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Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence
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  • Published on:
    Authors’ response to ICCPR, BACPR and CACPR
    • Richard Powell, Clinical Exercise Physiologist Department of Cardiac Rehabilitation, Centre for Exercise & Health, Coventry
    • Other Contributors:
      • Gordon McGregor, Clinical Research Fellow
      • Stuart Ennis, Clinical Exercise Physiologist
      • Peter K Kimani, Assistant Professor in Medical Statistics
      • Martin Underwood, Professor

    We are delighted that our paper on exercise-based CR has generated a lively debate(1). We are also pleased that correspondents all agree that our findings are robust(2-4). No correspondents have identified any important RCTs we have overlooked that might have changed our conclusions, and none have challenged the veracity of our findings. The majority of concerns were already addressed in the discussion of our original review, and are clarified below.

    Correspondents have identified three main areas for discussion-

    1. Mortality as the main metric of effectiveness-

    Reduction in all-cause mortality has been the focus of the majority of research in this area. Nineteen of the 22 studies in our review reported on this outcome. It was also the primary outcome in all three previous Cochrane reviews(5-7). This focus on all-cause mortality, or cardiovascular mortality, as the justification for offering exercise-based CR is also reflected in current guidance, and must therefore continue to be of some importance. We provide here some examples-

    • NICE Myocardial Infarction secondary prevention; ‘All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component.’ The evidence statements underpinning this recommendation include; ‘Cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component’(8).

    • Bri...

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    Conflict of Interest:
    None declared.
  • Published on:
    Cardiac Rehabilitation Effectiveness? A response from the Canadian Association of Cardiovascular Prevention and Rehabilitation (CACPR)
    • Sherry L Grace, Professor York University, Toronto, Canada.
    • Other Contributors:
      • Gabriela LM Ghisi, Scientific Associate
      • Caroline Chessex, Cardiologist

    In the January 2018 issue of BMJ Open, Powell et al. published a review which pointedly challenges the effectiveness of cardiac rehabilitation (CR) in reducing mortality. This response is forwarded with: (1) respect for the quality of this study (although we might dispute inclusion of some of the trials),[1] (2) consideration of other recent reviews of CR efficacy in the modern era, [2-5] and (3) the desire to incite a balanced discussion of the merits of CR. CACPR invites readers to take into consideration a few important factors when reading Powell et al.’s article.
    First, Powell et al. identify the importance of CR dose and patient adherence and how it was not considered in their work. Actual dose received may often be too low, such that the impact of CR is reduced. [6] There is wide variation in exercise prescriptions and how they are progressed. [7] Degree of improvement and degree of cardiorespiratory fitness is one of the major mechanisms through which CR can reduce mortality,[8] yet often this is not described in trials. In future trials, these factors need to be better documented and considered statistically. Powell et al. recommend a nice framework (see their reference 63), and the TiDIER framework provides another option.[9]
    Second, CR is a “complex”, [10] multi-component intervention.[5,11,12] As Powell et al. state, many of the included trials were exercise-only, and for those that were comprehensive, there was substantial variation. Therefore, it...

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    Conflict of Interest:
    None declared.
  • Published on:
    Response from the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) in collaboration with NACR, the Cochrane Heart Rehabilitation Review Coordination Centre and ACPICR
    • Aynsley Cowie, Scientific Officer BACPR, Research Officer Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR)

    Powell et al’s systematic review and meta-analysis acknowledges that previous meta-analyses have included trials undertaken in the 1970s and 80s that may overestimate the contemporary benefit of exercise-based cardiac rehabilitation (CR) in terms of mortality[1]. The authors recognise the impact of the improvement in the acute medical management of patients with coronary artery disease since the turn of the century, which has led to better survival. Whilst we advocate that more reviews should acknowledge the wider clinical context when evaluating interventions, this particularly broad-brushed approach to the overall effectiveness of CR warrants several counter responses.

    Most notably, it is disappointing that the article depicts mortality as the main barometer of the effectiveness of CR, and conveys the message that the contemporary approach to CR generates no effect. In their updated 2016 Cochrane Review and meta-analysis, Anderson et al[2] acknowledge a linear reduction in all-cause mortality effect over time (i.e., with publication date) but importantly stress that promotion of CR should now focus upon reduced hospital admissions and clinically relevant improvements in quality of life, rather than mortality[3]. This view is supported by Lavie et al[4] who reiterate that CR is known to improve cardiorespiratory fitness and quality of life, and reduce cardiovascular disease (CVD) risk factors, providing cost-effective secondary CVD prevention. Lavie et al[4] al...

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    Conflict of Interest:
    None declared.
  • Published on:
    Cardiac Rehabilitation Effectiveness? *A commentary from the International Council of Cardiovascular Prevention and Rehabilitation
    • John P Buckley, Professor Applied Exercise Science International Council of Cardiovascular Prevention and Rehabilitation (Past Chair, UK)
    • Other Contributors:
      • Aashish Contractor, Rehabilitation Physician
      • Gabriela Ghisi, Post Doctoral Fellow Kinesiology and Health Sciences
      • Colin Yeung, Physician Cardiology
      • Sherry L Grace, Professor Kinesiology and Health Sciences

    In the January 2018 issue of BMJ Open, Powell et al. published a well-performed systematic review/meta-analyses, which pointedly challenges the effectiveness of cardiac rehabilitation (CR) (2). Our commentary to follow is forwarded with respect for the quality of this study, but we challenge how they chose to define the term “effective” CR. We focus on three areas of concern in relation to this article:

    i. the value of mortality as the key metric for judging effectiveness;

    ii. the lack of analysis of exercise participation (compliance/adherence) which impacts on aerobic fitness as probably the single most important exercise component outcome linked with morbidity and mortality, and

    i. the value of CR and lifestyle interventions in developing countries who do not yet have well-structured, aggressive and modern medical approaches to preventing or treating coronary heart disease.

    Mortality Metric
    It would have been more fitting if this article were titled: Does exercise-based cardiac rehabilitation still lead to reduced mortality and (re) hospitalisation? To suggest it is not effective is a bit of an over-generalisation. Over the past four decades CR’s effectiveness has been assessed across numerous outcomes bio-medically, psychosocially and health-economically. Granted, this most recent review has added to an evolving picture that since the first systematic reviews by Oldridge et al. and O’Connor et al in the 1980s (1, 3) the impact of ex...

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    Conflict of Interest:
    None declared.