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NIHR Signal Cardiac rehabilitation for heart failure can improve quality of life and fitness

Published on 6 August 2019

doi: 10.3310/signal-000803

Exercise-based cardiac rehabilitation may improve the quality of life and physical fitness of people with heart failure but does not reduce their risk of being admitted to hospital or dying. This is irrespective of factors such as age and ethnicity.

This NIHR study summarised the outcome data from trials assessing exercise programmes for over 4,000 people with heart failure. At an individual level, the review looked for any improvements in physical symptoms and the psychological impacts of living with such a long-term condition. In particular, the study sought to find out whether individual patient characteristics influenced effectiveness.

While the evidence did not demonstrate any substantial gains in terms of mortality and hospital admission, there were tangible improvements relating to exercise capacity and health-related quality of life. This supports current NICE guidance recommending the use of exercise-based programmes and, crucially, confirms that all patients can gain from rehabilitation, regardless of their age, sex, current fitness level or disease severity.

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Why was this study needed?

Over 900,000 people in the UK are living with heart failure, a long-term condition that affects the heart’s ability to pump blood effectively. Symptoms, including shortness of breath and fatigue, can seriously restrict a person’s ability to carry out their daily activities. Life expectancy is reduced.

Diverse cardiac rehabilitation programmes can help alleviate symptoms and enable people to live a less restricted life. Programmes aim to approach both the physical and emotional aspects of the condition by incorporating exercise and patient education.

Although research on this topic exists, little is known about whether patient characteristics such as age and gender influence effectiveness. This study sought to explore how different patient subgroups respond to exercise-based rehabilitation.

What did this study do?

This NIHR health technology assessment incorporated data from 23 randomised controlled trials of 4,398 people with heart failure. Trials were either European or North American and were published between 1990 and 2012. All assessed an aerobic exercise-based rehabilitation intervention predominantly delivered in a clinic or hospital setting (rather than home-based) and compared these to a control group who had no prescribed exercise.

The quality was moderate to good, and the baseline characteristics of participants were similar across intervention and control groups. The amount of exercise prescribed varied greatly across programmes: 15 to 120 minutes per session, two to seven sessions per week, and lasting from 12 to 90 weeks. This lack of consistency makes it more difficult to recommend which programme intensity is best.

What did it find?

  • Exercise capacity improved with the rehabilitation, as assessed by the six-minute walk test (6MWT). From a baseline of around 368m in each group, the exercise-based rehabilitation group were able to walk 21m further at the 12-month follow-up (95% confidence interval [CI] 1.57 to 40.4m).
  • Health-related quality of life, as assessed by the Minnesota living with heart failure questionnaire, improved slightly in the exercise-based rehabilitation group, reducing by 6 points more than the control group (95% CI –1.0 to –10.9) on a scale of 0 (no symptoms) to 105 (very poor quality of life).
  • Exercise-based rehabilitation slightly improves exercise capacity and quality of life irrespective of individual patient characteristics. This includes age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology (cause of reduced blood supply), ejection fraction (proportion of blood pumped out of the heart) and baseline exercise capacity. None appears to have any significant bearing upon results.
  • Exercise-based rehabilitation did not affect the risk of death from any cause (hazard ratio [HR] 0.83 (95% CI 0.67 to 1.04) or death due to heart failure (HR 0.84, 95% CI 0.48 to 1.46).
  • Similarly, there was no difference in risk of any hospitalisation (HR of 0.90, 95% CI 0.76 to 1.06), or heart failure-specific hospitalisation (HR 0.98, 95% CI 0.72 to 1.35).

What does current guidance say on this issue?

NICE 2018 guidance recommends offering personalised exercise-based cardiac rehabilitation programmes to heart failure patients. They suggest all patients should be assessed before embarking on a programme to ensure it will be suitable for them.

Programmes should be provided in a setting that is easily accessible for the person, be that home or hospital. It should also include both psychological and educational components.

What are the implications?

People with heart failure may be more inclined to start and adhere to exercise-based rehabilitation programmes if they are aware of the likely benefits. Being able to lead a less restricted day to day life may be as much of an incentive for some people as outcomes such as hospitalisation and mortality.

Healthcare professionals working with this patient group can help by ensuring patients receive appropriate information to aid their decision making.

Citation and Funding

Taylor RS, Walker S, Ciani O et al. Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis. Health Technol Assess. 2019; 23(25). 

This project was funded by the NIHR Health Technology Assessment Programme (project number 15/80/30).

Bibliography

BHF. Cardiac rehabilitation. London: British Heart Foundation; 2019.

BHF. National Audit of Cardiac Rehabilitation (NACR) Quality and Outcomes report 2018. London: British Heart Foundation; 2018.

Long L, Mordi IR, Bridges C et al. Exercise‐based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019;(1):CD003331.

NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.

NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

Over 900,000 people in the UK are living with heart failure, a long-term condition that affects the heart’s ability to pump blood effectively. Symptoms, including shortness of breath and fatigue, can seriously restrict a person’s ability to carry out their daily activities. Life expectancy is reduced.

Diverse cardiac rehabilitation programmes can help alleviate symptoms and enable people to live a less restricted life. Programmes aim to approach both the physical and emotional aspects of the condition by incorporating exercise and patient education.

Although research on this topic exists, little is known about whether patient characteristics such as age and gender influence effectiveness. This study sought to explore how different patient subgroups respond to exercise-based rehabilitation.

What did this study do?

This NIHR health technology assessment incorporated data from 23 randomised controlled trials of 4,398 people with heart failure. Trials were either European or North American and were published between 1990 and 2012. All assessed an aerobic exercise-based rehabilitation intervention predominantly delivered in a clinic or hospital setting (rather than home-based) and compared these to a control group who had no prescribed exercise.

The quality was moderate to good, and the baseline characteristics of participants were similar across intervention and control groups. The amount of exercise prescribed varied greatly across programmes: 15 to 120 minutes per session, two to seven sessions per week, and lasting from 12 to 90 weeks. This lack of consistency makes it more difficult to recommend which programme intensity is best.

What did it find?

  • Exercise capacity improved with the rehabilitation, as assessed by the six-minute walk test (6MWT). From a baseline of around 368m in each group, the exercise-based rehabilitation group were able to walk 21m further at the 12-month follow-up (95% confidence interval [CI] 1.57 to 40.4m).
  • Health-related quality of life, as assessed by the Minnesota living with heart failure questionnaire, improved slightly in the exercise-based rehabilitation group, reducing by 6 points more than the control group (95% CI –1.0 to –10.9) on a scale of 0 (no symptoms) to 105 (very poor quality of life).
  • Exercise-based rehabilitation slightly improves exercise capacity and quality of life irrespective of individual patient characteristics. This includes age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology (cause of reduced blood supply), ejection fraction (proportion of blood pumped out of the heart) and baseline exercise capacity. None appears to have any significant bearing upon results.
  • Exercise-based rehabilitation did not affect the risk of death from any cause (hazard ratio [HR] 0.83 (95% CI 0.67 to 1.04) or death due to heart failure (HR 0.84, 95% CI 0.48 to 1.46).
  • Similarly, there was no difference in risk of any hospitalisation (HR of 0.90, 95% CI 0.76 to 1.06), or heart failure-specific hospitalisation (HR 0.98, 95% CI 0.72 to 1.35).

What does current guidance say on this issue?

NICE 2018 guidance recommends offering personalised exercise-based cardiac rehabilitation programmes to heart failure patients. They suggest all patients should be assessed before embarking on a programme to ensure it will be suitable for them.

Programmes should be provided in a setting that is easily accessible for the person, be that home or hospital. It should also include both psychological and educational components.

What are the implications?

People with heart failure may be more inclined to start and adhere to exercise-based rehabilitation programmes if they are aware of the likely benefits. Being able to lead a less restricted day to day life may be as much of an incentive for some people as outcomes such as hospitalisation and mortality.

Healthcare professionals working with this patient group can help by ensuring patients receive appropriate information to aid their decision making.

Citation and Funding

Taylor RS, Walker S, Ciani O et al. Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis. Health Technol Assess. 2019; 23(25). 

This project was funded by the NIHR Health Technology Assessment Programme (project number 15/80/30).

Bibliography

BHF. Cardiac rehabilitation. London: British Heart Foundation; 2019.

BHF. National Audit of Cardiac Rehabilitation (NACR) Quality and Outcomes report 2018. London: British Heart Foundation; 2018.

Long L, Mordi IR, Bridges C et al. Exercise‐based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019;(1):CD003331.

NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.

NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.

Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis

Published on 29 May 2019

Taylor R S, Walker S, Ciani O, Warren F, Smart N A, Piepoli M & Davos C H.

Health Technology Assessment Volume 23 Issue 25 , 2019

Background Current national and international guidelines on the management of heart failure (HF) recommend exercise-based cardiac rehabilitation (ExCR), but do not differentiate this recommendation according to patient subgroups. Objectives (1) To obtain definitive estimates of the impact of ExCR interventions compared with no exercise intervention (control) on mortality, hospitalisation, exercise capacity and health-related quality of life (HRQoL) in HF patients; (2) to determine the differential (subgroup) effects of ExCR in HF patients according to their age, sex, left ventricular ejection fraction, HF aetiology, New York Heart Association class and baseline exercise capacity; and (3) to assess whether or not the change in exercise capacity mediates for the impact of the ExCR on final outcomes (mortality, hospitalisation and HRQoL), and determine if this is an acceptable surrogate end point. Design This was an individual participant data (IPD) meta-analysis. Setting An international literature review. Participants HF patients in randomised controlled trials (RCTs) of ExCR. Interventions ExCR for at least 3 weeks compared with a no-exercise control, with 6 months’ follow-up. Main outcome measures All-cause and HF-specific mortality, all-cause and HF-specific hospitalisation, exercise capacity and HRQoL. Data sources IPD from eligible RCTs. Review methods RCTs from the Exercise Training Meta-Analysis of Trials for Chronic Heart Failure (ExTraMATCH/ExTraMATCH II) IPD meta-analysis and a 2014 Cochrane systematic review of ExCR (Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014;4:CD003331). Results Out of the 23 eligible RCTs (4398 patients), 19 RCTs (3990 patients) contributed data to this IPD meta-analysis. There was a wide variation in exercise programme prescriptions across included studies. Compared with control, there was no statistically significant difference in pooled time-to-event estimates in favour of ExCR, although confidence intervals (CIs) were wide: all-cause mortality had a hazard ratio (HR) of 0.83 (95% CI 0.67 to 1.04); HF-related mortality had a HR of 0.84 (95% CI 0.49 to 1.46); all-cause hospitalisation had a HR of 0.90 (95% CI 0.76 to 1.06); and HF-related hospitalisation had a HR of 0.98 (95% CI 0.72 to 1.35). There was a statistically significant difference in favour of ExCR for exercise capacity and HRQoL. Compared with the control, improvements were seen in the 6-minute walk test (6MWT) (mean 21.0 m, 95% CI 1.57 to 40.4 m) and Minnesota Living with Heart Failure Questionnaire score (mean –5.94, 95% CI –1.0 to –10.9; lower scores indicate improved HRQoL) at 12 months’ follow-up. No strong evidence for differential intervention effects across patient characteristics was found for any outcomes. Moderate to good levels of correlation (R2trial > 50% and p > 0.50) between peak oxygen uptake (VO2peak) or the 6MWT with mortality and HRQoL were seen. The estimated surrogate threshold effect was an increase of 1.6 to 4.6 ml/kg/minute for VO2peak. Limitations There was a lack of consistency in how included RCTs defined and collected the outcomes: it was not possible to obtain IPD from all includable trials for all outcomes and patient-level data on exercise adherence was not sought. Conclusions In comparison with the no-exercise control, participation in ExCR improved the exercise and HRQoL in HF patients, but appeared to have no effect on their mortality or hospitalisation. No strong evidence was found of differential intervention effects of ExCR across patient characteristics. VO2peak and 6MWT may be suitable surrogate end points for the treatment effect of ExCR on mortality and HRQoL in HF. Future studies should aim to achieve a consensus on the definition of outcomes and promote reporting of a core set of HF data. The research team also seeks to extend current policies to encourage study authors to allow access to RCT data for the purpose of meta-analysis. Funding The National Institute for Health Research Health Technology Assessment programme.

Expert commentary

This review shows that exercise-based rehabilitation for chronic heart failure patients does not affect mortality or hospitalisation, but does lead to improvements in exercise capacity and health-related quality of life. Importantly, these effects are seen regardless of age, sex, ethnicity, initial level of physical fitness or disease severity. This supports the current international clinical guidelines that exercise-based rehabilitation should be offered to all those with heart failure and should not be limited to patient subgroups.

The authors highlight a need for future consistent collection, reporting and sharing of patient-level data by researchers to increase the potential to examine whether or not the effect of exercise-based rehabilitation varies with patient characteristics.

Coral Hanson, Research Fellow, Cardiovascular Health Theme, School of Health and Social Care, Edinburgh Napier University

The commentator declares no conflicting interests