Review: Multicomponent exercise and psychosocial programs are somewhat effective for cardiac rehabilitation
ACP J Club. 1999 Sept-Oct;131:41. doi:10.7326/ACPJC-1999-131-2-041
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• Correction: Review: Multicomponent exercise and psychosocial programs are somewhat effective for cardiac rehabilitation
Dinnes J, Kleijnen J, Leitner M, Thompson D. Cardiac rehabilitation. Qual Health Care. 1999 Mar;8:65-71.*
How effective are nondrug, exercise, psychological, and educational interventions for adults enrolled in cardiac rehabilitation programs?
Studies were identified by searching MEDLINE, EMBASE/Excerpta Medica, CINAHL, and PsycLIT with the terms cardiac rehabilitation, myocardial infarction, angioplasty, and coronary artery bypass. Bibliographies of relevant studies were also checked.
Systematic reviews supplemented by randomized controlled trials (RCTs) were selected if they assessed cardiac rehabilitation programs that used non-drug therapies.
Data were extracted on the objective of the review or study, search strategies, inclusion criteria for studies or patients, interventions evaluated (single or combined programs of exercise, psychological interventions, or education), organization of the programs, and results.
9 systematic reviews and 28 separate RCTs met the inclusion criteria. Most studies included low-risk men who were white, were middle-aged, and had had a myocardial infarction. Programs often included combined interventions (e.g., exercise 3 to 5 times/wk plus education and counseling); the programs lasted approximately 12 weeks and were held in hospital outpatient settings or at home. 15% to 59% of patients accepted the offered programs; 20% to 25% dropped out within the first 3 months.
Exercise alone improved physical ability to exercise and physiologic measures of cardiac disease but did not improve smoking cessation, cholesterol levels, angina, reinfarction or related morbidity, or all-cause mortality. No evidence exists for change in body weight, blood pressure, physiologic or social outcomes, or return to work. Exercise was not associated with any harms.
Education, counseling, and behavioral interventions reduced blood pressure and cholesterol levels; improved psychosocial well-being and patient knowledge; and in patients with coronary artery disease, reduced mortality by 20% to 25%. Inpatient education decreased smoking and improved activity levels and compliance with actions to improve health. Combined multi-component programs (exercise and psychological or educational programs) improved cardiac risk factors, especially lipid levels and blood pressure, smoking cessation rates, and exercise levels; they also decreased cardiac mortality (2 of 3 meta-analyses) but did not change return to work or mortality. Small RCTs showed some symptomatic improvement for patients with congestive heart failure. Programs that targeted lifestyle changes were often effective. Limited evidence suggests that women and elderly persons benefit from cardiac rehabilitation, although they are usually underrepresented in studies.
Cardiac rehabilitation programs, especially those that combine exercise, psychological, and educational components, improve symptoms and some disease outcomes.
Source of funding: Not stated.
For correspondence: Dr. J. Dinnes, National Health Service Centre for Reviews and Dissemination, University of York, York YO10 5DD, England, UK. FAX 44-1904-433661.
Many interventions, most of which are based on use of medications, improve outcomes in patients with cardiac disease. The review by Dinnes and colleagues focuses specifically on cardiac rehabilitation interventions rather than drug therapies. The authors performed a comprehensive literature review to retrieve meta-analyses and RCTs.
The main take-home message is that cardiac rehabilitation is efficacious, improves overall patient well-being, and reduces cardiac mortality by 20% to 25%, but it does not significantly affect nonfatal reinfarctions. Combined programs (including exercise, dietary, and psychological interventions) seemed most effective and resulted in improved risk factor profiles. Furthermore, these services may be cost-effective, with a cost per quality-adjusted life-year of U.S. $21 800 (1).
Many issues remain unaddressed. Most studies have been done in young, white men after myocardial infarction who were not especially sick; however, we have no reason to believe that the benefits would not extend to older, sicker patients and persons of nonwhite ethnicity. In addition, most studies have been done after cardiac events, although many include patients who had coronary artery bypass grafting or angioplasty. Many patients either refuse to enroll or drop out; these events occur more frequently among women. Most cardiac rehabilitation programs are based in hospitals, and evaluations of home-based programs are needed. These programs are also heterogeneous, and the specific elements that are most beneficial need further definition.
The bottom line, however, is that these programs improve outcomes after myocardial infarction and are cost-effective; most of the remaining challenges relate to defining how best to deliver the services and identifying which patients should receive them.
David Bates, MD, MSc
Brigham and Women's HospitalBoston, Massachusetts, USA