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BJSM Online First, published on October 27, 2016 as 10.1136/bjsports-2016-096864
PEDro systematic review update
Statistical methods
This section features a recent systematic review that is indexed on Dichotomous outcomes were expressed as risk ratios (RR) with
PEDro, the Physiotherapy Evidence Database (http://www.pedro. 95% CIs. Continuous outcomes were planned to be pooled using
org.au). PEDro is a free, web-based database of evidence relevant standardised mean differences (SMDs) and 95% CI. Random-
to physiotherapy. effects models were used to pool results. Heterogeneity was
explored by comparing the characteristics of included studies,
and using the χ2 test and I2 statistic. Length of follow-up was
PEDro systematic review defined as short term (6–12 months), medium term (13–
36 months) or long term (>36 months). Univariate meta-regression
update: exercise for coronary was undertaken to explore heterogeneity and examine potential
treatment effect modifiers.
heart disease RESULTS
Sixty-three trials (14 486 participants) were included in this
review. The mean age of participants ranged from 48 to
▸ Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, Taylor RS. 71 years, and most of them were men. Most trials included
Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database patients post-MI and postrevascularisation. The overall quality
Syst Rev 2016;(1):CD001800. of the evidence was assessed using the GRADE method.
CR was effective for reducing cardiovascular mortality when
BACKGROUND compared with usual care (RR 0.74, 95% CI 0.64 to 0.86, 27
Coronary heart disease (CHD) is the leading cause of death trials) but not for reducing total mortality (RR 0.96, 95% CI
worldwide.1 2 Owing to advances in treatments and a focus on 0.88 to 1.04, 47 trials), based on moderate quality evidence.
aggressive risk factor reduction, the mortality rate has decreased, There was low quality evidence that CR reduced the overall risk
especially in older people.1 This means that more people with of hospitalisation (RR 0.82, 95% CI 0.70 to 0.96, 15 trials). CR
CHD will survive and will thus require ongoing management of had no significant impact on the risk of MI with low quality evi-
their condition. Cardiac rehabilitation (CR) encompasses differ- dence (RR 0.90, 95% CI 0.79 to 1.04, 36 trials), CABG with
ent interventions such as exercise, risk factor education and moderate quality evidence (RR 0.96, 95% CI 0.80 to 1.16, 29
reduction, behaviour change and psychological support. trials) and PCI with moderate quality evidence (RR 0.85, 95%
Although exercise-based CR after a cardiac event is safe and CI 0.70 to 1.04, 18 trials).
recommended by multiple cardiac societies,3–5 it is still underu- Twenty trials assessed HRQL, but given the heterogeneity in
tilised.6 Exercise training has direct benefits on the cardiovascu- outcome measures and reporting methods, meta-analysis was
lar system and can also work indirectly, by reducing risk factors not carried out. Nevertheless, five trials showed significant
for CHD. improvement in nearly all of the subscales due to CR. Data
from four trials indicated that CR is a potentially cost-effective
AIM use of resources in terms of gain in quality-adjusted life years.
To determine the effectiveness and cost-effectiveness of exercise- Univariate meta-regression was performed to analyse the predic-
based CR (exercise training alone or in combination with psy- tors of clinical outcomes across the longest follow-ups. The bene-
chosocial or educational interventions) compared with usual fits in outcomes were not related to the patient population selected
care on mortality, morbidity and health-related quality of life (eg, MI, revascularisation), CR type (eg, setting, interventions) or
(HRQL) in patients with CHD. factors related to the study (eg, location, risk of bias).
SEARCHES AND INCLUSION CRITERIA LIMITATIONS
The searches from a 2011 Cochrane review7 was updated with Many of the included trials were small including only short-
studies published up to July 2014. The review included rando- term follow-up. Most trials did not include sufficient details of
mised controlled trials (RCTs) of exercise-based CR versus usual the patients included. Funnel plot asymmetry for the risk of MI
care (no structured exercise programme) with a follow-up and hospital admission is indicative of small-study bias and pos-
period of at least 6 months. Patients had to fit into one of these sible publication bias. There were insufficient data to stratify
categories: myocardial infarction (MI); revascularisation with trials by type of CHD.
either percutaneous coronary intervention (PCI) or coronary
artery bypass graft (CABG); active angina pectoris; or CHD as
defined by angiography.
CLINICAL IMPLICATIONS
Exercise-based CR provides benefits for reducing cardiovascular
mortality and hospitalisation, although it does not reduce total
INTERVENTIONS
mortality. All forms of CR appear to be equally effective. The
Exercise training (supervised or not) carried out in a CHD
generalisation of the findings of this review is limited by the
population. The intervention could be complemented be
small number of women and elderly patients as well as the lack
psychosocial interventions, educational interventions or both.
of description of the population in the trials.
The usual care group could not receive any sort of structured
exercise training or advice.
Ricardo C Deveza,1 Mark Elkins,2,3 Bruno T Saragiotto3
MAIN OUTCOMES 1
St Vincent’s Hospital, Sydney, New South Wales, Australia
The primary outcomes were total and cardiovascular mortality, 2
Centre for Education & Workforce Development, Sydney Local Health District,
MI (fatal or non-fatal), revascularisations (CABG or PCI) and Sydney, New South Wales, Australia
hospitalisations. The secondary outcomes were HRQL assessed 3
The George Institute for Global Health, Sydney Medical School, University of
by validated tools (eg, SF-36), costs and cost-effectiveness. Sydney, Sydney, New South Wales, Australia
Deveza RC, et al. Br J Sports Med Month 2016 Vol 0 No 0 1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
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PEDro systematic review update
Correspondence to Bruno T Saragiotto, The George Institute for Global Health, 2 Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016
Sydney Medical School, University of Sydney, SLevel 13, 321 Kent St, Sydney, update: a report from the American Heart Association. Circulation 2016;133:e38–360.
NSW 2000, Australia;
[email protected] 3 Balady GJ, Ades PA, Bittner VA, 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.
Contributors BTS selected the systematic review. RCD and BTS wrote the first draft
4 Perk J, De Backer G, Gohlke H, et al. European Guidelines on cardiovascular disease
of the manuscript. ME contributed to interpretation of the data and revision of the
prevention in clinical practice (version 2012). The Fifth Joint Task Force of the
final manuscript.
European Society of Cardiology and Other Societies on Cardiovascular Disease
Competing interests None declared. Prevention in Clinical Practice (constituted by representatives of nine societies and by
invited experts). Eur Heart J 2012;33:1635–701.
Provenance and peer review Not commissioned; externally peer reviewed. 5 Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk
reduction therapy for patients with coronary and other atherosclerotic vascular disease:
To cite Deveza RC, Elkins M, Saragiotto BT. Br J Sports Med Published Online First: 2011 update: a guideline from the American Heart Association and American College
[ please include Day Month Year] doi:10.1136/bjsports-2016-096864 of Cardiology Foundation endorsed by the World Heart Federation and the Preventive
Accepted 12 October 2016 Cardiovascular Nurses Association. J Am Coll Cardiol 2011;58:2432–46.
6 Bethell H, Lewin R, Evans J, et al. Outpatient cardiac rehabilitation attendance in
Br J Sports Med 2016;0:1–2. doi:10.1136/bjsports-2016-096864 England: variability by region and clinical characteristics. J Cardiopulm Rehabil Prev
2008;28:386–91.
REFERENCES 7 Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for
1 Nichols M, Townsend N, Scarborough P, et al. Cardiovascular disease in Europe coronary heart disease. Cochrane Database Syst Rev 2011(7):CD001800.
2014: epidemiological update. Eur Heart J 2014;35:2950–9.
2 Deveza RC, et al. Br J Sports Med Month 2016 Vol 0 No 0
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PEDro systematic review update: exercise for
coronary heart disease
Ricardo C Deveza, Mark Elkins and Bruno T Saragiotto
Br J Sports Med published online October 27, 2016
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