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Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence

You can read a response to this article from BACPR in collaboration with NACR, the Cochrane Heart Rehabilitation Review Coordination Centre and ACPICR here

Effects of early mobilisation in patients after cardiac surgery: a systematic review

‚ÄčThis review of nine RCT's concludes that early mobilisation is important in preventing post operative complications, improving functional capacity and reducing hospital length of stay.  The studies reviewed used a variety of interventions but regardless of techniques used it is important to avoid bed rest.

Obesity and Cardiovascular Disease: Friend or Foe?

This abstract introduces some of the emerging thoughts on obesity and cardiovascular disease.

Sodium intake and all-cause mortality over 20 years in the trials of hypertension prevention

‚ÄčThis paper reveals that an increased risk of mortality for high-sodium intake and a direct relationship with total mortality, even at the lowest levels of sodium intake. These results are consistent with a benefit of reduced sodium and sodium/potassium intake on total mortality over a 20-year period.

Oxygen costs of the Incremental Shuttle Walk Test in Cardiac rehabiliation participants: A historical and contemporary analysis

This article by John Buckley reveals that the change in oxygen cost (VO2) during a standardised incremental walking test in healthy and cardiac rehabilitation participants responds in a classic curvilinear nature; linear regression should not be used to estimate oxygen uptake (VO2/ metabolic equivalents) from walking speed.

Coronary heart disease patients performing incremental walking tests require up to 30 % more oxygen compared with age-matched non-CHD controls.

A region-wide audit of cardiac rehabilitation services

This is an audit of 10 Anglia region cardiac rehabilitation services against the BACPR seven core standards.  Anglia CR services were shown to be fit-for-purpose and there were local areas of excellence, but local areas of need and gaps in CR were highlighted that will cross-pollinate to improve all CR services in East Anglia.  Our ACPICR Chair, Laura Burgess has commented on a paragraph in the article regarding Physiotherapy and exercise prescription (scroll to the bottom of the article to read her comment).

Practical barriers affect exercise adherence and have subsequent outcomes in heart failure patients 

New research reports on the common barriers for heart failure patients wanting to participate in exercise, and the effect on cardiac outcomes.


Cardiac Rehabilitation: BMJ Clinical review

This review focuses on what cardiac rehabilitation is and the evidence of its benefit and effects on cardiovascular mortality, morbidity and quality of life.

Physical activity may increase survival in ICD patients says latest ALTITUDE study

This report published by Medscape Cardiology reveals that those with ICD's who were most active had survival benefits.  The findings, which were published in the Journal of the American Heart Association and included almost 100,000 ICD patients, showed 4-year post procedure survival rates of 91% in the subgroup that was most active at baseline (mean 33 min/day) vs 50% in the least active group (mean 208 min/day; P<0.001).

Future care planning: A first step to palliative care for all patients with advanced heart disease

Future care planning provides a framework for discussing a range of palliative care options.  Integrating cardiology care and palliative care can benefit many patients with advanced heart disease.

Almanac 2014: Aortic Valve Disease (you will require an Athens password to access this article)

This article which was published in The Heart Journal in March 2014 summarises research from 2013 and 2014 into Aortic Valve Disease and includes a discussion of the potential impact of these new research findings on the clinical approach to management of adults with aortic valve disease.


Exercise can keep ICD patients fit without raising shock risk

This report which appears in outlines how moderately strenuous aerobic exercise can improve cardiovascular health in patients who have received an implantable cardioverter-defibrillator (ICD)—without causing the device shocks that many patients fear working out might cause, according to researchers.


Exercise: The miracle cure and the role of doctors in promoting it

This article from The Academy of Medical Royal Colleges calls on doctors to promote the benefits of regular physical activity to their patients and communities.  Thrpugh a series of case studies it demonstrates that relatively simple measures designed to promote physical activity can make an impact on individuals health.


Editorial: Exercise for people with high cardiovascular risk

This editorial in 'Heart' Journal comments on a recent Cochrane review


The effects of cold and exercise on the Cardiovascular system

It is well-known that those with coronary heart disease can have a worsening of angina in winter months, as well as an increased risk of acute cardiac events.  This informative article in 'Heart' Journal outlines the effects of cold stress on the cardiovascular system, before going on to discuss the effects of exercise. 


Editorial:  Type 2 myocardial infarction

An interesting editorial discussing redefinition of myocardial infarction from 'Heart' journal.


Interesting BMJ Editorial: Optimism and consent to treatment

Fiona Godlee, editor in chief, The British Medical Journal

ritish medicalJMJMJM (  BMJ 2014;349:g6118 

We know that patients and doctors tend to overestimate the benefits of treatment and underestimate the harms. We also know that people’s natural optimism is often boosted by the systematic optimism bias of the medical literature (Br J Psych 2010;197:441-7, doi:10.1192/bjp.bp.110.078006; PLoS One 2014;9(5):e98246, doi:10.1371/journal.pone.0098246). But in the case of percutaneous coronary intervention there is no such excuse. Experts and guidelines are clear: it improves symptoms but not survival. Nor does it reduce the risk of myocardial infarction. It should be offered to patients with stable coronary artery disease only if medical treatment is failing to manage their angina.

Despite this clarity, Faraz Kureshi and colleagues confirm that patients still believe that it will do more than just control their symptoms (BMJ 2014;349:g5309, doi:10.1136/bmj.g5309). Of about 1000 patients surveyed, the vast majority thought that the procedure would extend or save their lives and would prevent myocardial infarction. Only 1% correctly reported that relief of symptoms was the only expected benefit.

Efforts to improve informed participation of patients in decision making are clearly failing. In what I believe is our first editorial coauthored by patients, Jeff Whittle and colleagues ask why this might be (BMJ 2014;349:g5613, doi:10.1136/bmj.g5613). The three coauthor patients all have personal or family experience of coronary revascularisation. Their views may prompt new thinking. One recalled that, although there was no statement that the procedure would prolong life, he sensed that the surgeon thought it would. Another was made aware of the seriousness of his condition and congratulated on its early discovery, which perhaps suggested that intervention would change the course of the disease. A third noted that having lots of time for questions doesn’t help if the patient doesn’t know which questions to ask.

Our editorialists consider what they acknowledge might be considered a heretical question: does it matter if patients don’t have an entirely accurate understanding of the benefits of treatment? They conclude that it may not—and they even say that insisting that patients understand that treatment won’t prolong life may be demoralising.

Some of us may find this hard to swallow. What of the risks of overtreatment based on unrealistic expectations? In their study Kureshi and colleagues found that patients’ level of understanding varied between the 10 different sites and that the informed consent procedures differed. It may take only a few words to give a patient a false impression of what they can expect from a procedure.

I’m reminded of one of Daniel Sokol’s recent columns (BMJ 2014;348:g2192, doi:10.1136/bmj.g2192). Consent should not be something we do to patients, he said. It should be seen more as a unique gold coin. "The clinician should not snatch it away, abruptly, deceptively, or without careful explanation. He or she should explain why the patient may wish to hand over the coin. What will the patient get in return? What if the patient wishes to keep it? Explaining all this can take time and skill. It is a two way process, but ultimately the decision remains with the patient."

Joint British Societies' consensus recommendations for the prevention of cardiovascular disease

(JBS3 Board) Published on-line Heart 10.1136/heartjnl-2014-365643    10.1136/heartjnl-2014-3656431

This evidence based consensus statement and recommendations considers all the risk factors for cardiovascular disease, and emphasises a greater focus on prevention in light of increasing levels of obesity and diabetes. It is a valuable resource for anyone working with patients with cardiovascular disease.

Estimating the effect of long-term physical activity on cardiovascular disease and mortality: evidence from the Framingham Heart Study

Susan M Shortreed, Anna Peeters, Andrew B Forbes
Published online on March 8, 2013 as 10.1136/heartjnl-2012-303461

This article provides the latest data from the Framingham Cohort on the effects of long-term physical activity and concludes that cumulative long-term PA has a protective effect on incidence of all-cause and CVD-attributable mortality compared with long-term physical inactivity. In men, but not women, long-term PA also appears to have a protective effect on incidence of CVD.

Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up.

