Does cardiac rehabilitation work in

chronic heart failure patients?

... [and what can we learn from meta-
analyses?]
Rod Taylor, MSc, PhD
Professor of Population Health Research, University of Glasgow. UK
Professor of Health Services Research, University of Exeter Medical 
School, UK

EUROPREVENT 2019, 11-13th April 2019

Meta-Analyses Exercise/Rehabilitation
for Heart Failure
Pubmed (((exercise OR rehabilitation) AND (meta-analysis OR 
systematic review))) AND heart failure [Title] 
 Presentation
• Review the results of Cochrane (trial level) 
meta-analyses of exercise-based CR for 
HF and ExTraMATCH II individual patient 
data meta-analyses

• What can we learn from these meta-
analyses?
 Cochrane Meta-analyses
Participant Characteristics
Cochrane v1 Cochrane v2 Cochrane v3 Cochrane v4
Rees et al (2004) Davies et al (2010) Sagar et al (2014) Long et al (2019)

N trials 29 RCTs 19 RCTs 33 RCTs 44 RCTs

N patients 1,126 3,647 4,740 5,783
Age in years: median 60 yrs 56 yrs 60.5 yrs 62.5 yrs

% male: median 91% 95% 87% 81%

Ejection fraction (%): NR [all <40%] 28% 29% 32.5%
median
Included HFpEF 0/29 0/19 5/33 7/44
Included NHYA IV 0/29 4/19 6/33 8/44
Follow up in months: 4 [1 to 26] 6 [6 to 60] 6 [6 to 120] 6 [6 to 120]
median [range]
 Cochrane Meta-analyses
Intervention Characteristics
Cochrane v1 Cochrane v2 Cochrane v3 Cochrane v4
Rees et al (2004) Davies et al (2010) Sagar et al (2014) Long et al (2019)

Overall duration: 6 months [1 to 30]

median [range]
Frequency: median
[range] 3 sessions/wk [1 to 7]
Length, min/session:
median [range] 30 mins/session [8 to 60]
Intensity
40 to 80%
Maximal heart rate
50 to 85%
VO2max 11 to 18
Borg rating
Exercise-only 28/29 16/19 25/33 31/44
programmes
Aerobic & resistance 8/29 5/19 12/33 12/44
interventions
Exclusively home- 0/29 2/19 6/33 9/44
based programmes
 Cochrane Meta-analyses
Outcome Findings
Cochrane v1 Cochrane v2 Cochrane v3 Cochrane v4
Rees et al (2004) Davies et al (2010) Sagar et al (2014) Long et al (2019)
Minnesota
All-cause mortality         Living with HF
≤12 months fu RR: 1.12 (0.58 to 2.15) RR: 1.02 (0.70 to 1.51) RR: 0.93 (0.67 to 1.27) RR: 0.89 (0.66 to 1.21)
Not reported RR: 0.91 (0.78 to 1.06) RR: 0.88 (0.75 to 1.02) RR: 0.88 (0.75 to 1.02)
>12 months fu

All-cause Not reported RR: 0.79 (0.58 to1.07) RR: 0.61 (0.46 to 0.80) RR: 0.70 (0.60 to 0.83)

hospitalisation

HF-related Not reported RR: 0.72 (0.52 to 0.99) RR: 0.75 (0.62 to 0.92) RR: 0.59 (0.42 to 0.84)

hospitalisation

Exercise capacity        
VO2max 2.2 (2.8 to 1.5)  Not reported 2.8 (2.1 to 3.5)  MCID
Not reported ≥ -5
ml/kg/min ml/kg/min

HRQoL        
MLwHF Not reported -10.3 (-4.8 to -15.9) -5.8 (-0.2 to -2.4) -7.1 (-10.5 to -3.7)
Not reported 0.63 (0.37 to 0.80) 0.46 (0.26 to 0.66) 0.60 (0.39 to 0.82)
All outcomes
Explaining outcome variation
Trial level characteristics
Explaining outcome variation
Patient characteristics

MLwHF
Meta-analysis Learnings?

• Evidence for outcomes

– No effect on mortality
– consistently see across MA’s improvements in  
patient HRQoL: stats significant AND clinically 
“…the time has now come to establish a consensus
meaningful
meeting and Task Force, possibly developed under
– Also evidence CR may reduce hospitalisation 
the umbrella of the European Society of Cardiology.
The aims of this Task Force would be to reach
(EMII query) – need more evidence?
consensus on individualised ExCR prescriptions,
patient assessment, exercise programming as it
– Need for reporting & analysis of outcomes by 
relates to guidelines, and methods of data collection
actual participation/adherence (rather than 
and sharing.”
prescription)
 Meta-analysis Learnings?
• Generalisability
– trial populations increasingly reflective of clinical 
practice
– trial evidence of CR increasingly in different 
(less/unsupervised) settings – home/e-technology
– trial & patient level analyses show effects of CR 
appear to be consistent across programme and 
patient characteristics 
– HFpEF: await Ex-DHF trial reporting
Thank you!

Acknowledge my Cochrane review 
& ExTraMATCH II co-authors and 
contributors

rod.taylor@gla.ac.uk