Hasnain M Dalal

Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis.

Objective To compare the effect of home based and supervised centre based cardiac rehabilitation on mortality and morbidity, health related quality of life, and modifiable cardiac risk factors in patients with coronary heart disease. Design Systematic review. Data sources Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, CINAHL, and PsycINFO, without language restriction, searched from 2001 to January 2008. Review methods Reference lists checked and advice sought from authors. Included randomised controlled trials that compared centre based cardiac rehabilitation with home based programmes in adults with acute myocardial infarction, angina, or heart failure or who had undergone coronary revascularisation. Two reviewers independently assessed the eligibility of the identified trials and extracted data independently. Authors were contacted when possible to obtain missing information. Results 12 studies (1938 participants) were included. Most studies recruited patients with a low risk of further events after myocardial infarction or revascularisation. No difference was seen between home based and centre based cardiac rehabilitation in terms of mortality (relative risk 1.31, 95% confidence interval 0.65 to 2.66), cardiac events, exercise capacity (standardised mean difference −0.11, −0.35 to 0.13), modifiable risk factors (weighted mean difference systolic blood pressure (0.58 mm Hg, −3.29 mm Hg to 4.44 mm Hg), total cholesterol (−0.13 mmol/l, −0.31 mmol/l to 0.05 mmol/l), low density lipoprotein cholesterol (−0.15 mmol/l, −0.31 mmol/l to 0.01 mmol/l), or relative risk for proportion of smokers at follow-up (0.98, 0.73 to 1.31)), or health related quality of life, with the exception of high density lipoprotein cholesterol (−0.06, −0.11 to −0.02) mmol/l). In the home based participants, there was evidence of superior adherence. No consistent difference was seen in the healthcare costs of the two forms of cardiac rehabilitation. Conclusions Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients’ adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the “Heart Manual.” The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.

Cardiac rehabilitation in the United Kingdom

Cardiac rehabilitation (CR) is a cost-effective, life-enhancing and life-saving treatment for patients recovering from cardiac illness—from myocardial infarction, revascularisation, angina, heart failure, etc. Its main aims are to help the patient to recover as quickly and completely as possible and then to reduce to a minimum the chance of recurrence of the cardiac illness—it should be an integral step in the management of the patient’s condition. Despite the inclusion of CR in the National Service Framework for coronary heart disease only a minority of cardiac patients join CR programmes. Suggestions are made for increasing the uptake.

Achieving national service framework standards for cardiac rehabilitation and secondary prevention

Abstract Problem: Integrated care for patients who survive a myocardial infarction is lacking. Many patients are not offered cardiac rehabilitation, and secondary prevention is not optimal. Design: 12 month audit of 106 patients who survived an acute myocardial infarction. Background and setting: Carrick Primary Care Trust in Cornwall (population 98 500) and one district general hospital. Key measures for improvement: Proportion of patients who complete a cardiac rehabilitation programme after a myocardial infarction. Proportion of patients with optimal secondary prevention, as measured by smoking status, body mass index, cholesterol <5.0 mmol/l, and blood pressure <140/85 mm Hg. Strategies for change: We set up a novel, integrated, and seamless system for cardiac rehabilitation. We employed a cardiac liaison nurse to identify and assess in hospital all patients with suspected acute myocardial infarction. The nurse offered patients the choice of home based rehabilitation with the Heart Manual or hospital based rehabilitation. The nurse gave discharge details to the patients general practice; these were to be included on a practice based register of coronary heart disease. Effects of change: All 106 eligible patients were offered cardiac rehabilitation and were included in a practice based register of coronary heart disease to facilitate long term follow up in primary care. 47 (44%) patients chose home based rehabilitation with the Heart Manual, and 41 (87%) of these completed the programme; 35 (33%) patients chose hospital based rehabilitation, and 17 (49%) of these completed the programme. The numbers of patients achieving secondary prevention targets improved significantly: those with serum cholesterol <5.0 mmol/l at discharge increased from 28% at baseline to 75% at 12 months. Optimal care (at least 80-90% uptake of an intervention) was seen with antiplatelet and statin treatments and with smoking cessation. Significantly more patients were prescribed statins at follow up than at baseline (77/106 v 80/91, P=0.005). Lessons learnt: National service framework targets for cardiac rehabilitation and secondary prevention can be achieved in patients who survive a myocardial infarction by integrating rehabilitation services (home and hospital) with secondary prevention clinics in primary care. Nurse led clinics in primary care facilitate long term structured care and optimal secondary prevention.

