the newer trials had HFpEF. Exercise-based cardiac rehabilitation was defined as exercise-based interventions alone or as a component of a comprehensive cardiac rehabilitation program. The control group populations did not receive exercise therapy but may have received education or psychological therapy in addition to usual medical care. Short-term follow-up was defined as less than 12 months duration and long-term follow-up was defined as 12 months or more.

Moderate-certainty evidence showed that exercise-based cardiac rehabilitation reduced short-term all-cause hospital admissions compared with usual care (risk ratio = 0.69; 95% CI, 0.56-0.86; P = .0010; number needed to treat = 13).¹ In studies that used the Minnesota Living With Heart Failure questionnaire to assess health-related quality of life, short-term follow-up showed exercise-based cardiac rehabilitation likely led to a clinically important improvement in health-related quality of life (mean difference = −7.39; 95% CI, −10.30 to −4.47) where 5 or more points is considered clinically meaningful. Rehabilitation did not result in a statistically significant difference in short-term all-cause mortality.