Exercise-based cardiac rehabilitation for adults after heart valve surgery

Background

Cardiac rehabilitation has been recommended as a treatment after heart valve surgery, but we have been unable to identify a previous systematic review of the evidence. This systematic review assesses the benefits and harms of exercise-based cardiac rehabilitation in adults who have undergone heart valve surgery.

Study characteristics

We searched for randomised clinical trials (experiments in which participants are randomly allocated to an experimental compared with a control intervention) examining the effect of exercise-based cardiac rehabilitation compared with no exercise after heart valve surgery for heart valve disease (from any cause) in adults (18 years or older). Our literature searches were undertaken up to March 2015.

Key results

We found two randomised clinical trials published in 1987 and 2004 that included a total of 148 participants. Due to the limited amount of data, we were not able to determine the effect of exercise-based rehabilitation on mortality, serious adverse events, health-related quality of life, ability to return to work, New York Heart Association class, left ventricular ejection fraction, or cost. However, exercise-based rehabilitation did appear to increase exercise capacity at up to 12 months follow-up, although this should be interpreted with caution as the included trials had a high risk of systematic error (bias). Further randomised clinical trials are needed to definitely understand the effect of physical exercise in adults after heart valve surgery.

Quality of the evidence

Given that the included studies are relatively old, and included narrowly-selected trial populations, the evidence is likely to be of limited applicability to clinical practice. Both trials had a high risk of bias (systematic errors) and the quality of the evidence was low. Due to the scarcity of the evidence there is also a high risk that the results may be subject to random errors (play of chance). Therefore, further high-quality randomised clinical trials are needed to assess the effects of exercise-based interventions.

Authors' conclusions: 

Our findings suggest that exercise-based rehabilitation for adults after heart valve surgery, compared with no exercise, may improve exercise capacity. Due to a lack of evidence, we cannot evaluate the impact on other outcomes. Further high-quality randomised clinical trials are needed in order to assess the impact of exercise-based rehabilitation on patient-relevant outcomes, including mortality and quality of life.

Read the full abstract...
Background: 

Exercise-based cardiac rehabilitation may benefit heart valve surgery patients. We conducted a systematic review to assess the evidence for the use of exercise-based intervention programmes following heart valve surgery.

Objectives: 

To assess the benefits and harms of exercise-based cardiac rehabilitation compared with no exercise training intervention, or treatment as usual, in adults following heart valve surgery. We considered programmes including exercise training with or without another intervention (such as a psycho-educational component).

Search strategy: 

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL); the Database of Abstracts of Reviews of Effects (DARE); MEDLINE (Ovid); EMBASE (Ovid); CINAHL (EBSCO); PsycINFO (Ovid); LILACS (Bireme); and Conference Proceedings Citation Index-S (CPCI-S) on Web of Science (Thomson Reuters) on 23 March 2015. We handsearched Web of Science, bibliographies of systematic reviews and trial registers (ClinicalTrials.gov, Controlled-trials.com, and The World Health Organization International Clinical Trials Registry Platform).

Selection criteria: 

We included randomised clinical trials that investigated exercise-based interventions compared with no exercise intervention control. The trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and received either heart valve replacement, or heart valve repair.

Data collection and analysis: 

Two authors independently extracted data. We assessed the risk of systematic errors (‘bias’) by evaluation of bias risk domains. Clinical and statistical heterogeneity were assessed. Meta-analyses were undertaken using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence. We sought to assess the risk of random errors with trial sequential analysis.

Main results: 

We included two trials from 1987 and 2004 with a total 148 participants who have had heart valve surgery. Both trials had a high risk of bias.

There was insufficient evidence at 3 to 6 months follow-up to judge the effect of exercise-based cardiac rehabilitation compared to no exercise on mortality (RR 4.46 (95% confidence interval (CI) 0.22 to 90.78); participants = 104; studies = 1; quality of evidence: very low) and on serious adverse events (RR 1.15 (95% CI 0.37 to 3.62); participants = 148; studies = 2; quality of evidence: very low). Included trials did not report on health-related quality of life (HRQoL), and the secondary outcomes of New York Heart Association class, left ventricular ejection fraction and cost. We did find that, compared with control (no exercise), exercise-based rehabilitation may increase exercise capacity (SMD -0.47, 95% CI -0.81 to -0.13; participants = 140; studies = 2, quality of evidence: moderate). There was insufficient evidence at 12 months follow-up for the return to work outcome (RR 0.55 (95% CI 0.19 to 1.56); participants = 44; studies = 1; quality of evidence: low). Due to limited information, trial sequential analysis could not be performed as planned.

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