Exercise-based rehabilitation for heart failure: systematic review and meta-analysis

Objective To update the Cochrane systematic review of exercise-based cardiac rehabilitation (CR) for heart failure. Methods A systematic review and meta-analysis of randomised controlled trials was undertaken. MEDLINE, EMBASE and the Cochrane Library were searched up to January 2013. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise interventions alone or as a component of comprehensive CR programme compared with no exercise control. Results 33 trials were included with 4740 participants predominantly with a reduced ejection fraction (<40%) and New York Heart Association class II and III. Compared with controls, while there was no difference in pooled all-cause mortality between exercise CR with follow-up to 1 year (risk ratio (RR) 0.93; 95% CI 0.69 to 1.27, p=0.67), there was a trend towards a reduction in trials with follow-up beyond 1 year (RR 0.88; 0.75 to 1.02, 0.09). Exercise CR reduced the risk of overall (RR 0.75; 0.62 to 0.92, 0.005) and heart failure-specific hospitalisation (RR 0.61; 0.46 to 0.80, 0.0004) and resulted in a clinically important improvement in the Minnesota Living with Heart Failure questionnaire (mean difference: −5.8 points, −9.2 to −2.4, 0.0007). Univariate meta-regression analysis showed that these benefits were independent of the type and dose of exercise CR, and trial duration of follow- up, quality or publication date. Conclusions This updated Cochrane review shows that improvements in hospitalisation and health-related quality of life with exercise-based CR appear to be consistent across patients regardless of CR programme characteristics and may reduce mortality in the longer term. An individual participant data meta-analysis is needed to provide confirmatory evidence of the importance of patient subgroup and programme level characteristics (eg, exercise dose) on outcome.

Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction

Primary care has a key role in improving the health of patients who have had a myocardial infarction Acute myocardial infarction remains a common cause of death worldwide. Despite decreases in mortality from coronary heart disease in most developed countries, mortality is increasing in most eastern European countries and developing countries.1 In the United Kingdom 1.2 million people are estimated to have survived heart attacks, yet few survivors are offered comprehensive cardiac rehabilitation.2 Effective implementation of secondary prevention is a great challenge,w1 and lack of implementation has been described as a collective failure of medical practice, as clear evidence shows that several interventions could reduce the risk of recurrent disease and death.3 Primary cares challenge is to make this happen. Two recent initiatives will change the face of secondary prevention in British primary care: Growing evidence shows suboptimal application of secondary prevention, and examples show how evidence based practice can be applied in primary care to improve the quality of care for patients with coronary heart disease.3–6 The number of patients in each practice, the benefits of continuity and the high frequency of comorbidity, and psychosocial problems have increased the role of the generalist. This puts primary care in the vanguard of saving lives.7 This review thus focuses on topics related to primary care. We searched Medline for relevant reviews related to secondary prevention (after acute myocardial infarction) and papers published in the past three years; …

Why do so few patients with heart failure participate in cardiac rehabilitation? A cross-sectional survey from England, Wales and Northern Ireland

Objectives To determine why so few patients with chronic heart failure in England, Wales and Northern Ireland take part in cardiac rehabilitation. Design Two-stage, postal questionnaire-based national survey. Participants and setting Stage 1: 277 cardiac rehabilitation centres that provided phase 3 cardiac rehabilitation in England, Wales and Northern Ireland registered on the National Audit of Cardiac Rehabilitation register. Stage 2: 35 centres that indicated in stage 1 that they provide a separate cardiac rehabilitation programme for patients with heart failure. Results Full data were available for 224/277 (81%) cardiac rehabilitation centres. Only 90/224 (40%) routinely offered phase 3 cardiac rehabilitation to patients with heart failure. Of these 90 centres that offered rehabilitation, 43% did so only when heart failure was secondary to myocardial infarction or revascularisation. Less than half (39%) had a specific rehabilitation programme for heart failure. Of those 134 centres not providing for patients with heart failure, 84% considered a lack of resources and 55% exclusion from commissioning contracts as the reason for not recruiting patients with heart failure. Overall, only 35/224 (16%) centres provided a separate rehabilitation programme for people with heart failure. Conclusions Patients with heart failure as a primary diagnosis are excluded from most cardiac rehabilitation programmes in England, Wales and Northern Ireland. A lack of resources and direct exclusion from local commissioning agreements are the main barriers for not offering rehabilitation to patients with heart failure.

Effect of patient education in the management of coronary heart disease: a systematic review and meta-analysis of randomized controlled trials:

Background: To assess the effects of patient education on mortality, morbidity, health-related quality of life (HRQoL), and healthcare costs in people with coronary heart disease (CHD). Design: Systematic review and meta-analysis. Methods: Data sources were Cochrane Library, Medline, Embase, PsycINFO, CINAHL, and ongoing trial registries until August 2010. We also checked study references. The study selection was based on design (randomized controlled trials with follow up of at least 6 months, published from 1990 onwards), population (adults with CHD), intervention (patient education stated to be the primary intervention), and comparators (usual care or no educational intervention). Results: Thirteen studies (68,556 people with CHD) were included. Educational interventions ranged from two visits to a 4-week residential stay with 11 months of reinforcement sessions. Compared to no educational intervention, there was weak evidence that education reduced all-cause mortality (pooled relative risk (RR) 0.79, 95% CI 0.55 to 1.13) and cardiac morbidity outcomes: myocardial infarction (pooled RR 0.63, 95% CI 0.26 to 1.48), revascularization (pooled RR 0.58, 95% CI 0.19 to 1.71), and hospitalization (pooled RR 0.83, 95% CI 0.65 to 1.07) at median 18-months follow up. There was evidence to suggest that education can improve HRQoL and decrease healthcare costs by reductions in downstream healthcare utilization. Conclusions: Our review had insufficient power to exclude clinically important effects of education on mortality and morbidity. Nevertheless it supports the practice of CHD secondary prevention and rehabilitation programmes including education as an intervention. Further research is needed to determine the most effective and cost-effective format, duration, timing, and methods of education delivery.

Heart failure patients’ attitudes, beliefs, expectations and experiences of self-management strategies: A qualitative synthesis

Objectives To develop a model of heart failure patients’ attitudes, beliefs, expectations, and experiences based on published qualitative research that could influence the development of self-management strategies. Methods A synthesis of 19 qualitative research studies using the method of meta-ethnography. Results This synthesis offers a conceptual model of the attitudes, beliefs, and expectations of patients with heart failure. Patients experienced a sense of disruption before developing a mental model of heart failure. Patients’ reactions included becoming a strategic avoider, a selective denier, a well-intentioned manager, or an advanced self-manager. Patients responded by forming self-management strategies and finally assimilated the strategies into everyday life seeking to feel safe. Discussion This conceptual model suggests that there are a range of interplaying factors that facilitate the process of developing self-management strategies. Interventions should take into account patients’ concepts of heart failure and their subsequent reactions.

Communicating the results of research: how do participants of a cardiac rehabilitation RCT prefer to be informed?

Objective  To determine the preferred means by which participants in a study of cardiac rehabilitation wish to be informed of the study’s results.

The efficacy of exercise-based cardiac rehabilitation: the changing face of usual care

We would like to take this opportunity to respond to the criticism of exercise-based cardiac rehabilitation systematic reviews/meta-analyses in the recent State-of-the-Art review from Drs. Sheridan and Julian [(1)][1]. The authors argue that small bias study/publication bias is a reason for concern