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

Sports Medicine - Open, May 2017

Background While 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. Methods In 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. Results Sixty-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). Conclusions Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://link.springer.com/content/pdf/10.1186%2Fs40798-017-0086-z.pdf

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

Abell et al. Sports Medicine - Open The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression Bridget Abell 0 Paul Glasziou 0 Tammy Hoffmann 0 0 Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University , Gold Coast, Queensland 4229 , Australia Background: While 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. Methods: In 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. (Continued on next page) - (Continued from previous page) Key Points Exercise-based cardiac rehabilitation interventions demonstrate considerable heterogeneity in format, yet few individual exercise training components predict better or worse clinical outcomes. Adherence to the exercise intervention as prescribed may however be important in affecting mortality outcomes. Clinicians should be aware that structured exercise programs can be flexible in design, without greatly impacting on the clinical outcomes expected. Results Trial Selection Sixty-eight publications [34–101] met our inclusion criteria (see Fig. 1 for PRISMA flow chart), reporting on clinical outcomes and follow-up of 69 different trials (one publication [98] reported outcomes of a collaborative study which involved several individual trial centres). Several trials included multiple intervention arms [39, 71, 72, 87] resulting in a total of 72 individual exercise interventions. characteristic of session time, session frequency or exercise intensity. Hence, while these trials and interventions are included in the overall meta-analysis, they could not be entered into the meta-regression where these covariates were missing. Prescribed Exercise Intervention Dose, Intensity and Adherence Across all interventions (missing for 21 interventions), participants were reported to begin exercise training a mean of 4.8 weeks (SD 2.8) after the initial diagnosis or cardiac incident. The prescribed ‘dose’ of exercise training in these interventions varied widely (Table 2). The median to g ) n isc rs d ild tu iin e a to re iif m b ra b c a c y ty t h fa c e il i e it k la sp ad itv is w irs o m w (n so o c rae ;)d on d icg re fro lca rxe rae no c ie d ra lo th a e c lsauU ifscep irtaen taSnd ircaod (tono icved isych ivod lsau icved A p a U a V A C C I M En [5 : a e ta d e y -b th ts rte su tud lien cao ing % op itn fs e m d 7 re ta o iud rah lcu r9 to so rae G p in fo N n y a ileen caom ingd 7% ilen a o e co ts id ra lu 9 id ram tn u h c r u h u G p in fo G p b re s e isc rs ilca n irsce isc rs ab tco e n log o x ab tcao rko th fa sam ito io ice ed th f w r re n rn h o rd it t a o tu c y a c la ice xe ra d w fca la ice re sn itt in % a d rs ito s ud 07> ed ap ye : y a ca up lcn ro rt r i o i o e p ed rg lly fs ep th -u r n w y llm toh auq ittan to itta llo ud A b e s N s fo ts V A C C n o s itsnn aengb lira ittsan itenon ssaeum sa itsanp rsad a t o rv ic w ip rm ng .)N te :d yp rta on irtc a ir % in rte ra p 4 a re ud 60 in o e p ca s p th ted 200 Seom lsauu ittsan (tuop rttsaed .ram rteoN ittsan irrceu from ilca tn i)tsg iican R g e o s d C lo n uq ilo y ed lra io io e d hp iv i d t r r r f a fo ro im ca ica ,t c p s re s V A C C ad (n th no inng raen iton ten e tcoh ittsan cao ;ed in a en sa iln a o ram iru eg lca rve itn ied ram tn Ph req tab suu itn tsa u h u G p b su e su e sa ud sa ud sed ryap tsn sn : : ap it e s d e s d ab teh iic ts d e y d e y a rt u tu rt u tu o rt op itn fs op itn fs lien ca ap ing 0% re ta o re ta o e m ll d 9 to so rae to so rae iud rah ra lcu r> N n y N n y G p fo in fo I U v e e t t a a r r e e h d h d h h ig o ig o ig ig d e t a ic g d ~ T d T T T T T T T T re T T T T T T T E p E E E E E E E c T T T T T T ) T T T T T T d E E E E E E e x x x x x x a a a a a a d e t a ic g d ~ T d T T T T T T T T re T T T T T T T E p E E E E E E E n a i c rseu lth isyh lth lth lth n ae p ae n n ae ae d h d h ia ia h h an d an d isc isc d se d H llie H llie yh yh llie ru llie – – – 8 8 8 sc M p Publication Bias and Quality Assessment Publication Bias The funnel plot for the primary outcome