The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis

doi:10.1016/j.cjca.2018.11.013

Canadian Journal of Cardiology

Volume 35, Issue 3, March 2019, Pages 352-364

https://doi.org/10.1016/j.cjca.2018.11.013 Get rights and content

Abstract

Background

The clinical effectiveness of cardiac rehabilitation (CR) on health-related quality of life (HRQOL) is an area that has not been consistently explored. The objective of this systematic review was to evaluate the effectiveness of providing any core component of CR on HRQOL domains.

Methods

We performed a meta-analysis and meta-regression of randomized controlled trials (RCTs) on the core components of CR. RCTs included adult patients with diagnosed coronary artery disease via angiography, myocardial infarction, angina, or who had undergone coronary revascularization. The Cochrane Library, MEDLINE, EMBASE, CINAHL, SCI-EXPANDED, Psych INFO, and Web of Science were searched from inception to April 27, 2017. Outcomes included overall, physical, emotional, and social HRQOL. Outcomes were reported as standardized mean change (SMC) with 95% confidence intervals (CIs). Effect size changes of 0.2, 0.5, and 0.8 SD units reflect a small, moderate, and large effect, respectively.

Results

Forty-nine reports of 41 RCTs with 11,747 patients were included. Summary effect sizes were: overall HRQOL SMC, 0.28 (95% CI, 0.05-0.50), physical HRQOL SMC, 0.47 (95% CI, 0.13-0.81), emotional HRQOL SMC, 0.37 (95% CI, −0.02 to 0.77), and social HRQOL SMC, 0.13 (95% CI, −0.06 to 0.32). Meta-regression revealed type of CR intervention and year of publication as positive statistically significant treatment effect modifiers.

Conclusions

Receiving CR was shown to improve HRQOL, with exercise-, nonexercise-, and psychological-based interventions playing a vital role. Although these improvements in HRQOL were modest they still reflect an incremental benefit compared with receiving usual care.

Résumé

Contexte

L’efficacité clinique de la réadaptation cardiaque (RC) sur la qualité de vie liée à la santé (QVLS) est un domaine qui n’a pas été exploré de façon méthodique. L’objectif de cette revue systématique était d’évaluer l’efficacité de l’un ou l’autre des éléments centraux de la RC sur les domaines de la qualité de vie liée à la santé.

Méthodologie

Nous avons réalisé une méta-analyse et une méta-régression des essais contrôlés avec répartition aléatoire (ECRA) portant sur les éléments centraux de la RC. Les participants des ECRA étaient des patients adultes ayant reçu un diagnostic de coronaropathie par angiographie, ayant eu un infarctus du myocarde, atteints d’angine ou ayant subi une revascularisation coronarienne. Une recherche a été effectuée dans les bases de données Cochrane Library, MEDLINE, EMBASE, CINAHL, SCI-EXPANDED, Psych INFO et Web of Science de leur date de création au 27 avril 2017. Les paramètres d’évaluation étaient la QVLS globale, physique, émotionnelle et sociale. Les résultats étaient présentés sous la forme de variation moyenne standardisée (VMS) avec intervalles de confiance (IC) à 95 %. Des variations de l’ampleur de l’effet de 0,2, 0,5 et 0,8 unité d’écart type (ET) représentent un effet faible, modéré et important, respectivement.

Résultats

Quarante-neuf rapports portant sur 41 ECRA auxquels avaient participé 11 747 patients ont été inclus. En résumé, les variations de l’ampleur de l’effet étaient les suivantes : VMS de la QVLS globale, 0,28 (IC à 95 %, 0,05-0,50), VMS de la QVLS physique, 0,47 (IC à 95 %, 0,13-0,81), VMS de la QVLS émotionnelle, 0,37 (IC à 95 %, −0,02-0,77), et VMS de la QVLS sociale, 0,13 (IC à 95 %, −0,06-0,32). La méta-régression a révélé que le type d’intervention de RC et l’année de publication étaient des modificateurs positifs de l’effet du traitement statistiquement significatifs.

