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

  • L.J. Anderson
    Exeter Cochrane Cardiac Rehabilitation Review Group, Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, United Kingdom
    Search for articles by this author
  • R.S. Taylor
    Corresponding author at: Institute of Health Research, University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, United Kingdom. Tel.: +44 1392 406980.
    Exeter Cochrane Cardiac Rehabilitation Review Group, Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, United Kingdom
    Search for articles by this author


      • A contemporary review of the evidence for cardiac rehabilitation (CR) is presented.
      • The findings of six Cochrane systematic reviews of 148 RCTs of CR are summarised.
      • Exercise-based CR is effective and safe for stable patients with HF or post-MI or PCI.
      • We present recommendations for design and conduct of future RCTs and systematic reviews of CR.



      Overviews are a new approach to summarising evidence and synthesising results from related systematic reviews.


      To conduct an overview of Cochrane systematic reviews to provide a contemporary review of the evidence for cardiac rehabilitation (CR), identify opportunities for merging or splitting existing Cochrane reviews, and identify current evidence gaps to inform new review titles.


      The Cochrane Database of Systematic Reviews was searched to identify reviews that address the objectives of this overview. Data presentation is descriptive with tabular presentations of review- and trial-level characteristics and results.


      The six included Cochrane systematic reviews were of high methodological quality and included 148 randomised controlled trials in 97,486 participants. Compared to usual care alone, exercise-based CR reduces hospital admissions and improves patient health related quality of life (HRQL) in low to moderate risk heart failure and coronary heart disease (CHD) patients. At 12 months or more follow-up, there was evidence of some reduction in mortality in patients with CHD. Psychological- and education-based interventions appear to have little impact on mortality or morbidity but may improve HRQL. Home- and centre-based programmes are equally effective in improving HRQL at similar costs. Selected interventions can increase the uptake of CR programmes but evidence to support interventions that improve adherence is weak.


      This overview confirms that exercise-based CR is effective and safe in the management of clinically stable heart failure and post-MI and PCI patients. We discuss the implications of this overview on the future direction of the Cochrane CR reviews portfolio.


