Exercise-based cardiac rehabilitation may improve the quality of life and physical fitness of people with heart failure but does not reduce their risk of being admitted to hospital or dying. This is irrespective of factors such as age and ethnicity.
This NIHR study summarised the outcome data from trials assessing exercise programmes for over 4,000 people with heart failure. At an individual level, the review looked for any improvements in physical symptoms and the psychological impacts of living with such a long-term condition. In particular, the study sought to find out whether individual patient characteristics influenced effectiveness.
While the evidence did not demonstrate any substantial gains in terms of mortality and hospital admission, there were tangible improvements relating to exercise capacity and health-related quality of life. This supports current NICE guidance recommending the use of exercise-based programmes and, crucially, confirms that all patients can gain from rehabilitation, regardless of their age, sex, current fitness level or disease severity.
Why was this study needed?
Over 900,000 people in the UK are living with heart failure, a long-term condition that affects the heart’s ability to pump blood effectively. Symptoms, including shortness of breath and fatigue, can seriously restrict a person’s ability to carry out their daily activities. Life expectancy is reduced.
Diverse cardiac rehabilitation programmes can help alleviate symptoms and enable people to live a less restricted life. Programmes aim to approach both the physical and emotional aspects of the condition by incorporating exercise and patient education.
Although research on this topic exists, little is known about whether patient characteristics such as age and gender influence effectiveness. This study sought to explore how different patient subgroups respond to exercise-based rehabilitation.
What did this study do?
This NIHR health technology assessment incorporated data from 23 randomised controlled trials of 4,398 people with heart failure. Trials were either European or North American and were published between 1990 and 2012. All assessed an aerobic exercise-based rehabilitation intervention predominantly delivered in a clinic or hospital setting (rather than home-based) and compared these to a control group who had no prescribed exercise.
The quality was moderate to good, and the baseline characteristics of participants were similar across intervention and control groups. The amount of exercise prescribed varied greatly across programmes: 15 to 120 minutes per session, two to seven sessions per week, and lasting from 12 to 90 weeks. This lack of consistency makes it more difficult to recommend which programme intensity is best.
What did it find?
- Exercise capacity improved with the rehabilitation, as assessed by the six-minute walk test (6MWT). From a baseline of around 368m in each group, the exercise-based rehabilitation group were able to walk 21m further at the 12-month follow-up (95% confidence interval [CI] 1.57 to 40.4m).
- Health-related quality of life, as assessed by the Minnesota living with heart failure questionnaire, improved slightly in the exercise-based rehabilitation group, reducing by 6 points more than the control group (95% CI –1.0 to –10.9) on a scale of 0 (no symptoms) to 105 (very poor quality of life).
- Exercise-based rehabilitation slightly improves exercise capacity and quality of life irrespective of individual patient characteristics. This includes age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology (cause of reduced blood supply), ejection fraction (proportion of blood pumped out of the heart) and baseline exercise capacity. None appears to have any significant bearing upon results.
- Exercise-based rehabilitation did not affect the risk of death from any cause (hazard ratio [HR] 0.83 (95% CI 0.67 to 1.04) or death due to heart failure (HR 0.84, 95% CI 0.48 to 1.46).
- Similarly, there was no difference in risk of any hospitalisation (HR of 0.90, 95% CI 0.76 to 1.06), or heart failure-specific hospitalisation (HR 0.98, 95% CI 0.72 to 1.35).
What does current guidance say on this issue?
NICE 2018 guidance recommends offering personalised exercise-based cardiac rehabilitation programmes to heart failure patients. They suggest all patients should be assessed before embarking on a programme to ensure it will be suitable for them.
Programmes should be provided in a setting that is easily accessible for the person, be that home or hospital. It should also include both psychological and educational components.
What are the implications?
People with heart failure may be more inclined to start and adhere to exercise-based rehabilitation programmes if they are aware of the likely benefits. Being able to lead a less restricted day to day life may be as much of an incentive for some people as outcomes such as hospitalisation and mortality.
Healthcare professionals working with this patient group can help by ensuring patients receive appropriate information to aid their decision making.
Citation and Funding
Taylor RS, Walker S, Ciani O et al. Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis. Health Technol Assess. 2019; 23(25).
This project was funded by the NIHR Health Technology Assessment Programme (project number 15/80/30).
BHF. Cardiac rehabilitation. London: British Heart Foundation; 2019.
BHF. National Audit of Cardiac Rehabilitation (NACR) Quality and Outcomes report 2018. London: British Heart Foundation; 2018.
Long L, Mordi IR, Bridges C et al. Exercise‐based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019;(1):CD003331.
NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.
NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre