Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction

Doll, Jacob A.; Hellkamp, Anne S.; Thomas, Laine; Ho, P. Michael; Kontos, Michael C.; Whooley, Mary A.; Boyden, Thomas F.; Peterson, Eric D.; Wang, Tracy Y.

doi:10.1016/j.ahj.2015.08.001

Cited by 74 publications

(49 citation statements)

References 21 publications

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“…Consequently, good exercise adherence could be considered a marker for adherence to other positive health behaviours which may also decrease the risk of mortality and clinical events. This has been previously observed by others, with increased attendance at on-site cardiac rehabilitation sessions related not only to reductions in all-cause mortality, re-admissions and major events, but also to greater improvements in clinical risk profile and secondary prevention behaviours such as medication and dietary adherence [128, 129]. Additionally, some ‘clustering’ of good lifestyle behaviours (diet, exercise, smoking cessation) was observed in survivors of MI, where increased adherence led to a decrease in mortality, myocardial infarction and stroke [130].…”

Section: Discussionsupporting

confidence: 58%

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

2017

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BackgroundWhile the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease.MethodsIn this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome.ResultsSixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy (I 2 = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047).ConclusionsE...

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Section: Discussionsupporting

confidence: 58%

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

2017

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“…Whereas in Eastern Europe and Central Europe, except Austria and Germany where outpatient CR is becoming more common, a short in-patient CR setting has emerged, most other European countries contrast with the tradition of the out-patient setting, which in general is offered over a longer period. The best scientific evidence of improvement in morbidity and mortality in the literature is found for programmes with more sessions and longer duration [16]. Therefore prompted by ECRIS and now by EuroCaReD, across Europe consensus should be found in future on programme content and duration, as well as on patient characteristics for each CR setting.…”

Section: Heterogeneity Of Cr Programme Delivery Across European Countmentioning

confidence: 99%

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry

Benzer¹,

Rauch

Schmid

et al. 2017

International Journal of Cardiology

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Aim:Results from EuroCaReD study should serve as a benchmark to improve guideline adherence and treatment quality of cardiac rehabilitation (CR) in Europe. Methods and results: Data from 2.054 CR patients in 12 European countries were derived from 69 centres. 76% were male. Indication for CR differed between countries being predominantly ACS in Switzerland (79%), Portugal (62%) and Germany (61%), elective PCI in Greece (37%), Austria (36%) and Spain (32%), and CABG in Croatia and Russia (36%). A minority of patients presented with chronic heart failure (4%). At CR start, most patients already were under medication according to current guidelines for the treatment of CV risk factors. A wide range of CR programme designs was found (duration 3 to 24 weeks; total number of sessions 30 to 196). Patient programme adherence after admission was high (85%). With reservations that eCRF follow-up data exchange remained incomplete, patient CV risk profiles experienced only small improvements. CR success as defined by an increase of exercise capacity N 25 W was significantly higher in young patients and those who were employed. Results differed by countries. After CR only 9% of patients were admitted to a structured post-CR programme. Conclusions: Clinical characteristics of CR patients, indications and programmes in Europe are different. Guideline adherence is poor. Thus, patient selection and CR programme designs should become more evidence-based. Routine eCRF documentation of CR results throughout European countries was not sufficient in its first application because of incomplete data exchange. Therefore better adherence of CR centres to minimal routine clinical standards is requested.

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“…Relevant important covariates were included in the analysis. Age (years), gender (male/female) and number of comorbidities have both been shown to influence the outcomes following a variety of different interventions, including CR [17], [18] The duration of CR (length of core rehabilitation) was accounted for in analysis. The type of event/treatment prior to CR is likely to affect the patients' outcomes, to account for this variation patients were coded as medically managed or re-vascularised as shown in the NACR statistics report [6]. The IMD was calculated and ranked, from the most deprived to the least deprived regions, at for all 209 clinical commissioning groups and was included in this analysis [19].…”

Section: Methodsmentioning

confidence: 99%

Relationship between employment and mental health outcomes following Cardiac Rehabilitation: an observational analysis from the National Audit of Cardiac Rehabilitation

Harrison

Sumner

McMillan

et al. 2016

International Journal of Cardiology

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BackgroundEmployment status has been shown to impact mental health state and intervention outcomes, yet still to be studied in a Cardiac Rehabilitation (CR) population. This observational study investigated the relationship between employment status and mental health outcomes following Cardiac Rehabilitation (CR).MethodsAll patients with an eligible cardiovascular incident entered into the National Audit of Cardiac Rehabilitation (NACR) 1 January 2013–31st December 2015. Logistic regression comparing the association between employment status and normal mental health categories.ResultsA total of 24,242 CR patients with completed post CR assessments were included and had representative age and gender distribution (mean 65 years, 73.2% male). At baseline the unemployed status had a lower proportion of patients in normal healthy categories than other groups (T-test and chi-squared p = < 0.05). The regression analyses revealed no significant association between retired and employed groups and outcome. There was significant association between unemployed patients and all mental health outcomes except anxiety; all p values < 0.05 and odds ratios between 0.525 and 0.772 showing less likelihood of achieving the normal healthy category.ConclusionsThis is the first UK study, using routinely collected data, to investigate in coronary heart disease patients the impact of employment status on outcomes. The findings were that when weighted for baseline differences, unemployed patients mostly had poorer outcomes. Teams involved in CR delivery should take particular care when interpreting mental health baseline measures when setting CR goals, especially in relation to unemployed patients, and efforts should be made in providing more patient tailored interventions.

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Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction

Cited by 74 publications

References 21 publications

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry

Relationship between employment and mental health outcomes following Cardiac Rehabilitation: an observational analysis from the National Audit of Cardiac Rehabilitation

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