A Cochrane review included 33 studies with a total of 4 740 subjects with heart failure (HF), predominantly with HF due to reduced ejection fraction (HFREF) and NYHA classes II and III. Programmes were typically based on aerobic exercise training with or without a resistance exercise element. There was no difference in mortality between exercise-based rehabilitation versus no exercise control in studies with up to one-year follow-up. However, there was trend towards a reduction in mortality with exercise in studies with more than one year of follow-up (table ). Compared with control, exercise training reduced the rate of overall and HF specific hospitalisation. Exercise also resulted in a clinically important improvement superior in the Minnesota Living with Heart Failure questionnaire - a disease specific health-related quality of life measure. However, levels of statistical heterogeneity across studies in this outcome were substantial (I2=70%).
| Outcome | Relative effect (95% CI) | Participants (studies) |
|---|---|---|
| *I2 = 63%; **I2 = 70% | ||
| All-cause mortality up to 12 months’ follow-up | RR 0.93 (0.69 to 1.27) | 1 871 (25 studies) |
| All-cause mortality more than 12 months’ follow-up | RR 0.88 (0.75 to 1.02) | 2 845 (6 studies) |
| All hospital admissions up to 12 months’ follow-up | RR 0.75 (0.62 to 0.92) | 1 328 (15 studies) |
| All hospital admissions more than 12 months' follow-up | RR 0.92 (0.66 to 1.29)* | 2 722 (5 studies) |
| Hospital admissions due to heart failure | RR 0.61 (0.46 to 0.80) | 1 036 (12 studies) |
| Health-related quality of life (Minnesota Living with Heart Failure questionnaire) up to 12 months’ follow-up | MD -5.8 points (-9.2 to -2.4 points)** | 1 270 (13 studies) |
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 HF due to preserved ejection fraction (HFPEF; 3 studies, undefined participant number) and when exclusively delivered in a home-based setting (5 studies, n=521). 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.
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment and blinding).