of cardiovascular mortality did not suggest asymmetry or publication bias (Additional file 1: Figure S4a). Similarly, evidence of publication bias was not observed for the outcomes of total mortality, myocardial infarction or CABG. The funnel plot for the PCI outcome however displayed possible asymmetry, suggesting the absence of small studies with favourable effects from the analysis (Additional file 1: Figure S4b). Additional file 1: Table S7c), and no evidence of heterogeneity was observed (I2 = 0%). Future Questions It appears obvious that structured exercise training has clear benefits over usual care, even when this includes Additional file Additional file 1: Supplementary Material 1. (DOCX 131 kb) Acknowledgements The authors wish to thank Sarah Thorning (Medical Librarian, Centre for Research in Evidence-Based Practice, Bond University, QLD, Australia) for the assistance with designing search strategies for this study and Elaine Beller (Statistician, Centre for Research in Evidence-Based Practice, Bond University, Queensland, Australia) for the statistical consultation. We also kindly thank all authors of the included trials who responded to our requests for intervention descriptions or data. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. BA is supported by an Australian Postgraduate Award funded by the Australian Federal Government. PG is supported by the National Health and Medical Research Council Research GNT1080042. Authors’ Contributions BA contributed to the conception of the idea, study planning, collection, analysis and interpretation of the data and writing of the manuscript. PG contributed to the conception of the idea, study planning, interpretation of the data and critical revision of the manuscript. TH contributed to the study planning, interpretation of the data and critical revision of the manuscript. All authors read and approved the final manuscript. Competing Interests Bridget Abell, Paul Glasziou and Tammy Hoffmann declare no financial relationships or conflicts of interest which may have influenced the results of this research. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1. Finegold JA , Asaria P , Francis DP . Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations . Int J Cardiol . 2013 ; 168 : 934 - 45 . 2. Australian Institute of Health and Welfare. Australia's health 2014 . Australia's health series no . 14. Cat. no. AUS 178. Canberra: AIHW ; 2014 . 3. Briffa TG , Hobbs MS , Tonkin A , Sanfilippo FM , Hickling S , Ridout SC , et al. Population trends of recurrent coronary heart disease event rates remain high . Circ Cardiovasc Qual Outcomes . 2011 ; 4 : 107 - 13 . 4. Kerr AJ , Broad J , Wells S , Riddell T , Jackson R. Should the first priority in cardiovascular risk management be those with prior cardiovascular disease? Heart . 2009 ; 95 : 125 - 9 . 5. Motivala A , Tamhane U , Ramanath VS , Saab F , Montgomery DG , Fang J , et al. A prior myocardial infarction: how does it affect management and outcomes in recurrent acute coronary syndromes? Clin Cardiol . 2008 ; 31 : 590 - 6 . 6. Redfern J , Hyun K , Chew DP , Astley C , Chow C , Aliprandi-Costa B , et al. Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand . Heart. 2014 ; 100 : 1281 - 1 . 7. Nieuwlaat R , Schwalm J-D , Khatib R , Yusuf S. Why are we failing to implement effective therapies in cardiovascular disease ? Eur Heart J . 2013 ; 34 : 1262 - 9 . 8. Anderson L , Oldridge N , Thompson DR , Zwisler A-D , Rees K , Martin N , et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis . J Am Coll Cardiol . 2016 ; 67 : 1 - 12 . 9. Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited . Future Cardiol . 2012 ; 8 : 729 - 51 . 10. Brown A , Taylor R , Noorani H , Stone J , Skidmore B. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systematic clinical and economic review, Technol . Rep. no 34. Ottawa: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2003. 11. Abell B , Glasziou P , Hoffmann T. Reporting and replicating trials of exercisebased cardiac rehabilitation: do we know what the researchers actually did? Circ Cardiovasc Qual Outcomes . 2015 ; 8 : 187 - 94 . 12. Clark AM , Hartling L , Vandermeer B , McAlister FA . Meta-analysis: secondary prevention programs for patients with coronary artery disease . Ann Intern Med . 2005 ; 143 : 659 - 72 . 13. Anderson L , Taylor RS . Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews . Cochrane Database Syst Rev . 2014 ; 12 :CD011273. 