      To read this article in full you will need to make a payment


      Subscribe to International Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • British Association for Cardiovascular Prevention, Rehabilitation
        The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation.
        in: 2nd ed. 2012 ([])
        • Moseley A.M.
        • Elkins M.R.
        • Herbert R.D.
        • Maher C.G.
        • Sherrington C.
        Cochrane reviews used more rigorous methods than non-Cochrane reviews: survey of systematic reviews in physiotherapy.
        J Clin Epidemiol. 2009; 62: 1021-1030
        • Wen J.
        • Ren Y.
        • Wang L.
        • Li Y.
        • Liu Y.
        • Zhou M.
        • et al.
        The reporting quality of meta-analyses improves: a random sampling study.
        J Clin Epidemiol. 2008; 61: 770-775
        • Collier A.
        • Heilig L.
        • Schilling L.
        • Williams H.
        • Dellavalle R.P.
        Cochrane Skin Group systematic reviews are more methodologically rigorous than other systematic reviews in dermatology.
        Br J Dermatol. 2006; 155: 1230-1235
        • Oldridge N.B.
        • Guyatt G.H.
        • Fischer M.E.
        • Rimm A.A.
        Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials.
        JAMA. 1988; 260: 945-950
        • O'Connor G.T.
        • Buring J.E.
        • Yusuf S.
        • Goldhaber S.Z.
        • Olmstead E.M.
        • Paffenbarger Jr., R.S.
        • et al.
        An overview of randomized trials of rehabilitation with exercise after myocardial infarction.
        Circulation. 1989; 80: 234-244
        • Jolliffe J.A.
        • Rees K.
        • Taylor R.S.
        • Thompson D.
        • Oldridge N.
        • Ebrahim S.
        Exercise-based rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2001; ([CD001800])
        • Taylor R.S.
        • Sagar V.A.
        • Davies E.J.
        • Briscoe S.
        • Coats A.J.
        • Dalal H.
        • et al.
        Exercise-based rehabilitation for heart failure.
        Cochrane Database Syst Rev. 2014; 4 ([CD003331])
        • Taylor R.S.
        • Dalal H.
        • Jolly K.
        • Zawada A.
        Home-based versus centre-based cardiac rehabilitation.
        Cochrane Database Syst Rev. 2014; ([in press])
        • Heran B.S.
        • Chen J.M.
        • Ebrahim S.
        • Moxham T.
        • Oldridge N.
        • Rees K.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2011; ([CD001800])
        • Whalley B.
        • Rees K.
        • Davies P.
        • Bennett P.
        • Ebrahim S.
        • Liu Z.
        • et al.
        Psychological interventions for coronary heart disease.
        Cochrane Database Syst Rev. 2011; ([CD002902])
        • Brown J.P.
        • Clark A.M.
        • Dalal H.
        • Welch K.
        • Taylor R.S.
        Patient education in the management of coronary heart disease.
        Cochrane Database Syst Rev. 2011; ([CD008895])
        • Karmali K.N.
        • Davies P.
        • Taylor F.
        • Beswick A.
        • Martin N.
        • Ebrahim S.
        Promoting patient uptake and adherence in cardiac rehabilitation.
        Cochrane Database Syst Rev. 2014; 6 ([CD007131])
        • Becker L.
        • Oxman A.
        Chapter 22: overviews of reviews.
        in: Higgins J. Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 510 [updated March 2011]. The Cochrane Collaboration. 2011 ([Available from])
        • Kung J.
        • Chiappelli F.
        • Cajulis O.O.
        • Avezova R.
        • Kossan G.
        • Chew L.
        • et al.
        From systematic reviews to clinical recommendations for evidence-based health care: validation of revised assessment of multiple systematic reviews (R-AMSTAR) for grading of clinical relevance.
        Open Dent J. 2010; 4: 84-91
        • Shea B.J.
        • Hamel C.
        • Wells G.A.
        • Bouter L.M.
        • Kristjansson E.
        • Grimshaw J.
        • et al.
        AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.
        J Clin Epidemiol. 2009; 62: 1013-1020
        • Higgins J.
        Chapter 8: assessing risk of bias in included studies.
        in: Higgins J. Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 510 (updated March 2011). The Cochrane Collaboration. 2011 ([Available from])
        • Bushman B.J.
        Vote-counting procedures in meta-analysis.
        in: Cooper H. Hedges L.V. The handbook of research synthesis. Russell Sage Foundation, New York1984: 193-213
        • Comparing Multiple Interventions Methods Group
        Undertaking, publishing and maintaining Cochrane Reviews that compare multiple interventions.
        • Hulzebos Erik H.J.
        • Smit Y.
        • Helders Paul
        • van Meeteren P.J.M.
        • LU Nico
        Preoperative physical therapy for elective cardiac surgery patients.
        Cochrane Database Syst Rev. 2012; ([CD010118.pub2])
        • P.RE.COR.
        • Leizoroviez A.
        • Saint-Pierre A.
        • Vasselon C.
        • Boissel J.P.
        Comparison of a rehabilitation programme, a counselling programme and usual care after an acute myocardial infarction: results of a long-term randomized trial.
        Eur Heart J. 1991; 12: 612-616
        • Lisspers J.
        • Sundin O.
