Although cardiac rehabilitation has been defined as relevant to all patients with heart disease, most of the research to date concerns middle-aged white males with recent myocardial infarction or coronary artery surgery. Other groups, notably older patients, women and higher risk patients with heart failure or angina were excluded from most early trials^135,136,146 yet these groups make up the majority of patients with coronary heart disease.¹³⁷ A small, but increasing, amount of research has been conducted into the effects of cardiac rehabilitation in these subgroups. Evidence level 1+

4.1 Post myocardial infarction

As discussed in section 3.1, both exercise-only and comprehensive cardiac rehabilitation reduce all cause mortality and cardiac death, non fatal myocardial infarction and revascularisation.^93,135,136 Exercise has also been shown to improve physical performance, muscle strength, and symptoms of breathlessness and angina, whilst comprehensive cardiac rehabilitation aids psychological function, social recovery, return to work and biological risk factors.⁹¹ Rehabilitation programmes should be tailored to the needs of each individual patient (see section 1.2).

Comprehensive cardiac rehabilitation is recommended following myocardial infarction.

4.2 Post coronary bypass and angioplasty

The benefits of exercise-based cardiac rehabilitation for patients undergoing revascularisation were not considered separately in any of the reviews identified. Three randomised trials included in the Cochrane review reported the effects of exercise-based cardiac rehabilitation after bypass surgery,^138,139,140 while one comprised only patients who had undergone angioplasty.¹⁴¹ None of the studies reviewed were designed or powered to show the effect of cardiac rehabilitation on cardiovascular morbidity or mortality post revascularisation. Comprehensive cardiac rehabilitation led to lower serum lipids¹⁴⁰ and a perception of improved health¹³⁸ after bypass surgery, while exercise-only cardiac rehabilitation was associated with improved exercise capacity but had no effect on lipids or body weight.¹³⁹ Evidence level 1+

In the trial of cardiac rehabilitation following angioplasty included in the Cochrane review, the exercise group was less likely to require revascularisation during follow up.¹⁴¹ Possibly because they have not undergone bypass surgery or survived an MI, angioplasty patients make fewer lifestyle changes than other cardiac patients¹⁴² and are less likely to attend a cardiac rehabilitation programme.¹⁴³ Two additional randomised trials of cardiac rehabilitation post angioplasty were identified.^144,145 One found that comprehensive cardiac rehabilitation improved exercise capacity, diet and smoking but not quality of life or psychological factors,¹⁴⁴ while the other provided further evidence that comprehensive cardiac rehabilitation following angioplasty reduces the need for further revascularisation.¹⁴⁵ Evidence level 1+

Comprehensive cardiac rehabilitation is recommended for patients who have undergone coronary revascularisation.

4.3 Stable angina

Systematic reviews of exercise-only cardiac rehabilitation for patients with angina have shown that exercise training improves exercise capacity, symptoms and ischaemia.^{137,146,147,148,149} Comprehensive cardiac rehabilitation has shown similar benefits and either less progression or more regression of atherosclerosis in the intervention groups.^88,150 The programmes included in these studies were all more intensive than contemporary programmes in Scotland.²⁶ Evidence level 1++, 1+

Three more recent trials of exercise-only cardiac rehabilitation confirm that exercise training improves exercise capacity. One found improvements in myocardial ischaemia on exercise testing.¹⁵¹ One trial evaluated effects on quality of life and found improvements.¹⁵² Evidence from two trials suggests a dose response: there were more benefits with higher exercise intensity.^152,153 Two recent randomised controlled trials of comprehensive cardiac rehabilitation have also reported benefits. In one trial there were fewer cardiac events in the intervention group,¹⁵⁴ and in the other patients waiting for non urgent coronary artery bypass graft (CABG) had improved quality of life, although length of stay in hospital was reduced by an average of only one day.¹⁵⁵ Evidence level 1+

Comprehensive cardiac rehabilitation based predominantly on a cognitive behavioural approach was evaluated in one randomised trial involving 80 patients with angina.⁷³ There were improvements in exercise capacity, emotional distress, symptoms and disability. A randomised trial of health education for patients with angina in primary care found that it improved exercise, diet, and quality of life, but did not affect smoking rates, lipids, or blood pressure levels. ^156,157 Evidence level 1+

Patients with stable angina should be considered for comprehensive cardiac rehabilitation if they have limiting symptoms.