14. Thompson SG , Higgins JPT . Treating individuals 4: can meta-analysis help target interventions at individuals most likely to benefit? Lancet . 2005 ; 365 : 341 - 6 . 15. Taylor RS , Brown A , Ebrahim S , Jolliffe J , Noorani H , Rees K , et al. Exercisebased rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials . Am J Med . 2004 ; 116 : 682 - 92 . 16. Clark AM , Hartling L , Vandermeer B , Lissel SL , McAlister FA . Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions . Eur J Cardiovasc Prev Rehabil . 2007 ; 14 : 538 - 46 . 17. Ashor AW , Lara J , Siervo M , Celis-Morales C , Oggioni C , Jakovljevic DG , et al. Exercise modalities and endothelial function: a systematic review and dose-response meta-analysis of randomized controlled trials . Sport Med . 2015 ; 45 : 279 - 96 . 18. Uddin J , Zwisler A-D , Lewinter C , Moniruzzaman M , Lund K , Tang LH , et al. Predictors of exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure: a meta-regression analysis . Eur J Prev Cardiol . 2016 ; 23 : 683 - 93 . 19. Hoffmann TC , Glasziou PP , Boutron I , Milne R , Perera R , Moher D , et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide . BMJ . 2014 ; 348 :g1687. 20. Kip KE , Hollabaugh K , Marroquin OC , Williams DO . The problem with composite end points in cardiovascular studies: the story of major adverse cardiac events and percutaneous coronary intervention . J Am Coll Cardiol . 2008 ; 51 : 701 - 7 . 21. Ferreira-González , Ignacio Montori VM , Busse JW , Schünemann, Holger J. Jaeschke R , Deveraux P , Permanyer-Miralda G , Guyatt G. Chapter 12.4: Composite end points . Users' Guid. to Med. Lit. A Man. evidence-based Clin. Pract . 3rd ed . New York : McGraw-Hill Education ; 2015 . 22. Higgins JPT , Altman DG , Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies . In: Higgins JPT, Green S, editors. Cochrane Handb. Syst. Rev. Interv. Version 5.1.0 (updated March 2011 ). The Cochrane Collaboration; 2011 . p. www.handbook.cochrane.org. 23. Higgins JPT , Deeks JJ , Altman DG , (editors). Chapter 16 : Special topics in statistics . In: Higgins JPT, Green S, editors. Cochrane Handb. Syst. Rev. Interv. version 5.1.0 (updated March 2011 ). The Cochrane Collaboration; 2011 . p. www.handbook.cochrane.org. 24. Akl EA , Kahale LA , Agoritsas T , Brignardello-Petersen R , Busse JW , CarrascoLabra A , et al. Handling trial participants with missing outcome data when conducting a meta-analysis: a systematic survey of proposed approaches . Syst Rev . 2015 ; 4 : 98 . 25. Akl EA , Johnston BC , Alonso-Coello P , Neumann I , Ebrahim S , Briel M , et al. Addressing dichotomous data for participants excluded from trial analysis: a guide for systematic reviewers . PLoS One . 2013 ; 8 : e57132 . 26. World Health Organization. Global recommendations on physical activity for health . Geneva: World Heath Organisation ; 2010 . 27. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand . Reducing risk in heart disease: an expert guide to clinical practice for secondary prevention of coronary heart disease . Melbourne: National Heart Foundation of Australia; 2012 . 28. Janssen V , De Gucht V , Dusseldorp E , Maes S. Lifestyle modification programmes for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials . Eur J Prev Cardiol . 2013 ; 20 : 620 - 40 . 29. Clark AM , Redfern J , Briffa T. Cardiac rehabilitation: fit to face the future? Heart . 2014 ; 100 : 355 - 6 . 30. Weisfeldt ML , Zieman SJ . Advances in the prevention and treatment of cardiovascular disease . Health Aff . 2007 ; 26 : 25 - 37 . 31. Harbord RM , Higgins JPT. Meta-regression in Stata . Stata J . 2008 ; 8 : 493 - 519 . 32. Fletcher GF , Balady GJ , Amsterdam EA , Chaitman B , Eckel R , Fleg J , et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association . Circulation. 2001 ; 104 : 1694 - 740 . 33. Norton K , Norton L , Sadgrove D. Position statement on physical activity and exercise intensity terminology . J Sci Med Sport . 2010 ; 13 : 496 - 502 . 34. Albus C , Theissen P , Hellmich M , Griebenow R , Wilhelm B , Aslim D , et al. Long-term effects of a multimodal behavioral intervention on myocardial perfusion-a randomized controlled trial . Int J Behav Med . 2009 ; 16 : 219 - 26 . 35. Andersen GS , Christiansen P , Madsen S , Schmidt G. Value of regular supervised physical training after acute myocardial infarction . Ugeskr Laeger . 1981 ; 143 : 2952 - 5 . 