The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies – The Cardiac Rehabilitation Outcome Study (CROS)

Abstract

BackgroundThe prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.DesignStructured review and meta-analysis.MethodsRandomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.ResultsOut of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; rCCS: HR 0.64, 95% CI 0.49–0.84; odds ratio 0.20, 95% CI 0.08–0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54–0.70) and in mixed CAD populations.ConclusionsCR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

Impact of cardiac rehabilitation and exercise training programs in coronary heart disease

“…95 In a large population-based surveillance study from the RCTs included in this study did not specify whether the hospital admissions were recurrent hospitalizations or first-time admissions and the trend for improvement in hospital readmissions was inconsistent as other studies failed to observe any benefit of CR. This is especially true when more recent trials and observational studies were included, 96 confirming the notion that optimal medical management and early intervention may have a major impact on reducing recurrent hospitalizations in CHD. In contrast, the benefit of CR in reducing hospitalization has been shown for HF patients, which is reviewed in another section.…”

“…A large meta-analysis of 25 randomized and nonrandomized studies from 1995 onward evaluating 219,702 patients supported the benefit of CR in overall mortality reduction in patients who were post-acute coronary syndrome, post-CABG, and in mixed CHD populations. 96 A trend in favor of CR in the reduction of major CVD and cerebrovascular events was also observed. 96 In a recent Cochrane review and meta-analysis of 63 RCTs between 1970 and 2014, including 14,486 CHD patients, CR was associated with an absolute risk reduction for CVD mortality from 10.4% to 7.6%.…”

“…96 A trend in favor of CR in the reduction of major CVD and cerebrovascular events was also observed. 96 In a recent Cochrane review and meta-analysis of 63 RCTs between 1970 and 2014, including 14,486 CHD patients, CR was associated with an absolute risk reduction for CVD mortality from 10.4% to 7.6%. 97 However, no difference in all-cause mortality between CR and conventional care was observed.…”

“…2,98 A lack of benefit in the prevention of recurrent non-fatal MI in the CR group was reported by others. 96,97 It was suggested that this was due to the conversion of fatal to non-fatal MIs, thereby decreasing mortality rates once CR was incorporated into routine cardiac care.…”

A Review of Cardiac Rehabilitation Delivery Around the World

“…Many meta-analyses demonstrate that participation in CR is associated with improved quality of life, as well as decreased morbidity and mortality [4][5][6][7] . CR is also cost-effective 8 .…”