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)
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
Clinicians should be aware that structured exercise
programs can be flexible in design, without greatly
impacting on the clinical outcomes expected.
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  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
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
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Publication Bias and Quality Assessment
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%).
It appears obvious that structured exercise training has
clear benefits over usual care, even when this includes
Additional file 1: Supplementary Material 1. (DOCX 131 kb)
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.
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
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.
Bridget Abell, Paul Glasziou and Tammy Hoffmann declare no financial
relationships or conflicts of interest which may have influenced the results
of this research.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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