Does exercise-based cardiac rehabilitation in persons with coronary heart disease affect morbidity and mortality?
Exercise-based cardiac rehabilitation reduces cardiovascular mortality and hospitalization. There is no evidence that it reduces the rates of total mortality, myocardial infarctions, coronary artery bypass grafts, or percutaneous coronary interventions.1 (Strength of Recommendation: B, based on lower-quality clinical trials or studies with inconsistent findings.)
Although modern medical and surgical management allows patients with coronary heart disease to live longer than ever before, cardiovascular disease remains the leading cause of death in the United States.2 Exercise-based cardiac rehabilitation has been suggested as a modality to reduce morbidity and mortality in this growing population. The authors of this review sought to evaluate the effect of exercise-based cardiac rehabilitation on morbidity and mortality in patients with cardiovascular disease.1
This Cochrane review identified 63 randomized controlled trials comparing exercise-based cardiac rehabilitation with usual care (e.g., education, medical management) in 14,486 patients with coronary heart disease.1 Most participants had experienced a myocardial infarction and/or a revascularization procedure, and the mean ages of patients across studies ranged from 48 to 71 years. The quality of the trials ranged from low to moderate, with a lack of adequate reporting on methodology in many trials. Exercise-based cardiac rehabilitation reduced cardiovascular mortality (number needed to treat [NNT] = 36; 95% confidence interval [CI], 27 to 64) and overall risk of hospital admissions (NNT = 22; 95% CI, 11 to 81) compared with control. There was no reduction in the rate of myocardial infarctions, total mortality, coronary artery bypass grafts, or percutaneous coronary interventions.
The authors did not pool the data for health-related quality of life. They found that 14 of 20 studies reported improvement in one or more of the subscales assessing this outcome (e.g., physical functioning and performance, general health, pain), but the results were inconsistent across studies. Four studies reviewed the cost-effectiveness of exercise-based cardiac rehabilitation. Estimates ranged from a cost savings of $650 to an expenditure of $42,535 to gain one quality-adjusted life year.
Current American, Canadian, and European guidelines encourage cardiac rehabilitation with an exercise component for secondary prevention as part of a multifaceted strategy for patients with coronary heart disease.3,4 This review provides further evidence that cardiac rehabilitation offers significant patient benefit.
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD001800.
editor's note: The numbers needed to treat reported in this Cochrane for Clinicians were calculated by AFP medical editors based on raw data provided in the original Cochrane review.
The views expressed herein do not necessarily reflect the views of the Uniformed Services University of the Health Sciences, the U.S. Army, or the Department of Defense.