36. Aronov DM , Krasnitskiĭ VB , Bubnova MG , Pozdniakov IM , Ioseliani DG , Shchegol'kov AN , et al. Physical training at ambulatory-polyclinical stage in complex rehabilitation and secondary prevention of patients with ischemic heart disease after acute incidents . Effect on physical working capacity , hemodynamics, blood lipids, clinical course and prognosis (Russian cooperative study) . Kardiologiia . 2009 ; 49 : 49 - 56 . 37. Belardinelli RB , Paolini P , Cianci GCG , Piva RPR , Solenghi MSM . The efficacy of exercise training after coronary angioplasty: the ETICA trial . Eur Heart J . 2001 ; 22 : 200 . 38. Belardinelli R , Lacalaprice F , Cianci G , Piva R , Purcaro A. Abstract 3793: Exercise Training Intervention After Coronary Angioplasty (The ETICA Trial): ten-year followup . Am. Hear. Assoc. Sci. Sess. Orlando, Florida: Circulation; 2007 ; 116 (Suppl 16): 862 . 39. Bell J. A comparison of a multi-disciplinary home based cardiac rehabilitation programme with comprehensive conventional rehabilitation in post-myocardial infarction patients . ( PhD Thesis ) (University of London). London: University of London; 1998 . 40. Bengtsson K. Rehabilitation after myocardial infarction. A controlled study . Scand J Rehabil Med . 1983 ; 15 : 1 - 9 . 41. Bertie J , King A , Reed N , Marshall AJ , Ricketts C. Benefits and weaknesses of a cardiac rehabilitation programme . J R Coll Physicians Lond . 1992 ; 26 : 147 - 51 . 42. Bethell HJ , Mullee MA. A controlled trial of community based coronary rehabilitation . Br Heart J . 1990 ; 64 : 370 - 5 . 43. Blumenthal JA , Sherwood A , Babyak MA , Watkins LL , Waugh R , Georgiades A , et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease . JAMA . 2005 ; 293 : 1626 - 34 . 44. Briffa TG , Eckermann SD , Griffiths AD , Harris PJ , Heath MR , Freedman SB , et al. Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial . Med J Aust . 2005 ; 183 : 450 - 5 . 45. Byrkjeland R , Njerve IU , Anderssen S , Arnesen H , Seljeflot I , Solheim S. Effects of exercise training on HbA1c and VO2peak in patients with type 2 diabetes and coronary artery disease: a randomised clinical trial . Diab Vasc Dis Res . 2015 ; 12 : 325 - 33 . 46. Carlsson R. Serum cholesterol, lifestyle, working capacity and quality of life in patients with coronary artery disease . Experiences from a hospital-based secondary prevention programme . Scand Cardiovasc J . 1998 ; 32 : 1 - 20 . 47. Carson P , Phillips R , Lloyd M , Tucker H , Neophytou M , Buch N , et al. Exercise after myocardial infarction: a controlled trial . J R Coll Physicians Lond . 1982 ; 16 : 147 - 51 . 48. DeBusk RF , Miller NH . Superko R , Dennis C a , Thomas RJ , Lew HT , et al. A case-management system for coronary risk factor modification after acute myocardial infarction . J Cardiopulm Rehabil . 1994 ; 14 : 407 - 8 . 49. Dugmore LD , Tipson RJ , Phillips MH , Flint EJ , Stentiford NH , Bone MF , et al. Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme . Heart . 1999 ; 81 : 359 - 66 . 50. Engblom E , Ronnemaa T , Hämäläinen H , Kallio V , Vanttinen E , Knuts LR. Coronary heart disease risk factors before and after bypass surgery: results of a controlled trial on multifactorial rehabilitation . Eur Heart J . 1992 ; 13 : 232 - 7 . 51. Engblom E , Korpilahti K , Hämäläinen H , Rönnemaa T , Puukka P. Quality of life and return to work 5 years after coronary artery bypass surgery: long-term results of cardiac rehabilitation . J Cardiopulm Rehabil Prev . 1997 ; 17 : 29 - 36 . 52. Erdman R , Duivenvoorden H , Verhage F , Kazemier M , Hugenholtz P. Predictability of beneficial effects in cardiac rehabilitation: a randomized clinical trial of psychosocial variables . J Cardiopulm Rehabil . 1986 ; 6 : 206 - 13 . 53. Ferreira N. , Fontes-Carvalho R , Sousa O , Silva G , Fonseca M , Sampaio F , et al. Effect of a cardiovascular rehabilitation program on exercise capacity and left ventricular diastolic function after an acute coronary syndrome: experience from a randomized, controlled study . Eur Heart J . 2010 ; 31(suppl_1):xiv-xix . 54. Fletcher BJ , Dunbar SB , Felner JM , Jensen BE , Almon L , Cotsonis G , et al. Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease . Am J Cardiol . 1994 ; 73 : 170 - 4 . 55. Fontes-Carvalho R , Azevedo AI , Sampaio F , Teixeira M , Bettencourt N , Campos L , et al. The effect of exercise training on diastolic and systolic function after acute myocardial infarction: a randomized study . Medicine (Baltimore) . 2015 ; 94 :e1450. 