Alison Beauchamp, Marian Worcester, Andrew Ng, Barbara Murphy, James Tatoulis, Leeanne Grigg, Robert Newman & Alan Goble. Heart Online First, published on December 4, 2012 as 10.1136/heartjnl-2012-303022

This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose–response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation. An editorial on this article has been written by Patrick Doherty and Geraldine Rauch who explain why the results should be treated with caution.

The Chartered Society of Physiotherapy Research Priorities project

The aims of this project are to:

  • Identify areas of physiotherapy practice requiring evidence most urgently
  • Strategically direct and maximise opportunities to develop the evidence base in these areas ensuring involvement of service users and all other stakeholders throughout the process.

The topics felt to be most relevant to physiotherapists working in Cardiac rehabilitation appear on the 'Cardiorespiratory and medical rehabilitation' and 'Mental and physical health and well-being' streams. The topics on these lists felt to be of particular importance have been highlighted.  If you are in the process of selecting a topic for research, please consider whether you could contribute to the wider physiotherapy evidence base by using these priorities to guideyou.

“Being Inactive Kills as Many as Cigarettes” hit our national headlines during mid-July, thanks to the publication of a paper whose authors are familiar to some of us: Dr I-Min Lee and Steven Blair. (The authors are part of the Lancet Physical Activity Series Working Group). The source of the startling headline was a paper published in the Lancet:

Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy (online ahead of print, 18th July 2012) Dr I-Minlee, Eric J Shiroma, Felipe Lobelo, Pekka Puska, Steven N Blair, Peter T Katzmarzyk.

This study looked at the global burden of physical inactivity and reported that the number of deaths (5 million) attributed to inactivity was the same as that attributed to cigarette smoking. Physical inactivity in this study was defined as performing less than 150 minutes of moderate activity each week – with the ‘moderate’ element encompassing an activity level of, for example, brisk walking. Physical inactivity was related to a 6% incidence of coronary heart disease, 7% incidence of diabetes, and 10% incidence of both breast and colon cancers. The authors acknowledge the study’s limitations in that their global estimates were likely to be on the conservative side – unsurprisingly one of the reasons given for this is well-known to us – ie the problems with physical activity levels which are self-reported.


New European Guidelines on Heart Failure (online ahead of print, 15th June 2012)

McMurrayJJV, Adamopolous S, Anker SD et al (2012) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J doi:10.1093/eurheart/ehs104

These guidelines update the previous version (2008). Included are changes around CRT for patients with LBBB QRS complexes and those in SR who will derive the greatest benefit from this treatment. Ventricular assist devices may start to be used more generally as an alternative to transplants. In pharmacotherapy, the guidelines recommend that to reduce congestion with diuretics, an ACE inhibitor or ARB, a beta-blocker and an MRA (mineralcorticoid receptor - ie eplerenone/spironolactone) should be considered as a treatment for all patients. The use of Ivabradine is also discussed.


Heart failure disease management programmes: a new paradigm for research (online ahead of print, July 12 2012)

Alexander M Clark, David R Thompson Heart published online doi:10.1136/heartjnl-2012-302572

From our very own David Thompson (Editor of the first BACR Guidelines), comes this editorial which urges us to research different types of programmes in different settings to discover what programmes work best for what patients and where and why.



Angina Pectoris in patients with normal coronary angiograms: current pathophysiological concepts and therapeutic options.

Ali Yilmaz, Udo Sechtem. Heart 2012; 98: 1020-1029 doi:10.1136/heartjnl-2011-301352

The Education section in the Heart Journal can easily be accessed using an Athens ‘log in’. This paper is lengthy, but I have copied the key points which are itemised below:

Key Points

The presence of angina pectoris (AP) in patients either with normal coronary angiograms or with non-obstructive coronary artery disease (CAD) is not only a frequent clinical finding but also a clinical and therapeutic challenge.

Structural alterations in patients with hypertensive heart disease comprise not only left ventricular hypertrophy and an increase in left ventricular mass but also a decrease in intramyocardial capillary density and arteriolar wall thickening, resulting in both epicardial CAD as well as microvascular disease.

Microvascular structural changes may lead to functional impairment and result in clinical symptoms and pathological non-invasive stress test results in the absence of significant epicardial stenosis.