Conclusions

Il a été montré que le fait de suivre une RC avait pour conséquence d’améliorer la QVLS, et que les interventions de nature psychologiques, ou encore fondées sur l’activité physique ou sur d’autres éléments que l’activité physique jouent un rôle vital. Ces améliorations de la QVLS, même si elles sont légères, n’en constituent pas moins un avantage supplémentaire par rapport aux soins usuels.

Section snippets

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) on CR interventions for CHD patients using Cochrane methods.¹⁰ We reported outcomes using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting standards.¹¹ The PRISMA checklist is shown in Supplemental Table S1. No review protocol exists for this study.

Study demographic characteristics

Figure 1 shows the selection of potentially eligible studies. A total of 1462 potential studies were identified for full-text review with 1413 trials being excluded. Forty-nine reports of 41 RCTs with 11,747 participants met the eligibility criteria and were included in the meta-analysis. Characteristics of included trials are shown in Supplemental Table S4.

The study and patient demographic characteristics are shown in Table 1. Studies were conducted primarily in Europe (46%) and Asia (20%). In

Discussion

Narrative and thematic reviews of CR have suggested that CR improves HRQOL in patients with CHD, but it has not been systematically proven.2, 8, 27 We found that patients who received CR did improve their HRQOL, but the magnitude of this effect was modest. Nonexercise- and psychological-based interventions produced a significant positive effect on HRQOL. When HRQOL was evaluated using a disease-specific measure, MacNew, HRQOL significantly improved in all domains. On average HRQOL scores in all

Acknowledgements

The authors thank Dr Paul Oh, Medical Director at the Cardiovascular Rehabilitation and Prevention Program, University Health Network, for his valuable insight into our study. Additionally, we thank the authors who took the time to send us additional data needed for our analysis.

Disclosures

The authors have no conflicts of interest to disclose.

References (34)

T.A. Gaziano et al.
Growing epidemic of coronary heart disease in low- and middle-income countries
Curr Probl Cardiol
(2010)
L. Anderson et al.
Exercise-based cardiac rehabilitation for coronary heart disease cochrane systematic review and meta-analysis
J Am Coll Cardiol
(2016)
B. Cepeda-Valery et al.
Measuring health related quality of life in coronary heart disease: the importance of feeling well
Int J Cardiol
(2011)
S. Wiebe et al.
Comparative responsiveness of generic and specific quality-of-life instruments
J Clin Epidemiol
(2003)
C.W. Shepherd et al.
Cardiac rehabilitation and quality of life: a systematic review
Int J Nurs Stud
(2012)
CHD mortality projections to 2020, comparing different policy scenarios
(2014)
R.S. Taylor et al.
Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews
Cochrane Database of Systematic Reviews
(2014)
L.J. Laslett et al.
The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology
J Am Coll Cardiol
(2012)
J.P. Buckley et al.
BACPR scientific statement: British standards and core components for cardiovascular disease prevention and rehabilitation
Heart
(2013)
G.J. Balady et al.
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation
Circulation
(2007)

B. Abell et al.

The contribution of individual exercise training components to clinical outcomes in randomised controlled trials of cardiac rehabilitation: a systematic review and meta-regression

Sports Med Open

(2017)

B.S. Heran et al.

Exercise-based cardiac rehabilitation for coronary heart disease

Cochrane Database Syst Rev

(2011)

Training Cochrane

Cochrane Handbook for Systematic Reviews of Interventions Version 5.1

D. Moher et al.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

(2009)

S.B. Morris

Estimating effect sizes from pretest-posttest-control group designs

Organ Res Methods

(2008)

J.P. Higgins et al.

The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials

BMJ

(2011)

M.A. Puhan et al.

Combining scores from different patient reported outcome measures in meta-analyses: when is it justified?

