Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials

Taslima Mamataz; Jamal Uddin; Sayed Ibn Alam; Rod S. Taylor; Maureen Pakosh; Sherry L. Grace; ACROSS Collaboration

doi:10.1016/j.pcad.2021.07.004

Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials

Taslima Mamataz
, Jamal Uddin
, Sayed Ibn Alam
, Rod S. Taylor
, Maureen Pakosh
, Sherry L. Grace^*
, ACROSS Collaboration

^*Corresponding author for this work

KI, REHPA - The Danish Knowledge Centre for Rehabilitation and Palliative Care

York University
Toronto Rehabilitation Institute
Peter Munk Cardiac Centre
Ibrahim Cardiac Hospital and Research Institute
University of Glasgow

Research output: Contribution to journal › Journal article › Research › peer-review

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Abstract

Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane's tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO_2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I² = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I² = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I² = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m², 95% CI = -1.61 to −0.07; moderate-quality evidence; I² = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I² = 93%, low-quality evidence; mental: MD = 5.38, 95% CI = 1.13 to 9.63; I² = 84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).

Original language	English
Journal	Progress in Cardiovascular Diseases
Volume	70
Pages (from-to)	119-174
ISSN	0033-0620
DOIs	https://doi.org/10.1016/j.pcad.2021.07.004
Publication status	Published - 1. Jan 2022

Funding

This study is a part of the ACROSS project (Affordable Cardiac Rehabilitation: An Outreach inter-disciplinary Strategic Study) funded by NIHR Research and Innovation for Global Health and Transformation (RIGHT) Call 3 Development Grant. This work was supported by the University of Glasgow project 311264-01 . The study sponsor(s) or funder(s) played no role in the conception of this study, analysis or interpretation of data, in the writing of the manuscript, nor in the decision to submit the article for publication. Moreover, we confirm the independence of researchers from the funder and that all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study. All authors take the responsibility for data integrity and the accuracy of the data analysis.

Keywords

Cardiac rehabilitation
Morbidity
Mortality
Quality of life
Randomised controlled trial
Systematic review

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@article{758a0016328f4b0ca63d7f0f9ce38e26,

title = "Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials",

abstract = "Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane's tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95\% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9\% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95\% CI = 2.61 to 3.65; I2 = 9.0\%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95\% CI = -8.12 to -2.46; I2 = 45\%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95\% CI = -29.97 to -3.14; I2 = 74\%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95\% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0\%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95\% CI = 1.77 to 10.34; I2 = 93\%, low-quality evidence; mental: MD = 5.38, 95\% CI = 1.13 to 9.63; I2 = 84\%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).",

keywords = "Cardiac rehabilitation, Morbidity, Mortality, Quality of life, Randomised controlled trial, Systematic review",

author = "Taslima Mamataz and Jamal Uddin and \{Ibn Alam\}, Sayed and Taylor, \{Rod S.\} and Maureen Pakosh and Grace, \{Sherry L.\} and \{ACROSS Collaboration\}",

note = "Funding Information: This study is a part of the ACROSS project (Affordable Cardiac Rehabilitation: An Outreach inter-disciplinary Strategic Study) funded by NIHR Research and Innovation for Global Health and Transformation (RIGHT) Call 3 Development Grant. This work was supported by the University of Glasgow project 311264-01 . The study sponsor(s) or funder(s) played no role in the conception of this study, analysis or interpretation of data, in the writing of the manuscript, nor in the decision to submit the article for publication. Moreover, we confirm the independence of researchers from the funder and that all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study. All authors take the responsibility for data integrity and the accuracy of the data analysis. Publisher Copyright: {\textcopyright} 2021 The Authors",

year = "2022",

month = jan,

day = "1",

doi = "10.1016/j.pcad.2021.07.004",

language = "English",

volume = "70",

pages = "119--174",

journal = "Progress in Cardiovascular Diseases",

issn = "0033-0620",

publisher = "W. B. Saunders Company",

}

TY - JOUR

T1 - Effects of cardiac rehabilitation in low-and middle-income countries

T2 - A systematic review and meta-analysis of randomised controlled trials

AU - Mamataz, Taslima

AU - Uddin, Jamal

AU - Ibn Alam, Sayed

AU - Taylor, Rod S.

AU - Pakosh, Maureen

AU - Grace, Sherry L.

AU - ACROSS Collaboration

N1 - Funding Information: This study is a part of the ACROSS project (Affordable Cardiac Rehabilitation: An Outreach inter-disciplinary Strategic Study) funded by NIHR Research and Innovation for Global Health and Transformation (RIGHT) Call 3 Development Grant. This work was supported by the University of Glasgow project 311264-01 . The study sponsor(s) or funder(s) played no role in the conception of this study, analysis or interpretation of data, in the writing of the manuscript, nor in the decision to submit the article for publication. Moreover, we confirm the independence of researchers from the funder and that all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study. All authors take the responsibility for data integrity and the accuracy of the data analysis. Publisher Copyright: © 2021 The Authors

PY - 2022/1/1

Y1 - 2022/1/1

N2 - Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane's tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI = 1.13 to 9.63; I2 = 84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).

AB - Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane's tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI = 1.13 to 9.63; I2 = 84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).

KW - Cardiac rehabilitation

KW - Morbidity

KW - Mortality

KW - Quality of life

KW - Randomised controlled trial

KW - Systematic review

U2 - 10.1016/j.pcad.2021.07.004

DO - 10.1016/j.pcad.2021.07.004

M3 - Journal article

C2 - 34271035

AN - SCOPUS:85111039673

SN - 0033-0620

VL - 70

SP - 119

EP - 174

JO - Progress in Cardiovascular Diseases

JF - Progress in Cardiovascular Diseases

ER -

Effects of cardiac rehabilitation in low-and middle-income countries: A systematic review and meta-analysis of randomised controlled trials

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