Abnormalities in the structure and function of the microvasculature occur not only in cases of hypertensive heart disease but also in many other clinical and pathological conditions comprising the presence of traditional risk factors (such as hypertension and diabetes) as well as cardiomyopathies (such as hypertrophic cardiomyopathy).

Cardiac syndrome X is diagnosed in those patients who have typical ‘exertional’ AP and demonstrate ST segment depression during exercise ECG in addition to a completely normal coronary angiogram.

The patient with Prinzmetal's or variant angina is clinically characterised by recurrent episodes of resting chest pain associated with reversible ST segment ‘elevation’ and preserved exercise tolerance in the absence of obstructive CAD.

The term ‘vasospastic angina’ encompasses both those patients with traditional ‘variant’ or Prinzmetal's angina and those with only transient vasoconstriction with reversible ST segment ‘depression’.

Myocardial inflammation and/or virus persistence may be associated with a coronary vasomotility disorder enabling the occurrence of coronary vasospasm and causing acute chest pain syndromes, particularly in young patients without risk factors for CAD.


Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial

of comprehensive cardiac rehabilitation in patients following acute myocardial infarction

West, R.R., Jones, D.A., Henderson, A.H. (2011) as 10.1136/heartjnl-2011-300302.

This study compared 1813 patients randomised to comprehensive cardiac rehab or 'usual care' (without referral to rehab).  The primary outcome measure was all-cause mortality with several secondary measures.  The results claim that there were no significant differences at 2 years between the groups in terms of mortality, cardiac and psychological mortality, QOL, risk factors or activity.  The results are obviously of concern for those working in cardiac rehabilitation, and the British Association of Cardiac Prevention and Rehabiltiation have issued a response to support health care professionals who may be challenged over the results of this study by commissioners, colleagues or managers.  You can view this by clicking on the link below:

BACPR response to the RAMIT trial - click here - (If you encounter an error message click 'okay')


Efficacy of Exercise-based Cardiac Rehabilitation Post-Myocardial Infarction

A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Patrick R Lawler, MD; Kristina B. Fillon, PhD; Mark J Eisenberg

American Heart Journal 2011; 162(4):571-584.

This systematic review published at the beginning of last year makes encouraging reading and is worthy of inclusion as a reference  for those of you involved in research or needing to provide evidence that cardiac rehab (CR) works – at least for our ACS/STEMI/NSTEMI patients. This is especially important in the light of the recent and somewhat negative publication of the results of the RAMIT* trial by Robert West and colleagues (2011 online only as yet).  All English-language randomised controlled trials (RCTs) looking at the effects of exercise-based CR in patients post MI were included. The researchers found a total of 34 RCTs which fitted their criterion (representing 6,111 patients). They reported that overall patients who participated in exercise-based CR had a lower risk of re-infarction whereas in the Cochrane review (2004) Taylor et al had been unable to demonstrate that CR reduced the risk of re-infarction. Moreover, both cardiac mortality and mortality from all-causes was also shown to be lower in the exercising CR groups. In addition, exercise-based CR had favourable effects on some of the cardiovascular risk factors: smoking, blood pressure, body weight and lipid profile.

Sally Turner PhD, MSc, MCSP Research Officer, ACPICR


* Robert R West, Dee A Jones, Andrew H Henderson. Rehabilitation after myocardial infarction (RAMIT); multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction (Heart Online 22nd December 2011).

Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease; systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116:682-692


Exercise based rehabilitation for heart failure. Cochrane Database of Systematic Reviews 2010.

Davies Ed, J., Moxham, T., Rees, K., Singh, S.,Coats Andrew, JS.,Ebrahim, S.,Lough, F., Taylor Rod, S. DOI: 10.1002/14651858.CD003331.pub3.

Exercise training may offer important improvements in patients' health-related quality of life.


Cardiac rehabilitation programme for coronary heart disease patients: An integrative literature review. Eshah NF and Bond AE :  International Journal of Nursing Practice 2009; 15 (3):131–139.

 Bottom-line conclusion: Cardiac rehabilitation programmes provided significant improvement in participants' quality of life, exercise capacity, lipid profile, body mass index, body weight, blood pressure, resting heart rate, survival rate, mortality rate and decreased myocardial infarction (MI) risk factors, although there was limited participation.


Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis.                                                                                                                                        

Hwang, R. and T. Marwick.  European Journal of Cardiovascular Prevention and Rehabilitation 2009; 16 (5): 527-35.

This review assessed the effectiveness of home-based exercise programmes compared with usual medical care in patients with chronic heart failure and concluded that there were short-term benefits. The reliability of the conclusions is unclear due to the unexplained variability and lack of information about the quality of included studies.


 Cardiac rehabilitation improves survival in older patients with coronary disease.
Suaya JA, Stason WB, Ades PA et al: J Am Coll Cardiol 2009; 54: 25-33

Most of the data on the benefits of cardiac rehabilitation comes from randomised controlled trials and meta-analyses data that focussed on young to middle aged low risk men. A recent study provides evidence that an older American population who had been hospitalised for heart disease or revascularisation procedures benefitted from attendance at cardiac rehab. Just over 12% of the older population participated in an average of 24 sessions of cardiac rehab. Attendance at cardiac rehab appeared to reduce mortality by between 21-34%. This benefit did not differentiate between the different clinical subgroups involved in the study population – subjects recruited to the study were post MI, post revasc., or had a diagnosis of heart failure. Moreover, for the patients who attended 25 or more sessions of cardiac rehab, the risk of dying was 19% less over the following 5 years than matched users who completed less than 25 rehab sessions (p<0.001).


High-Calorie-Expenditure Exercise - A New Approach to Cardiac Rehabilitation for Overweight Coronary Patients.
Ades PA, Savage MS, Toth MJ et al: Circulation 2009, 119: 2671-2678

The majority of patients who join rehab programmes are overweight and more than half of these patients have metabolic syndrome. (Metabolic syndrome is a combination of medical problems that increase risk of developing heart disease and diabetes. People with metabolic syndrome have some or all of the following: high blood glucose, high blood pressure, abdominal obesity, low HDL elevated cholesterol and high triglycerides; Public Health Agency of Canada 2008). This study from the USA looked at the effect of two different exercise regimes on overweight patients whilst they attended 5 months of supervised cardiac rehabilitation. The high calorie expenditure group had an exercise expenditure goal of > 3000-3500 kcal/week and their exercise prescription consisted of longer duration exercise lasting 45-60 minutes and more frequent exercise – 5-7 times weekly. This compared with the ‘standard’ care group who exercised for a shorter duration of 25-40 minutes a session, and only 3 times each week. Walking was the preferred type of exercise. All patients completed homework exercise diaries to monitor exercise, aid compliance with the study, and to estimate calorific expenditure. By 5 months, most of the patients had progressed to performing the exercise prescription at home, with one session of supervised exercise a week.

Results from this study showed that there was a 28% reduction in the prevalence of metabolic syndrome in the patients who had undergone the high calorie expenditure exercise regime. The high calorie expenditure group also lost more weight than those who had received standard care.


Effects of moderate-to-high intensity resistance training in patients with chronic heart failure.                                                                                                                                                                                       Spruit, MA., Eterman, RM., Hellwig, VA., Janssen, PP., Wouters, EF., Uszko-Lencer, NH.  Heart 2009; 95 (17): 1399-1408. 
                                                                                                                                                                  A predesigned data extraction form was used to obtain data on trial design and relevant results. Methodological quality of the identified trials were scored using the Delphi list.

Most of the 10 trials identified had moderate-to-severe methodological limitations. Effects of resistance training (alone or in combination with endurance training) are inconclusive for outcomes like exercise capacity and disease-specific quality of life.                                                                                                                         

Even though moderate-to-high intensity resistance training does not seem be harmful for patients with CHF, the current peer-reviewed evidence seems inadequate to generally recommend incorporation of resistance training into exercise-based rehabilitation programmes for patients with CHF.


Home-based versus centre-based cardiac rehabilitation.

Taylor Rod S, Dalal H, Jolly K, Moxham T, Zawada A. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007130.

OBJECTIVE: To compare the effect of home based and supervised centre based cardiac rehabilitation on mortality and morbidity, health related quality of life, and modifiable cardiac risk factors in patients with coronary heart disease.

CONCLUSIONS: Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients' adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the "Heart Manual." The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.