Research Article| Volume 221, P963-969, October 15, 2016

Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

  • Ann-Dorthe Zwisler
    Danish Centre of Rehabilitation and Palliative Care, University Hospital Odense, Odense, Denmark

    University of Southern Denmark, Odense, Denmark
    Search for articles by this author
  • Rebecca J. Norton
    Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, UK
    Search for articles by this author
  • Sarah G. Dean
    Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
    Search for articles by this author
  • Hayes Dalal
    Research, Development and Innovation, Knowledge Spa, Royal Cornwall Hospitals Trust, Truro, UK

    Primary Care Research Group, University of Exeter Medical School, Exeter, UK
    Search for articles by this author
  • Lars H. Tang
    Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    CopenRehab, Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

    Department of Physiotherapy and Occupational Therapy, Faculty of Health and Technology, Metropolitan University College, Copenhagen, Denmark
    Search for articles by this author
  • Jenny Wingham
    Research, Development and Innovation, Knowledge Spa, Royal Cornwall Hospitals Trust, Truro, UK

    Primary Care Research Group, University of Exeter Medical School, Exeter, UK
    Search for articles by this author
  • Rod S. Taylor
    Corresponding author at: Institute of Health Research, University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter EX1 2LU, UK.
    Primary Care Research Group, University of Exeter Medical School, Exeter, UK
    Search for articles by this author



      To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs.


      Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3 months were included — 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients).


      Compared to usual care, home-based CR improved VO2max (mean difference: 1.6 ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (−3.3, −7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3).


      Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.


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

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      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


        • Taylor R.S.
        • Sagar V.A.
        • Davies E.J.
        • Briscoe S.
        • Coats A.J.
        • Dalal H.
        • Lough F.
        • Rees K.
        • Singh S.
        Exercise-based rehabilitation for heart failure.
        Cochrane Database Syst. Rev. 2014; 4CD003331
        • Piepoli M.F.
        • Davos C.
        • Francis D.P.
        • Coats A.J.
        • ExTraMATCH Collaborative
        Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH).
        BMJ. 2004; 328: 189
        • Taylor R.S.
        • Davies E.J.
        • Dalal H.M.
        • Davis R.
        • Doherty P.
        • Cooper C.
        • Holland D.J.
        • Jolly K.
        • Smart N.A.
        Effects of exercise training for heart failure with preserved ejection fraction: a systematic review and meta-analysis of comparative studies.
        Int. J. Cardiol. 2012; 162: 6-13
        • Smart N.
        • Marwick T.H.
        Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity.
        Am. J. Med. 2004; 116: 693-706
        • National Institute for Health and Care
        Chronic heart failure. Management of chronic heart failure in adults in primary and secondary care. NICE clinical guideline CG108 2010.
        (last accessed 4th December 2015)
        • Pack Q.R.
        • Squires R.W.
        • Lopez-Jimenez F.
        • Lichtman S.W.
        • Rodriguez-Escudero J.P.
        • Lindenauer P.K.
        • Thomas R.J.
        Participation rates, process monitoring, and quality improvement among cardiac rehabilitation programs in the United States.
        J. Cardiopulm. Rehabil. Prev. 2015; 35: 173-180
        • Dalal H.M.
        • Wingham J.
        • Palmer J.
        • Taylor R.S.
        Why do so few patients with heart failure participate in cardiac rehabilitation? A cross-sectional survey from England, Wales and Northern Ireland.
        BMJ Open. 2012; 2e000787
        • Piepoli M.F.
        • Binno S.
        • Corrà U.
        • Seferovic P.
        • Conraads V.
        • Jaarsma T.
        • Schmid J.P.
        • Filippatos G.
        • Ponikowski P.P.
        Committee on Exercise Physiology & Training of the Heart Failure Association of the ESC. ExtraHF survey: the first European survey on implementation of exercise training in heart failure patients.
        Eur. J. Heart Fail. 2015; 17: 631-638
        • Johnson N.
        • Fisher J.
        • Nagle A.
        • Inder K.
        • Wiggers J.
        Factors associated with referral to outpatient cardiac rehabilitation services.
        J. Cardiopulm. Rehabil. Prev. 2004; 24: 165-170
        • Chien C.L.
        • Lee C.M.
        • Wu Y.W.
        • Wu Y.T.
        Home-based exercise improves the quality of life and physical function but not the psychological status of people with chronic heart failure: a randomised trial.
        J. Physiother. 2011; 57: 157-163
        • 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
        • Cowie A.
        • Thow M.K.
        • Granat M.H.
        • Mitchell S.L.
        A comparison of home and hospital-based exercise training in heart failure: immediate and long-term effects upon physical activity level.
        Eur. J. Cardiovasc. Prev. Rehabil. 2011; 18: 158-166
        • Daskapan A.
        • Arikan H.
        • Caglar N.
        • Tunali N.
        • Ataman S.
        Comparison of supervised exercise training and home-based exercise training in chronic heart failure.
        Saudi Med. J. 2005; 26: 842-847
        • Piotrowicz E.
        • Baranowski R.
        • Bilinska M.
        • Stepnowska M.
        • Piotrowska M.
        • Wójcik A.
        • Korewicki J.
        • Chojnowska L.
        • Malek L.A.
        • Klopotowski M.
        • Piotrowski W.
        • Piotrowicz R.
        A new model of home-based telemonitored cardiac rehabilitation in patients with heart failure: effectiveness, quality of life, and adherence.
        Eur. J. Heart Fail. 2010; 12: 164-171
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • The PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Br. Med. J. 2009; 339: b2535
        • Taylor R.S.
        • Dalal H.
        • Jolly K.
        • Zawada A.
        • Dean S.G.
        • Cowie A.
        • Norton R.J.
        Home-based versus centre-based cardiac rehabilitation.
        Cochrane Database Syst. Rev. 2015 Aug 18; 8CD007130
      1. Higgins JPT, Green S. [eds.] Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 [updated March 2011]. (last accessed 4th December 2015)