56. Fridlund B , Pihlgren C , Wannestig L. A supportive-educative caring rehabilitation programme; improvements of physical health after myocardial infarction . J Clin Nurs . 1992 ; 1 : 141 - 6 . 57. Lidell E , Fridlund B. Long-term effects of a comprehensive rehabilitation programme after myocardial infarction . Scand J Caring Sci . 1996 ; 10 : 67 - 74 . 58. Giallauria F , Cirillo P , Lucci R , Pacileo M , De Lorenzo A , D'Agostino M , et al. Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide . Eur J Cardiovasc Prev Rehabil . 2008 ; 15 : 113 - 8 . 59. Håglin L , Lundström S , Kaati G , Bäckman L , Bygren LO . All-cause mortality of patients with dyslipidemia up to 19 years after a multidisciplinary lifestyle modification programme: a randomized trial . Eur J Cardiovasc Prev Rehabil . 2011 ; 18 : 79 - 85 . 60. Haskell WL , Alderman EL , Fair JM , Maron DJ , Mackey SF , Superko HR , et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease . The Stanford Coronary Risk Intervention Project (SCRIP). Circulation . 1994 ; 89 : 975 - 90 . 61. Hofman-Bang C , Lisspers J , Nordlander R , Nygren A , Sundin O , Ohman A , et al. Two-year results of a controlled study of residential rehabilitation for patients treated with percutaneous transluminal coronary angioplasty. A randomized study of a multifactorial programme . Eur Heart J . 1999 ; 20 : 1465 - 74 . 62. Lisspers J , Sundin O , Ohman A , Hofman-Bang C , Rydén L , Nygren A. Longterm effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention . Health Psychol . 2005 ; 24 : 41 - 8 . 63. Holmbäck AM , Sawe U , Fagher B. Training after myocardial infarction: lack of long-term effects on physical capacity and psychological variables . Arch Phys Med Rehabil . 1994 ; 75 : 551 - 4 . 64. Kallio V , Hämäläinen H. Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction . Lancet . 1979 ; 314 : 1091 - 4 . 65. Hämäläinen H , Luurila O , Kallio V , Knuts LR . Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. 15- year follow-up study . Eur Heart J . 1995 ; 16 : 1839 - 44 . 66. Kovoor P , Lee AKY , Carrozzi F , Wiseman V , Byth K , Zecchin R , et al. Return to full normal activities including work at two weeks after acute myocardial infarction . Am J Cardiol . 2006 ; 97 : 952 - 8 . 67. Krasnitskiĭ VB , Sechenova EV , Bubnova MG , Aronov DM , Ioseliani DG . The use of a short program of physical training in patients with ischemic heart disease after endovascular (coronary) interventions in complex program of rehabilitation and secondary prevention at dispensary-ambulatory stage . Kardiologiia . 2010 ; 50 : 27 - 34 . 68. La Rovere MT , Bersano C , Gnemmi M , Specchia G , Schwartz PJ . Exerciseinduced increase in baroreflex sensitivity predicts improved prognosis after myocardial infarction . Circulation . 2002 ; 106 : 945 - 9 . 69. Lear SA , Singer J , Banner-Lukaris D , Horvat D , Park JE , Bates J , et al. Randomized trial of a virtual cardiac rehabilitation program delivered at a distance via the Internet . Circ Cardiovasc Qual Outcomes . 2014 ; 7 : 952 - 9 . 70. Leizorovic A. Comparison of a Rehabilitation Program, a Counseling Program and Usual Care After an Acute Myocardial-Infarction-Results of a Long-Term Randomized Trial (PRECOR Group) . Eur Heart J . 1991 ; 12 : 612 - 6 . 71. Marchionni N , Fattirolli F , Fumagalli S , Oldridge N , Del Lungo F , Morosi L , et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial . Circulation . 2003 ; 107 : 2201 - 6 . 72. Miller NH , Haskell WL , Berra K , DeBusk RF . Home versus group exercise training for increasing functional capacity after myocardial infarction . Circulation . 1984 ; 70 : 645 - 9 . 73. Maroto Montero JM , de Pable ZC , Morales Duran MD , Artigao RR . [Heart rehabilitation. Cost-effectiveness analysis] . Rev Esp Cardiol . 1996 ; 49 : 753 - 8 . 74. Maroto Montero JM , Artigao Ramírez R , Morales Durán MD , de Pablo ZC , Abraira V , Artigao Ramirez R , et al. Cardiac rehabilitation in patients with myocardial infarction: a 10-year follow-up study . Rev Esp Cardiol . 2005 ; 58 : 1181 - 7 . 75. Munk PS , Staal EM , Butt N , Isaksen K , Larsen AI . High-intensity interval training may reduce in-stent restenosis following percutaneous coronary intervention with stent implantation. A randomized controlled trial evaluating the relationship to endothelial function and inflammation . Am Heart J . 2009 ; 158 : 734 - 41 . 76. Mutwalli HA , Fallows SJ , Arnous AA , Zamzami MS . Randomized controlled evaluation shows the effectiveness of a home-based cardiac rehabilitation program . Saudi Med J . 