Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis

Abstract

A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane’s tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54–0.85) and ET (HR = 0.75, 95% CrI = 0.60–0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57–0.99), ET (HR = 0.75, 95% CrI = 0.56–0.99) and PE (HR = 0.68, 95% CrI = 0.47–0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58–0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.

Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis

“…Planned coaching combined with counselling can reduce these levels [36]. Cardiac rehabilitation programmes [107,108] and cognitive-behavioural therapies are also available, which reduce the levels of depression and even decrease the length of hospital stays [109]. However, further studies are needed to understand the potential prognostic implication of depression and investigate the best ways to approach the treatment of depression in this patient group.…”

Managed Care after Acute Myocardial Infarction (KOS-zawał) reduces major adverse cardiovascular events by 45% in 3-month follow-up – single-center results of Poland’s National Health Fund program of comprehensive post-myocardial infarction care

“…In the most complex meta-analysis by Kabboul et al [15] (148 studies, 50965 patients), in which not only exercise capacity but also nutritional counseling, risk factor modification, psychosocial management, and patient education were ana-lyzed, the authors found that different components of a complex CR program have a different effect on adverse events reduction. Not only physical training but also psychosocial management and patient education were found to influence the endpoints.…”

What is rehabilitation? An empirical investigation leading to an evidence-based description

“…For example, in cardiac rehabilitation, a recent review identified five core components of an effective programme. 51 Three of the components are applicable to almost all conditions -exercise training, psychosocial management, and patient education. Two could be considered more specific to cardiac disease, nutritional counselling and risk factor modification, but alternatively they could be considered specific aspects of patient education.…”