        • Egger M.
        • Davey Smith G.
        • Schneiger M.
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Uddin J.
        • Zwisler A.D.
        • Lewinter C.
        • Moniruzzaman M.
        • Lund K.
        • Tang L.H.
        • Taylor R.S.
        Predictors of exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure: a meta-regression analysis.
        Eur. J. Prev. Cardiol. 2016; 23: 683-693
        • 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
        • Ramadi A.
        • Haennel R.G.
        • Stone J.A.
        • Arena R.
        • Threlfall T.G.
        • Hitt E.
        • Aggarwal S.G.
        • Haykowsky M.
        • Martin B.-J.
        The sustainability of exercise capacity changes in home versus center-based cardiac rehabilitation.
        J. Cardiopulm. Rehabil. Prev. 2015; 35: 21-28
        • McMurray J.V.
        • Adamopoulos S.
        • Anker S.D.
        • et al.
        ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC.
        Eur. Heart J. 2012; 33: 1787-1847
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • 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
        • Dalal H.M.
        • Watt A.
        • Evans P.H.
        • Campbell J.L.
        • Read K.L.Q.
        • Mourant A.J.
        • Wingham J.
        • Thompson D.R.
        • Pereira Gray D.J.
        • Taylor R.S.
        Home-based cardiac rehabilitation versus hospital-based rehabilitation: a randomized controlled trial.
        Int. J. Cardiol. 2007; 119: 202-211
        • Grace S.
        • McDonald J.
        • Fishman D.
        • Caruso V.
        Patient preferences for home-based versus hospital-based cardiac rehabilitation.
        J. Cardpulm. Rehabil. 2005; 25: 24-29
        • Craig P.
        • Dieppe P.
        • Macintyre S.
        • Michie S.
        • Nazareth I.
        • Petticrew M.
        • Medical Research Council Guidance
        Developing and evaluating complex interventions: the new Medical Research Council guidance.
        BMJ. 2008; 337: a1655
        • Frederix I.
        • Vanhees L.
        • Dendale P.
        • Goetschalckx K.
        A review of telerehabilitation for cardiac patients.
        J. Telemed. Telecare. 2015; 21: 45-53
        • Taylor R.S.
        • Hayward C.
        • Eyre V.
        • Austin J.
        • Davies R.
        • Doherty P.
        • Jolly K.
        • Wingham J.
        • Van Lingen R.
        • Abraham C.
        • Green C.
        • Warren F.C.
        • Britten N.
        • Greaves C.J.
        • Singh S.
        • Buckingham S.
        • Paul K.
        • Dalal H.
        • REACH-HF investigators
        Clinical effectiveness and cost-effectiveness of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) facilitated self-care rehabilitation intervention in heart failure patients and caregivers: rationale and protocol for a multicentre randomised controlled trial.
        BMJ Open. 2015; 5: e009994
        • Jaarsma T.
        • Klompstra L.
        • Ben Gal T.
        • Boyne J.
        • Vellone E.
        • Bäck M.
        • Dickstein K.
        • Fridlund B.
        • Hoes A.
        • Piepoli M.F.
        • Chialà O.
        • Mårtensson J.
        • Strömberg A.
        Increasing exercise capacity and quality of life of patients with heart failure through Wii gaming: the rationale, design and methodology of the HF–Wii study; a multicentre randomized controlled trial.
        Eur. J. Heart Fail. 2015; 17: 743-748