112
VOLUME 11 NUMBER 3 • SEPTEMBER 2014
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
of follow up were included if they assessed the effects of exercise
training alone or in combination with psychological or educational
interventions.
In the results, 48 trials were included, with a total of 8 940
patients. Compared with usual care, cardiac rehabilitation was
associated with reduced all-cause mortality [odds ratio (OR): 0.80;
95% confidence interval (CI): 0.68–0.93] and cardiac mortality (OR:
0.74; 95% CI: 0.61–0.96); greater reductions in total cholesterol
level [weighted mean difference: –0.37 mmol/l (– 14.3 mg/dl); 95%
CI: –0.63 to –0.11 mmol/l (–24.3 to –4.2 mg/dl)]; triglyceride level
[weighted mean difference: –0.23 mmol/dl (–20.4 mg/dl); 95% CI:
–0.39 to –0.07 mmol/l (–34.5 to –6.2 mg/dl)], and systolic blood
pressure (weighted mean difference: –3.2 mmHg; 95% CI: –5.4 to
–0.9 mmHg); and lower rates of self-reported smoking (OR: 0.64;
95% CI: 0.50–0.83). There were no significant differences in the
rates of non-fatal myocardial infarction and revascularisation, and
changes in high- and low-density lipoprotein cholesterol levels and
diastolic pressure.
Health-related quality of life improved to similar levels with
cardiac rehabilitation and usual care. The effect of cardiac
rehabilitation on total mortality was independent of diagnosis
of coronary heart disease, type of cardiac rehabilitation, length
of exercise intervention, length of follow up, and trial quality
and publication date. The review by Taylor
et al
.
11
confirmed the
benefits of exercise-based cardiac rehabilitation within the context
of today’s cardiovascular service provision.
In another study by Lawler
et al.
,
12
a meta-analysis of randomised,
controlled trials (RCTs) was undertaken to (1) estimate the effect
of cardiac rehabililtation (CR) on cardiovascular outcomes, and
(2) examine the effect of CR programme characteristics on the
magnitude of CR benefits. The researchers systematically searched
MEDLINE as well as relevant bibliographies to identify all English-
language RCTs examining the effects of exercise-based CR among
post-MI patients.
Data were aggregated using random-effects models. Stratified
analyses were conducted to examine the impact of RCT-level
characteristics on treatment benefits. Thirty-four RCTs were
identified (
n
= 6.111).
Overall, patients randomised to exercise-based CR had a lower
risk of re-infarction (OR: 0.53; 95%CI: 0.38–0.76), cardiac mortality
(OR: 0.64; 95% CI: 0.46–0.88), and all-cause mortality (OR: 0.74;
95% CI: 0.58–0.95). In stratified analyses, treatment effects were
consistent, regardless of study periods, duration of CR, or time
beyond the active intervention. Exercise-based CR had favourable
effects on cardiovascular risk factors, including smoking, blood
pressure, body weight and lipid profile.
The study by Lawler
et al.
12
concluded that exercise-based
cardiac rehabilitation is associated with reductions in mortality and
re-infarction rate post MI. The researchers state that their secondary
analyses suggest even shorter CR programmes may translate into
improved long-term outcomes, although these results need to be
confirmed in an RCT.
Nursing
A study by Jiang in the West China School of Nursing, Sichuan
University, indicates that a nurse-led cardiac rehabilitation
programme improved health behaviours and cardiac physiological
risk parameters.
13
The aim of the study was to examine the effect
of a cardiac rehabilitation programme on health behaviours and
physiological risk parameters in patients with coronary heart disease
in Chengdu, China.
Epidemiological studies indicate a dose-, level- and duration-
dependant relationship exists between cardiac behavioural and
physiological risks and coronary heart disease incidence, as well as
subsequent cardiac morbidity and mortality.
Cardiac risk-factor modification has become the primary goal
of modern cardiac rehabilitation programmes. A randomised,
controlled trial was conducted. Coronary heart disease patients (
n
= 167) who met the sampling criteria in two tertiary medical centres
in Chengdu, south-west China were randomly assigned to either
an intervention group (the cardiac rehabilitation programme) or
control group (the routine care). The change of health behaviours
(walking performance, step II diet adherence, medication adherence,
smoking cessation) and physiological risk parameters (serum
lipids, blood pressure, body weight) were assessed to evaluate the
programme effect.
Patients in the intervention group demonstrated a significantly
better performance in walking, step II diet adherence, and
medication adherence; a significantly greater reduction in serum
lipid levels including triglycerides, total cholesterol, and low-density
lipoprotein cholesterol; and significantly better control of systolic
and diastolic blood pressure at three months. The majority of these
positive impacts was maintained at six months. The effect of the
programme on smoking cessation, body weight, and serum high-
density lipoprotein levels was not confirmed.
The study concluded that a cardiac rehabilitation programme
led by a nurse can significantly improve the health behaviours and
cardiac physiological risk parameters in coronary heart disease
patients. Nurses can fill significant treatment gaps in the risk-factor
management of patients with coronary heart disease.
This study raises attention regarding the important role nurses
can play in cardiac rehabilitation and the unique way for nurses
to meet the rehabilitative care needs of coronary heart disease
patients. Furthermore, the hospital–home bridging nature of the
programme also created a model for interfacing acute care and
community rehabilitative care.
Physician referral
A study by Smith
et al.
at McMaster University, Canada, explains
the role of automatic physician referral in predicting cardiac
rehabilitation enrolment.
14
Despite the established benefits of
cardiac rehabilitation, evidence suggests referral to and subsequent
enrolment in cardiac rehabilitation following a coronary event
remains low (10–25%). The aim of this study was to identify
predictors of attendance at cardiac rehabilitation intake and
subsequent enrolment in rehabilitation after CABG surgery within
the framework of an automatic referral system.
Researchers conducted a historical, prospective study of
patients who underwent CABG surgery between 1 April 1996
and 31 March 2000 and lived within the geographic referral
area of a multidisciplinary cardiac rehabilitation centre in south-
central Ontario, Canada. CABG surgery patients are automatically
referred for cardiac rehabilitation at the time of hospital discharge.
Consecutive health records of eligible patients were reviewed for
medical history, cardiac risk factor profiles, and evidence of cardiac
rehabilitation intake attendance and enrolment.
A total of 3 536 patients met the eligibility criteria. Patients
were predominantly male (79.1%), approximately 64 years of age,
