Review question
We compared home-based cardiac rehabilitation programmes (including those that involve use of digital technology, such as websites and apps) with supervised centre-based cardiac rehabilitation for adults with myocardial infarction (blood flow to the heart has stopped), angina (chest pain), heart failure (heart is unable to pump blood around the body properly) or who had undergone revascularisation (surgery to restore blood flow).
Background
Cardiac rehabilitation aims to restore people with heart disease to health, through a combination of exercise, education, and psychological support. Traditionally, centre-based cardiac rehabilitation programmes (e.g. based at a hospital, gymnasium or in community/sport centre) are offered to people after cardiac events. Home-based cardiac rehabilitation programmes, which can include digital platforms, have been introduced to increase access and participation.
Search date
We searched up to September 2022.
Study characteristics
We searched for randomised controlled trials (trials that randomly allocate participants to one of two or more treatment groups) looking at the effectiveness of home-based (which may include digital/telehealth technology) versus supervised centre-based cardiac rehabilitation programmes, in adults with heart disease.
We included 24 trials (3046 participants). We also found nine more studies and 14 trial registrations but they are ongoing or yet to be included in analyses. Most trials were relatively small (median 104 participants, range: 20 to 525). The average age of trial participants ranged from 51.6 to 69 years. Women accounted for only 19% of recruited participants; four trials did not include women. All trials included centre- and home-based models of delivery that required supervision (either in person or remote) by healthcare professionals. Four trials used digital/telehealth technology to support their home-based delivery.
Diagnoses recruited for the trials varied: nine studies included a mixed population with coronary heart disease, six studies in those who had experienced a heart attack/myocardial infarction, four studies following revascularisation, and five in those with heart failure.
Key results
We found that home- and centre-based cardiac rehabilitation programmes are similar in benefits, measured in terms of numbers of deaths, exercise capacity and health-related quality of life. Further data are needed to confirm if these short-term effects of home/digital & telehealth- and centre-based cardiac rehabilitation can be sustained over time.
Quality of the evidence
Evidence quality ranged from low (total mortality), to moderate (exercise capacity over 12 months and health-related quality of life). The main reasons for the low assessment of quality was poor study reporting.
This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services.
Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery.
Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.
Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.
To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease
We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.
We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.
Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.
We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported.
No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.