2012 ; 33 : 152 - 9 . 77. Oerkild B , Frederiksen M , Hansen JF , Simonsen L , Skovgaard LT , Prescott E. Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial . BMJ Open . 2012 ; 2 : e001820 . 78. Oldridge N , Guyatt G , Jones N , Crowe J , Singer J , Feeny D , et al. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction . Am J Cardiol . 1991 ; 67 : 1084 - 9 . 79. Ornish D , Brown S , Scherwitz L , Billings JH , Armstrong WT , Ports T , et al. Can lifestyle changes reverse coronary heart disease? Lancet . 1990 ; 336 : 129 - 33 . 80. Ornish D , Scherwitz LW , Billings JH , Brown SE , Gould KL , Merritt TA , et al. Intensive lifestyle changes for reversal of coronary heart disease . JAMA . 1998 ; 280 : 2001 - 7 . 81. Reid RD , Morrin LI , Beaton LJ , Papadakis S , Kocourek J , McDonnell L , et al. Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease . Eur J Prev Cardiol . 2012 ; 19 : 1357 - 64 . 82. Román O , Gutierrez M , Luksic I , Chavez E , Camuzzi A , Villalón E , et al. Cardiac rehabilitation after acute myocardial infarction. 9-year controlled follow-up study . Cardiology . 1983 ; 70 : 223 - 31 . 83. Schuler G , Hambrecht R , Schlierf G , Niebauer J , Hauer K , Neumann J , et al. Regular physical exercise and low-fat diet. Effects on progression of coronary artery disease . Circulation . 1992 ; 86 : 1 - 11 . 84. Niebauer J , Hambrecht R , Velich T , Hauer K , Marburger C , Kalberer B , et al. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise . Circulation . 1997 ; 96 : 2534 - 41 . 85. Shaw LW . Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after myocardial infarction . The National Exercise and Heart Disease Project. Am J Cardiol . 1981 ; 48 : 39 - 46 . 86. Dorn J , Naughton J , Imamura D , Trevisan M. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). Circulation . 1999 ; 100 : 1764 - 9 . 87. Sivarajan ES , Bruce RA , Lindskog BD , Almes MJ , Belanger L , Green B. Treadmill test responses to an early exercise program after myocardial infarction: a randomized study . Circulation . 1982 ; 65 : 1420 - 8 . 88. Specchia G , De Servi S , Scire A , Assandri J , Berzuini C , Angoli L , et al. Interaction between exercise training and ejection fraction in predicting prognosis after a first myocardial infarction . Circulation . 1996 ; 94 : 978 - 82 . 89. Ståhle A , Mattsson E , Rydén L , Unden A , Nordlander R. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. A 1 year follow-up randomized controlled study . Eur Heart J . 1999 ; 20 : 1475 - 84 . 90. Hage C , Mattsson E , Stahle A. Long-term effects of exercise training on physical activity level and quality of life in elderly coronary patients-a threeto six-year follow-up . Physiother Res Int . 2003 ; 8 : 13 - 22 . 91. Stern MJ , Gorman PA , Kaslow L. The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction . Arch Intern Med . 1983 ; 143 : 1719 - 25 . 92. Toobert DJ , Glasgow RE , Radcliffe JL . Physiologic and related behavioral outcomes from the Women's Lifestyle Heart Trial . Ann Behav Med . 2000 ; 22 : 1 - 9 . 93. Vecchio C , Cobelli F , Opasich C , Assandri J , Poggi G , Griffo R. Early functional evaluation and physical rehabilitation in patients with wide myocardial infarction [Valutazione funzionale precoce e riabilitazione fisica nei pazienti con infarto miocardico esteso] . G Ital Cardiol . 1981 ; 11 : 419 - 29 . 94. Vermeulen A , Lie K , Durrer D. Effects of cardiac rehabilitation infarction: changes in coronary long-term prognosis after myocardial risk factors and . Am Heart J . 1983 ; 105 : 798 - 801 . 95. The Vestfold Heartcare Study Group. Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease . Eur J Cardiovasc Prev Rehabil . 2003 ; 10 : 429 - 37 . 96. Wang W , Chair SY , Thompson DR , Twinn SF . Effects of home-based rehabilitation on health-related quality of life and psychological status in Chinese patients recovering from acute myocardial infarction . Hear Lung . 2012 ; 41 : 15 - 25 . 97. West RR , Jones DA , Henderson AH . Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction . Heart . 2012 ; 98 : 637 - 44 . 98. World Health Organisation. Rehabilitation and comprehensive secondary prevention after acute myocardial infarction. Report on a study . EURO Rep . Stud. Copenhagen; 1983 ; 84 : 1 - 99 . 99. Wilhelmsen L , Sanne H , Elmfeldt D , Grimby G , Tibblin G , Wedel H. A controlled trial of physical training after myocardial infarction . Effects on risk factors , nonfatal reinfarction, and death. Prev Med (Baltim) . 1975 ; 4 : 491 - 508 . 100. Yu C-M , Lau C-P , Chau J , McGhee S , Kong S-L , Cheung BM-Y , et al. A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention . Arch Phys Med Rehabil . 2004 ; 85 : 1915 - 22 . 101. Zwisler A-DO , Soja AMB , Rasmussen S , Frederiksen M , Abadini S , Appel J , et al. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial . Am Heart J . 2008 ; 155 : 1106 - 13 . 102. Lawler PR , Filion KB , Eisenberg MJ . Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and metaanalysis of randomized controlled trials . Am Heart J . 2011 ; 162 : 571 - 84 . e2. 103. O'Connor GT , Buring JE , Yusuf S , Goldhaber SZ , Olmstead EM , Paffenbarger Jr RS , et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction . Circulation . 1989 ; 80 : 234 - 44 . 104. Hevey D , Brown A , Cahill A , Newton H , Kierns M , Horgan JH . Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program . J Cardiopulm Rehabil Prev . 2003 ; 23 : 17 - 21 . 105. Dressendorfer RH , Franklin BA , Cameron JL , Trahan KJ , Gordon S , Timmis GC. Exercise training frequency in early post-infarction cardiac rehabitation: influence on aerobic conditioning . J Cardiopulm Rehabil Prev . 1995 ; 15 : 269 - 76 . 106. Worcester MC , Hare DL , Oliver RG , Reid MA , Goble AJ . Early programmes of high and low intensity exercise and quality of life after acute myocardial infarction . BMJ . 1993 ; 307 : 1244 - 7 . 107. Hansen D , Dendale P , Berger J , Onkelinx S , Reyckers I , Hermans A , et al. Importance of exercise training session duration in the rehabilitation of coronary artery disease patients . Eur J Cardiovasc Prev Rehabil . 2008 ; 15 : 453 - 9 . 108. Kugler J , Dimsdale JE , Hartley LH , Sherwood J. Hospital supervised vs home exercise in cardiac rehabilitation: effects on aerobic fitness , anxiety, and depression. Arch Phys Med Rehabil . 1990 ; 71 : 322 - 5 . 109. LaHaye SA , Lacombe SP , Koppikar S , Lun G , Parsons TL , Hopkins-Rosseel D. High and low contact frequency cardiac rehabilitation programmes elicit similar improvements in cardiorespiratory fitness and cardiovascular risk factors . Eur J Prev Cardiol . 2014 ; 21 : 1456 - 64 . 110. Farias-Godoy A. Design , implementation and evaluation of a reduced cardiac rehabiliation program (Phd Thesis) (Simon Fraser University) . Burnaby: Simon Fraser University; 2013 . 111. Liou K , Ho S , Fildes J , Ooi S-Y. High intensity interval versus moderate intensity continuous training in patients with coronary artery disease: a meta-analysis of physiological and clinical parameters . Heart Lung Circ . 2016 ; 25 : 166 - 74 . 112. Pattyn N , Coeckelberghs E , Buys R , Cornelissen V , Vanhees L. Aerobic interval training vs. moderate continuous training in coronary artery disease patients: a systematic review and meta-analysis . Sport Med . 2014 ; 44 : 687 - 700 . 113. Weston KS , Wisløff U , Coombes JS . High-intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis . Br J Sports Med . 2014 ; 48 : 1227 - 34 . 114. Vanhees L , Stevens A , Schepers D , Defoor J , Rademakers F , Fagard R. Determinants of the effects of physical training and of the complications requiring resuscitation during exercise in patients with cardiovascular disease . Eur J Cardiovasc Prev Rehabil . 2004 ; 11 : 304 - 12 . 115. Myers J , Prakash M , Froelicher V , Do D , Partington S , Atwood JE. Exercise capacity and mortality among men referred for exercise testing . N Engl J Med . 2002 ; 346 : 793 - 801 . 116. Vanhees L , Fagard R , Thijs L , Staessen J , Amery A. Prognostic significance of peak exercise capacity in patients with coronary artery disease . J Am Coll Cardiol . 1994 ; 23 : 358 - 63 . 117. Hung RK , Al-Mallah MH , McEvoy JW , Whelton SP , Blumenthal RS , Nasir K , et al. Prognostic value of exercise capacity in patients with coronary artery disease: the FIT (Henry Ford ExercIse Testing) project . Mayo Clin Proc . 2014 ; 89 : 1644 - 54 . 118. Rechnitzer PA , Cunningham DA , Andrew GM , Buck CW , Jones NL , Kavanagh T , et al. Relation of exercise to the recurrence rate of myocardial infarction in men. Ontario exercise-heart collaborative study . Am J Cardiol . 1983 ; 51 : 65 - 9 . 119. Fletcher GF , Balady G , Froelicher VF , Hartley LH , Haskell WL , Pollock ML . Exercise standards: a statement for healthcare professionals from the American Heart Association . Circulation Am Heart Assoc . 1995 ; 91 : 580 - 615 . 120. Duncker DJ , Bache RJ . Regulation of coronary blood flow during exercise . Physiol Rev . 