        • Hofman-Bang C.
        • Nordlander R.
        • Nygren A.
        • Ryden L.
        • et al.
        Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized controlled study.
        J Psychosom Res. 1999; 46: 143-154
        • Miller N.H.
        • Haskell W.L.
        • Berra K.
        • DeBusk R.F.
        Home versus group exercise training for increasing functional capacity after myocardial infarction.
        Circulation. 1984; 70: 645-649
        • Stern M.J.
        • Gorman P.A.
        • Kaslow L.
        The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction.
        Arch Intern Med. 1983; 143: 1719-1725
        • Duncan K.
        • Pozehl B.
        Effects of an exercise adherence intervention on outcomes in patients with heart failure.
        Rehabil Nurs. 2003; 28: 117-122
        • Esposito D.
        • Brown R.
        • Chen A.
        • Schore J.
        • Shapiro R.
        Impacts of a disease management program for dually eligible beneficiaries.
        Health Care Financ Rev. 2008; 30: 27-45
        • Georgiou D.
        • Chen Y.
        • Appadoo S.
        • Belardinelli R.
        • Greene R.
        • Parides M.K.
        • et al.
        Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure.
        Am J Cardiol. 2001; 87 ([A4]): 984-988
        • Flynn K.E.
        • Pina I.L.
        • Whellan D.J.
        • Lin L.
        • Blumenthal J.A.
        • Ellis S.J.
        • et al.
        Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial.
        JAMA. 2009; 301: 1451-1459
        • Brown A.
        • Taylor R.
        • Noorani H.
        • Stone J.A.
        • Skidmore B.
        Exercise-based cardiac rehabilitation programs for coronary artery disease: a systematic clinical and economic review.
        Canadian Coordinating office for Health Technology Assessment. Technology report #34. 2003
        • Lawler P.R.
        • Filion K.B.
        • Eisenberg M.J.
        Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials.
        Am Heart J. 2011; 162: 571-84 e2
        • Piepoli M.F.
        • Davos C.
        • Francis D.P.
        • Coats A.J.
        • ExTra M.C.
        Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH).
        BMJ. 2004; 328: 189
        • Haykowsky M.J.
        • Liang Y.
        • Pechter D.
        • Jones L.W.
        • McAlister F.A.
        • Clark A.M.
        A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed.
        J Am Coll Cardiol. 2007; 49: 2329-2336
        • Hwang R.
        • Marwick T.
        Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis.
        Eur J Cardiovasc Prev Rehabil. 2009; 16: 527-535
        • Taylor R.S.
        • Cochrane Review Authors
        The RAMIT trial: its results in the context of 2012.
        Cochrane Rev Heart. 2012; 98: 672-673
        • West R.R.
        • Jones D.A.
        • Henderson A.H.
        Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction.
        Heart. 2012; 98: 637-644
        • Mills E.J.
        • Thorlund K.
        • Ioannidis J.P.
        Demystifying trial networks and network meta-analysis.
        BMJ. 2013; 346: f2914
        • Cipriani A.
        • Higgins J.P.
        • Geddes J.R.
        • Salanti G.
        Conceptual and technical challenges in network meta-analysis.
        Ann Intern Med. 2013; 159: 130-137
        • Oldridge N.
        Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited.
        Future Cardiol. 2012; 8: 729-751
        • Clark A.M.
        • Hartling L.
        • Vandermeer B.
        • McAlister F.A.
        Meta-analysis: secondary prevention programs for patients with coronary artery disease.
        Ann Intern Med. 2005; 143: 659-672
        • Bucher H.C.
        • Guyatt G.H.
        • Griffith L.E.
        • Walter S.D.
        The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials.
        J Clin Epidemiol. 1997; 50: 683-691
        • Clark A.M.
        What are the components of complex interventions in healthcare? Theorizing approaches to parts, powers and the whole intervention.
        Soc Sci Med. 2013; 93: 185-193
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • Milne R.
        • Perera R.
        • Moher D.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • Butler J.
        • Casey D.E.
        • Drazner M.H.
        • et al.
        2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 62: e147-e239
        • NICE
        MI – secondary prevention.
        in: Excellence NIfHaC Secondary prevention in primary and secondary care for patients following a myocardial infarction. 2013
        • Balady G.J.
        • Williams M.A.
        • Ades P.A.
        • Bittner V.
        • Comoss P.
        • Foody J.M.
        • 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; 115: 2675-2682
        • Goble A.
        • Worcester M.
        Best practice guidelines for cardiac rehabilitation and secondary prevention.
        Heart Research Centre on behalf of Department of Human Services Victoria, Melbourne1999 ([URL: 1999])
        • Sagar V.
        • Davies E.
        • Briscoe S.
        • Coats A.J.
        • Dalal H.
        • Lough F.
        • et al.
        Exercise-based rehabilitation for heart failure: systematic review and meta-analysis.
        Open Heart. 2014; 4 ([CD003331])