4.4 Chronic heart failure

Systematic reviews of exercise-based cardiac rehabilitation in stable, chronic heart failure have found benefits to exercise capacity and possibly to symptoms.^{35,146,147,148,149} Benefit is probably derived from peripheral adaptations (vasodilation and improved muscle oxidative capacity) rather than improvements in ventricular function. ^35,137,146 An RCT of exercise training in heart failure reported improvements in exercise capacity, myocardial perfusion, quality of life, total mortality and hospital admissions.¹⁵⁸ An overview of randomised trials in Europe¹⁵⁹ that included 134 patients concluded that exercise training improved exercise capacity and autonomic indices (e.g. heart rate variability), that training could be conducted either in hospital or at home, that 16 weeks was better than six and that a combination of cycle ergometry and calisthenics was better than cycle ergometry alone. Women did as well as men, and elderly patients were able to train free from complications and with benefit to symptoms, although less effectively than younger patients. Evidence level 1+

In a systematic review of comprehensive disease management for heart failure, there were fewer hospital attendances, and improved quality of life, functional capacity, patient satisfaction and compliance with diet and medications.¹⁶⁰ The studies in the review were small with selected participants (who tended to be elderly) and the interventions included education, social support, nurse follow up at home, graduated exercise, and sometimes psychological and pharmacist input. In a more recent randomised trial in Scotland, specialist nurses provided follow up to patients with heart failure by home visits and telephone contact.¹⁶¹ The intervention, which included education, disease monitoring and psychological support, reduced the risk of readmission to hospital for heart failure by more than half. Evidence level 1+

There is limited evidence on the effects of psychological and education only intervention in heart failure. One pre-post test study of 50 patients reported fewer hospital re-admissions.¹⁶² In one recent randomised trial,¹⁶³ education in hospital with one home visit was found to increase self-care, but had no impact on hospital attendance rates. Evidence level 2+, 1+

Patients with chronic heart failure should be considered for comprehensive cardiac rehabilitation if they have limiting symptoms.

4.5 Older patients

Although many patients with coronary disease are older than 75 years, this group has been excluded from many trials of cardiac rehabilitation. Systematic reviews indicate that older patients benefit at least as much as younger patients from exercise-based cardiac rehabilitation.^146,147,149 A recent randomised trial of exercise-only cardiac rehabilitation in 101 elderly patients with coronary disease^164,165,166 reported not only greater exercise tolerance, but also improved physical activity, quality of life and well-being. Evidence level 1+, 2++

One non-randomised controlled trial compared primary care-based comprehensive cardiac rehabilitation (counselling and exercise) with usual care.¹⁶⁷ Uptake of the exercise component was low (20%). Despite this, there were fewer hospital re-admissions and visits to emergency departments in the intervention group. These findings are in line with a systematic review of comprehensive disease management in patients with heart failure, most of whom were elderly.¹⁶⁰ Evidence level 2+, 1+

Older people should be included in comprehensive cardiac rehabilitation programmes.

4.6 Women

Women were excluded from most of the early studies of cardiac rehabilitation, accounting for between only 4% and 11% of patients enrolled in exercise-only and comprehensive cardiac rehabilitation trials.

Systematic reviews indicate that women benefit from exercise-based cardiac rehabilitation in terms of functional capacity at least as much as men.^147,168 A review of 134 patients with heart failure undergoing exercise training found that women benefited as much as men in terms of increased exercise capacity and improved autonomic indices.¹⁵⁹ Evidence level 2++, 2+

More women have been included in studies of psychological and educational interventions. In a recent review⁶⁵ up to 34% of patients in some studies were women, suggesting that the benefits reported are relevant to women as well as men. Another systematic review reported on 12 comprehensive programmes aimed at lifestyle change (most of which were based on education, although some included psychological interventions or exercise programmes) which included women. In most trials benefits were similar in women and men.¹⁶⁹ Evidence level 1+, 2+

Women should be included in programmes of comprehensive cardiac rehabilitation.

4.7 Other groups

4.7.1 CARDIAC TRANSPLANT PATIENTS

Few studies have examined the effect of cardiac rehabilitation in patients following cardiac transplantation. One small RCT¹⁷⁰ compared a six-month exercise-based cardiac rehabilitation programme with usual care. There were improvements in exercise capacity of the exercise group. A series of five small observational studies also suggest that exercise-based cardiac rehabilitation improved exercise tolerance in these patients.¹⁴⁶ Evidence level 1+, 2+

4.7.2 VALVE SURGERY PATIENTS

There is little evidence on the benefits of cardiac rehabilitation following valve surgery. One small non-randomised trial reported no differences in exercise tolerance between groups (nor in reported physical activity levels).¹⁷¹ Evidence level 1-

4.7.3 PATIENTS WITH CONGENITAL HEART DISEASE

In a non-randomised, controlled trial in Norway, children with congenital heart disease who undertook supervised exercise appeared to achieve some improvements in exercise capacity and psychological function compared to a control group.¹⁷² Trials involving Chinese children (reviewed in abstract only) with congenital heart disease have found that behavioural and exercise training improved self care, compliance and reduced length of hospital stay^173,174

4.7.4 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS

Patients with implantable cardioverter defibrillators (ICDs) have high levels of psychological distress and continue to be at risk of sudden cardiac death.¹⁷⁵ They may benefit from comprehensive cardiac rehabilitation but research in this area is needed.