2008 ; 88 : 1009 - 86 . 121. Kazi DS , Hlatky MA. Repeat revascularization is a faulty end point for clinical trials . Circ Cardiovasc Qual Outcomes . 2012 ; 5 : 249 - 50 . 122. Windecker S , Kolh P , Alfonso F , Collet J-P , Cremer J , Falk V , et al. 2014 ESC/ EACTS Guidelines on myocardial revascularization . Eur Heart J . 2014 ; 35 : 2541 - 619 . 123. Michaelides AP , Soulis D , Antoniades C , Antonopoulos AS , Miliou A , Ioakeimidis N , et al. Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease . Heart . 2011 ; 97 : 832 - 7 . 124. Suaya JA , Stason WB , Ades PA , Normand S-LT , Shepard DS . Cardiac rehabilitation and survival in older coronary patients . J Am Coll Cardiol . 2009 ; 54 : 25 - 33 . 125. Martin B-J , Hauer T , Arena R , Austford LD , Galbraith PD , Lewin AM , et al. Cardiac rehabilitation attendance and outcomes in coronary artery disease patients . Circulation . 2012 ; 126 : 677 - 87 . 126. Hammill BG , Curtis LH , Schulman KA , Whellan DJ . Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries . Circulation Am Heart Assoc . 2010 ; 121 : 63 - 70 . 127. Simpson SH , Eurich DT , Majumdar SR , Padwal RS , Tsuyuki RT , Varney J , et al. A meta-analysis of the association between adherence to drug therapy and mortality . BMJ . 2006 ; 333 : 15 . 128. Alter DA , Zagorski B , Marzolini S , Forhan M , Oh PI . On-site programmatic attendance to cardiac rehabilitation and the healthy-adherer effect . Eur J Prev Cardiol . 2015 ; 22 : 1232 - 46 . 129. Doll JA , Hellkamp A , Thomas L , Ho PM , Kontos MC , Whooley MA , et al. Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction . Am Heart J . 2015 ; 170 : 855 - 64 . 130. Chow CK , Jolly S , Rao-Melacini P , Fox KAA , Anand SS , Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes . Circulation Am Heart Assoc . 2010 ; 121 : 750 - 8 . 131. Burke L , Dunbar-Jacob J , Hill M. Compliance with cardiovascular disease prevention strategies: a review of the research . Ann Behav Med . 1997 ; 19 : 239 - 63 . 132. Alm-Roijer C , Fridlund B , Stagmo M , Erhardt L. Knowing your risk factors for coronary heart disease improves adherence to advice on lifestyle changes and medication . J Cardiovasc Nurs . 2006 ; 21 : 24 - 31 . 133. Balady GJ , Ades PA , Bittner VA , Franklin BA , Gordon NF , Thomas RJ , et al. Referral , enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association . Circulation. 2011 ; 124 : 2951 - 60 . 134. Redfern J , Maiorana A , Neubeck L , Clark AM , Briffa T. Achieving coordinated secondary prevention of coronary heart disease for all in need (SPAN) . Int J Cardiol . 2011 ; 146 : 1 - 3 . 135. British Association for Cardiovascular Prevention and Rehabilitation. The BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012 (2nd edition) . London: The British Association for Cardiovascular Prevention and Rehabilitation; 2012 . 136. Daly J , Sindone AP , Thompson DR , Hancock K , Chang E , Davidson P. Barriers to participation in and adherence to cardiac rehabilitation programs: a critical literature review . Prog Cardiovasc Nurs . 2002 ; 17 : 8 - 17 . 137. Abell B , Glasziou P , Briffa T , Hoffmann T. Exercise training characteristics in cardiac rehabilitation programmes: a cross-sectional survey of Australian practice . Open Hear . 2016 ; 3 :e000374. British Cardiovascular Society. 138. Vale MJ , Jelinek MV , Best JD , Dart AM , Grigg LE , Hare DL , et al. Coaching patients On Achieving Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart disease . Arch Intern Med . 2003 ; 163 : 2775 - 83 . 139. Chow CK , Redfern J , Hillis GS , Thakkar J , Santo K , Hackett ML , et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease . JAMA . 2015 ; 314 : 1255 - 63 . 140. Swain DP , Franklin BA . Is there a threshold intensity for aerobic training in cardiac patients ? Med Sci Sport Exerc . 2002 ; 34 : 1071 - 5 . 2002 /07/20. 141. Hawe P , Shiell A , Riley T. Complex interventions: how “out of control” can a randomised controlled trial be? BMJ . 2004 ; 328 :1561. LP-1563. 142. Datta J , Petticrew M. Challenges to evaluating complex interventions: a content analysis of published papers . BMC Public Health . 2013 ; 13 :568. BioMed Central.


This is a preview of a remote PDF: https://link.springer.com/content/pdf/10.1186%2Fs40798-017-0086-z.pdf

Bridget Abell, Paul Glasziou, Tammy Hoffmann. The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression, Sports Medicine - Open, 2017, 19, DOI: 10.1186/s40798-017-0086-z