Health Qual Life Outcomes

(2006)

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Exploring timing and delivery of lifestyle advice following an acute cardiac event hospitalization: The cardiac patient's perspective
2024, Patient Education and Counseling
To explore the perspective of cardiac patients regarding the timing and manner of delivering lifestyle advice following an acute cardiac event hospitalization.
Dutch cardiac patients who experienced a cardiac event hospitalization participated in a semi-structured interview (n = 14) or a cross-sectional survey study (n = 119).
Our findings indicate that cardiac patients are receptive to lifestyle advice throughout the care trajectory. Advice delivered by a cardiologist had the highest self-reported impact. Furthermore, receiving advice at multiple phases during the care trajectory was associated with a greater intention to change lifestyle (B = 0.37, CI = 0.17 – 0.57). Patients favored clear-cut, feasible, and friendly but confronting advice. Moreover, they stressed the importance of advice being aligned with their identity and beliefs about the causes of their disease.
The period following an acute cardiac event provides a unique opportunity to offer tailored and patient-centered lifestyle advice. This “teachable window” for lifestyle change, when used wisely, may improve health outcomes for cardiac patients.
Healthcare professionals should initiate lifestyle advice already during hospitalization and continue during follow-up appointments and cardiac rehabilitation. Advice should be feasible and empathy-based, as well as tailored to the patient’s needs, values, and perceptions of the causes of their cardiovascular disease.
Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation
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Women are less likely than men to use cardiac rehabilitation (CR); thus, women-focused (W-F) CR was developed. Implementation of W-F CR globally was investigated, as well as barriers and enablers to its delivery.
In this cross-sectional study, a survey was administered to CR programs via Research Electronic Data Capture (REDCap) from May to July, 2023. Potential respondents were identified via the International Council of Cardiovascular Prevention and Rehabilitation’s network.
A total of 223 responses were received from 52 of 111 countries (46.8% country response rate) in the world that have any CR, across all 6 World Health Organization regions. Thirty-three programs (14.8%) from 30 countries reported offering any W-F programming. Programs commonly did offer elements preferred by women and recommended, namely, the following: patient choice of session time (n = 151; 70.6%); invitations for informal care providers and/or partners to attend sessions (n = 121; 57.1%); CR staff that have expertise in women and heart diseases (n = 112; 53.3%); separate changerooms for women (n = 38; 52.8%); and discussion of CR referral with patients (n = 112; 52.1%). Main barriers to delivery of W-F exercise were physical resources (n = 33; 14.8%), space (n = 30; 13.5%), and staff time (n = 26; 11.7%) and expertise (n = 33; 10.3%). Main barriers to delivery of W-F education were human resources (n = 114; 51.1%), educational resources (n = 26; 11.7%), and expertise in the content (n = 74; 33.2%). Enablers of W-F education delivery were availability of materials, in multiple modalities, as well as educated staff and financial resources.
Despite the benefits, W-F CR is not commonly offered globally. Considering the barriers and enablers identified, the International Council of Cardiovascular Prevention and Rehabilitation is developing resources to expand delivery.
Les femmes étant moins susceptibles que les hommes d’avoir recours à la réadaptation cardiaque (RC), il convient d’élaborer des programmes de RC qui sont mieux adaptés à leurs besoins. Le recours à de tels programmes dans le monde a fait l’objet d’une étude, laquelle portait également sur les obstacles à leur prestation et les facteurs qui les favorisent.
Dans cette étude transversale, un sondage a été mené auprès de programmes de RC via la REDCap (Research Electronic Data Capture) de mai à juillet 2023. Les participants potentiels au sondage ont été sélectionnés par le réseau de l’International Council of Cardiovascular Prevention and Rehabilitation.
Au total, 223 réponses ont été reçues de 52 pays sur 111 qui ont un programme de RC (taux de réponse des pays de 46,8 %), dans les 6 régions de l’Organisation mondiale de la Santé. Selon les résultats, trente-trois programmes (14,8 %) de 30 pays offrent des services axés sur les femmes. Les programmes offraient habituellement des éléments privilégiés par les femmes et recommandaient notamment des séances au moment choisi par les patientes (n = 151; 70,6 %); la possibilité de se faire accompagner par un aidant naturel et/ou un(e) partenaire (n = 121; 57,1 %); du personnel de RC possédant une expertise auprès des femmes et en matière de maladies cardiaques (n = 112; 53,3 %); des vestiaires réservés aux femmes (n = 38; 52,8 %); et une discussion avec les patientes sur leur orientation vers des spécialistes en RC (n = 112; 52,1 %). Les principaux obstacles à la prestation de services pour les femmes étaient les ressources physiques (n = 33; 14,8 %), l’espace (n = 30; 13,5 %) ainsi que la disponibilité du personnel (n = 26; 11,7 %) et son expertise (n = 33; 10,3 %). Les principaux obstacles à l’éducation destinée aux femmes étaient les ressources humaines (n = 114; 51,1 %), les ressources éducatives (n = 26; 11,7 %) et l’expertise liée au contenu (n = 74; 33,2 %). Les facteurs qui favorisent l’éducation destinée aux femmes étaient la disponibilité du matériel, sous plusieurs formes, de même que le personnel formé et les ressources financières.
En dépit des bienfaits, la RC axée sur les femmes n’est pas couramment offerte dans le monde. En tenant compte des obstacles et des facteurs favorisant la prestation des services cités, l’International Council of Cardiovascular Prevention and Rehabilitation s’affaire à concevoir des ressources pour élargir la portée des programmes destinés aux femmes.
Translation, cultural adaptation and psychometric validation of the Arabic short version of the coronary artery disease education questionnaire (CADE-Q SV) in Saudi Arabia
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To translate, culturally adapt, and psychometrically validate the Arabic Coronary Artery Disease Education Questionnaire Short Version (CADE-Q SV).
The CADE-Q SV was translated to Arabic by two independent translators, followed by back-translation. Then, an expert panel of 10 healthcare providers and 10 patients reviewed the survey and provided input for content validity (CV) and clarity of items. For the psychometric analysis, 202 cardiac patients from Saudi Arabia completed the questionnaire, of which factor structure, internal consistency, construct, and criterion validity were assessed.
Items were translated, and CV was confirmed. Items were rated based on relevance and understandability. The scale was finalized after changes in 5 items. Confirmatory factor analysis revealed 5 factors, all internally consistent: medical condition, risk factors, exercise, nutrition, and psychosocial health. Overall alpha was 0.84. Construct validity was established by significant associations between scores and occupation, educational level, family income, having a diagnosis of acute coronary syndrome or valve disorders and with a history of valve repair or replacement a coronary artery bypass graft procedure. Scores were significantly higher for those that participated in cardiac rehabilitation, confirming criterion validity.
Results from this study confirm the validity and reliability of the CADE-Q SV in Arabic-speaking patients.
The CADE-Q SV can be used as a knowledge measurement to support clinical work and development of education intervention for Arabic patients.
Health-Related Quality of Life After Percutaneous Coronary Intervention for Stable Ischemic Heart Disease: A Systematic Review and Meta-analysis
2023, Canadian Journal of Cardiology
There has been no meta-analysis of whether percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) improves health-related quality of life (HRQL) compared with OMT alone in patients with stable ischemic heart disease (SIHD).
We searched MEDLINE, Cochrane Central Registry of Controlled Trials, Embase, ClinicalTrials.gov, and International Clinical Trials Registry Platform in November 2022. We included randomized controlled trials (RCTs) that compared PCI with OMT vs OMT alone with HRQL in patients with SIHD. The primary outcome was the aggregated physical HRQL, including physical functioning using the Short Form (SF)-36 or RAND-36, physical limitation using the Seattle Angina Questionnaire (SAQ) or SAQ-7, McMaster Health Index Questionnaire, and Duke Activity Status Index within 6 months. Data were analyzed using a random effects model when substantial heterogeneity was identified or a fixed effect model otherwise.
