Elsevier

Mayo Clinic Proceedings

Volume 92, Issue 11, November 2017, Pages 1644-1659
Mayo Clinic Proceedings

Original article
Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis

https://doi.org/10.1016/j.mayocp.2017.07.019Get rights and content

Abstract

Objective

To ascertain the effect of cardiac rehabilitation (CR) dose (ie, duration × frequency/wk; categorized as low [<12 sessions], medium [12-35 sessions], or high [≥36 sessions]) on mortality and morbidity.

Methods

The Cochrane, CINAHL, EMBASE, PsycINFO, and MEDLINE databases were systematically searched from inception through November 30, 2015. Inclusion criteria included randomized or nonrandomized studies with a minimum CR dose of 4 or higher and presence of a control/comparison group. Citations were considered for inclusion, and data were extracted in included studies independently by 2 investigators. Studies were pooled using random-effects meta-analysis and meta-regression where warranted (covariates included study quality, country, publication year, and diagnosis).

Results

Of 4630 unique citations, 33 trials were included comparing CR to usual care (ie, no dose). In meta-regression, greater dose was significantly related to lower all-cause mortality (high: −0.77; SE, 0.22; P<.001; medium: −0.80; SE, 0.21; P<.001) when compared with low dose. With regard to morbidity, meta-analysis revealed that dose was significantly associated with fewer percutaneous coronary interventions (high: relative risk, 0.65; 95% CI, 0.50-0.84; medium/low: relative risk, 1.04; 95% CI, 0.74-1.48; between subgroup difference P=.03). This reduction was also significant in meta-regression (high vs medium/low: −0.73; SE, 0.20; P<.001). Publication bias was not evident. No dose-response association was found for cardiovascular mortality, all-cause hospitalization, coronary artery bypass graft surgery, or myocardial infarction.

Conclusion

A minimum of 36 CR sessions may be needed to reduce percutaneous coronary interventions. Future studies should examine the effect of actual dose of CR, and trials are needed comparing different doses.

PROSPERO Registration

CRD42016036029.

Section snippets

Methods

A protocol was developed and registered in the International Prospective Register of Systematic Reviews (ID No. CRD42016036029).21 The methodology was based on the Cochrane Collaboration handbook.22

Search Results

Figure 1 displays the results of the search and application of inclusion/exclusion criteria. Authors of the primary studies included in Table 1 were contacted if these studies were not eligible for inclusion because of lack of information (ie, hazard ratios reported but not outcome event data; none responded). Ultimately, 33 studies were included (Table 2).

Study Characteristics

Characteristics of each included study are summarized in Table 2. Publication year ranged from 1972 to 2013 (median, 2005). With regard to

Discussion

Results from this first-ever meta-regression with a primary objective of examining CR dose suggest that dose of CCR may impact mortality and morbidity. Although a dose-response association was not observed for many outcomes, results suggested patients with CVD should be prescribed at least 36 sessions to reduce PCI. Results also suggested that patients should be prescribed at least 12 sessions to reduce all-cause mortality, although this recommendation warrants replication of our results

Conclusion

An important association exists between CCR sessions and all-cause mortality as well as PCI. There was 35.0% less PCI when CCR participants were prescribed at least 36 sessions. Overall results suggest a minimum of 12 CCR sessions may be needed to improve clinical outcomes, although greater benefits may be achieved with at least 36. Cardiac rehabilitation guidelines globally should promote prescription of at least this many sessions by all programs. Future studies should examine the effect of

Acknowledgments

We thank Saba Ali and Beatrice Luu for quality assessment and data extraction.

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