Article

Previous systematic reviews and meta-analyses consistently show the
positive effect of exercise-based rehabilitation for heart failure (HF) on
exercise capacity; however, the direction and magnitude of effects on
health-related quality of life, mortality and hospital admissions in HF remain
less certain. This is an update of a Cochrane systematic review previously
published in 2010. OBJECTIVES: To determine the effectiveness of exercise-based
rehabilitation on the mortality, hospitalisation admissions, morbidity and
health-related quality of life for people with HF. Review inclusion criteria were
extended to consider not only HF due to reduced ejection fraction (HFREF or
'systolic HF') but also HF due to preserved ejection fraction (HFPEF or
'diastolic HF'). SEARCH METHODS: We updated searches from the previous Cochrane
review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL)
(Issue1, 2013) from January 2008 to January 2013. We also searched MEDLINE
(Ovid), EMBASE (Ovid), CINAHL (EBSCO) and PsycINFO (Ovid) (January 2008 to
January 2013). We handsearched Web of Science, bibliographies of systematic
reviews and trial registers (Controlled-trials.com and Clinicaltrials.gov).
SELECTION CRITERIA: Randomised controlled trials of exercise-based interventions
with six months' follow-up or longer compared with a no exercise control that
could include usual medical care. The study population comprised adults over 18
years and were broadened to include individuals with HFPEF in addition to HFREF.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened all
identified references and rejected those that were clearly ineligible. We
obtained full-text papers of potentially relevant trials. One review author
independently extracted data from the included trials and assessed their risk of
bias; a second review author checked data. MAIN RESULTS: We included 33 trials
with 4740 people with HF predominantly with HFREF and New York Heart Association
classes II and III. This latest update identified a further 14 trials. The
overall risk of bias of included trials was moderate. There was no difference in
pooled mortality between exercise-based rehabilitation versus no exercise control
in trials with up to one-year follow-up (25 trials, 1871 participants: risk ratio
(RR) 0.93; 95% confidence interval (CI) 0.69 to 1.27, fixed-effect analysis).
However, there was trend towards a reduction in mortality with exercise in trials
with more than one year of follow-up (6 trials, 2845 participants: RR 0.88; 95%
CI 0.75 to 1.02, fixed-effect analysis). Compared with control, exercise training
reduced the rate of overall (15 trials, 1328 participants: RR 0.75; 95% CI 0.62
to 0.92, fixed-effect analysis) and HF specific hospitalisation (12 trials, 1036
participants: RR 0.61; 95% CI 0.46 to 0.80, fixed-effect analysis). Exercise also
resulted in a clinically important improvement superior in the Minnesota Living
with Heart Failure questionnaire (13 trials, 1270 participants: mean difference:
-5.8 points; 95% CI -9.2 to -2.4, random-effects analysis) - a disease specific
health-related quality of life measure. However, levels of statistical
heterogeneity across studies in this outcome were substantial. Univariate
meta-regression analysis showed that these benefits were independent of the
participant's age, gender, degree of left ventricular dysfunction, type of
cardiac rehabilitation (exercise only vs. comprehensive rehabilitation), mean
dose of exercise intervention, length of follow-up, overall risk of bias and
trial publication date. Within these included studies, a small body of evidence
supported exercise-based rehabilitation for HFPEF (three trials, undefined
participant number) and when exclusively delivered in a home-based setting (5
trials, 521 participants). One study reported an additional mean healthcare cost
in the training group compared with control of USD3227/person. Two studies
indicated exercise-based rehabilitation to be a potentially cost-effective use of
resources in terms of gain in quality-adjusted life years (QALYs) and life-years
saved. AUTHORS' CONCLUSIONS: This updated Cochrane review supports the
conclusions of the previous version of this review that, compared with no
exercise control, exercise-based rehabilitation does not increase or decrease the
risk of all-cause mortality in the short term (up to 12-months' follow-up) but
reduces the risk of hospital admissions and confers important improvements in
health-related quality of life. This update provides further evidence that
exercise training may reduce mortality in the longer term and that the benefits
of exercise training on appear to be consistent across participant
characteristics including age, gender and HF severity. Further randomised
controlled trials are needed to confirm the small body of evidence seen in this
review for the benefit of exercise in HFPEF and when exercise rehabilitation is
exclusively delivered in a home-based setting.

Langue : ANGLAIS