Among 14 systematically reviewed RCTs, 12 RCTs with 12,238 patients were meta-analyzed. Only 1 trial had a low risk of bias in all domains. PCI with OMT improved aggregated physical HRQL (standardized mean difference, 0.16; 95% confidence interval [CI], 0.1-0.23; P < 0.0001) at 6 months. Also, PCI with OMT improved physical functioning on the SF-36/RAND-36 (mean difference 3.65; 95% CI, 1.88-5.41) and physical limitation on the SAQ/SAQ-7 (mean difference, 3.09; 95% CI, 0.93-5.24) compared with OMT alone at 6 months. However, all of the aggregated physical HRQL domains were classified into small effects, and no HRQL domain exceeded the prespecified minimal clinically important difference.
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Il n’existe aucune méta-analyse qui confirme si l’intervention coronarienne percutanée (ICP) associée à un traitement médical optimal (TMO) améliore la qualité de vie liée à la santé (QVLS) chez les patients atteints d’une cardiopathie ischémique stable (CIS) par rapport au TMO seul.
Nous avons effectué des recherches dans les bases de données MEDLINE, Cochrane Central Registry of Controlled Trials (CENTRAL), Embase, ClinicalTrials.gov et International Clinical Trials Registry Platform (ICTRP) en novembre 2022. Nous avons inclus les essais contrôlés randomisés (ECR) qui portaient sur la comparaison de l’ICP associée à un TMO et le TMO seul à la QVLS des patients atteints d’une CIS. Le critère d’évaluation principal était les données agrégées sur la QVLS physique, à savoir le fonctionnement physique au moyen du questionnaire Short Form (SF)-36 ou RAND-36, les limitations physiques au moyen du questionnaire d’évaluation d’angine de Seattle (SAQ, de l’anglais Seattle Angina Questionnaire ou SAQ-7, du questionnaire McMaster Health Index Questionnaire (MHIQ) et du questionnaire Duke Activity Status Index (DASI) dans les 6 mois. Les données ont été analysées à l’aide du modèle à effets aléatoires lorsqu’une hétérogénéité substantielle était observée, ou à l’aide d’un modèle à effets fixes.
Parmi les 14 ECR passés systématiquement en revue, 12 ECR regroupant 12 238 patients ont fait l’objet d’une méta-analyse. Seul un essai présentait un faible risque de biais dans tous les domaines. L’ICP associée à un TMO a permis d’améliorer les données agrégées sur la QVLS physique (différence moyenne standardisée, 0,16 ; intervalle de confiance [IC] à 95 %, 0,1-0,23 ; p < 0,0001) après six mois. De plus, l’ICP associée à un TMO par rapport au TMO seul après six mois a permis d’améliorer le fonctionnement physique au SF-36/RAND-36 (différence moyenne, 3,65 ; IC à 95 %, 1,88-5,41) et les limitations physiques au SAQ/SAQ-7 (différence moyenne, 3,09 ; IC à 95 %, 0,93-5,24). Toutefois, tous les domaines de données agrégées sur la QVLS physique ont été classifiés en faibles effets, et aucun domaine de la QVLS n’a excédé la différence minimale clinique importante prédéfinie.
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: See editorial by Goodman and Marzolini, pages 235–237 of this issue.

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Systematic Review/Meta-analysisThe Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis

Abstract

Background

Methods

Results

Conclusions

Résumé

Contexte

Méthodologie

Résultats

Conclusions

Section snippets

Methods

Study demographic characteristics

Discussion

Acknowledgements

Disclosures

Curr Probl Cardiol

J Am Coll Cardiol

Int J Cardiol

J Clin Epidemiol

Int J Nurs Stud

CHD mortality projections to 2020, comparing different policy scenarios

Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews

Cochrane Database of Systematic Reviews

The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology

J Am Coll Cardiol

BACPR scientific statement: British standards and core components for cardiovascular disease prevention and rehabilitation

Heart

Circulation

The contribution of individual exercise training components to clinical outcomes in randomised controlled trials of cardiac rehabilitation: a systematic review and meta-regression

Sports Med Open

Exercise-based cardiac rehabilitation for coronary heart disease

Cochrane Database Syst Rev

Cochrane Handbook for Systematic Reviews of Interventions Version 5.1

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

Estimating effect sizes from pretest-posttest-control group designs

Organ Res Methods

The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials

BMJ

Combining scores from different patient reported outcome measures in meta-analyses: when is it justified?

Health Qual Life Outcomes

Systematic Review/Meta-analysis
The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis