How effective is cardiac rehabilitation to improve physical activity habits?

A systematic review

Nienke ter Hoeve, Bionka Huisstede, Henk Stam, Ron van Domburg,

Madoka Sunamura, Rita van den Berg-Emons

Rotterdam

Cardiac Rehabilitation (CR) is multidisciplinairy

• group exercise sessions twice a week

• group education sessions on lifestyle and cardiovascular risk factors

• smoking cessation/ nutritional counseling/stress management

Health benefits

20-30% reduction mortality

favourable effects several cardiovascular risk factors

Guidelines CR:

“minimum of 5 times 30 minutes of moderate-intensity activities per week”

Known: CR programmes improve risk factors, quality of life, physical fitness

Unknown: are CR programmes sufficient to improve activity level

Goal cardiac rehabilitation: improving physical activity levels

To review the short-term (<6 months) & long-term (>6 months) effects of CR on physical activity levels

1. Literature search

– Search string

2. Study selection

– In- & exclusion criteria

– title, abstract, full text

Performing a systematic review

I. Study population: patients with an acute coronary syndrome

II. Intervention: exercise-based CR

III. Outcome measure: physical activity level

IV. Minimal follow-up: completion of CR

V. The article was written in English, Dutch,

French or German

Inclusion criteria

26 RCTs

CR vs. no intervention (9)

CR of different duration (10)

Two different types of CR (7)

1. Literature search

2. Study selection

3. Data extraction -short/mid/long duration CR

-short/long term results

4. Quality assessment

5. Data analysis

Performing a systematic review

Data analysis: best-evidence synthesis

Duration CR RCT low/high quality

short-term effects < 6mnts after

completion CR

long term-effects ≥6 mnts after

completion CR

Centre-based CR versus no intervention

short (1-3mnts) Best evidence synthesis: limited evidence moderate evidence

medium (4-11mnts) Best evidence synthesis: no evidence limited evidence

long (≥12 mnts) Best evidence synthesis: conflicting evidence no RCT

Home-based CR versus no intervention

short (1- 3mnts) no RCT

medium (4-11mnts) no RCT

long (≥12 mnts) Best evidence synthesis: moderate evidence no evidence

CR versus no intervention?

Conclusion: no clear evidence for centre-based CR, more research needed for

home-based CR

Duration RCT

short-term effects < 6mtns after completion

CR

long-term effects ≥6mnts after completion CR

Centre-based vs home-based

short (1-3mnts) Best evidence synthesis: no RCT no evidence

mid (4-11mnts) Best evidence synthesis: no RCT moderate evidence

long (≥12 mnts) Best evidence synthesis: no evidence no RCT

Centre-based versus home-based

Conclusion: Moderate evidence that home-based CR has better long-term effects,

more research needed

RCT low/high quality

short-term effects < 6mtns after

completion CR

long-term effects ≥6mnts after

completion CR

CR of medium (4-11mnts) versus short duration (1-3mnts)

Best evidence synthesis: conflicting evidence no evidence

CR of long (≥12 mnts) versus short duration (1-3mnts)

Best evidence synthesis: conflicting evidence no evidence

CR of long (≥12 mnts) versus medium duration (4-11mnts)

Best evidence synthesis: conflicting evidence no RCT

Conclusion: no clear evidence that extending duration is more effective

Optimal duration

Duration RCT

short-term effects < 6mtns after completion

CR

long-term effects ≥6mnts after completion CR

Low-volume vs high-volume training group

short (1-3mnts) Best evidence synthesis: no RCT no evidence

CR including a self-efficacy intervention to increase physical activity vs standard CR

mid(4-11mnts) Best evidence synthesis: no evidence no RCT

CR including self-monitoring to increase physical activity vs standard CR

mid(4-11mnts) Best evidence synthesis: no RCT limited evidence

CR based on problem-based learning to increase physical activity vs standard CR

long (≥12 mnts) Best evidence synthesis no evidence No RCT

Conclusion: no clear evidence that increasing training volume or adding an extra

intervention is more effective

Type of CR

Current standard CR seems insufficient to improve and maintain physical activity habits

No clear evidence that increasing training volume, extending duration or adding an extra intervention leads to greater physical activity levels

“Active lifestyle is essential, future research should focus on finding successful interventions “

Conclusions

Effective behavioral interventions (Chase 2011, Ferrier et al., 2011):

Motivational interviewing:

• self-monitoring

• goal-setting

• identifying barriers

• plan for relapse

3 sessions during CR, 3 booster sessions in first year after CR

OPTICARE: OPTimal CArdiac REhabilitation

2016:

“how to get and keep cardiac patients active?”

OPTICARE: OPTimal CArdiac REhabilitation

Randomized Controlled Trial:

300 intervention, 300 phone-based program, 300 controls