Heran Balraj S, Chen Jenny Mh, Ebrahim Shah, Moxham Tiffany, Oldridge Neil, Rees Karen, Thompson David R, Taylor Rod S
Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, British Columbia, Canada, V6T 1Z3.
Cochrane Database Syst Rev. 2011 Jul 6(7):CD001800. doi: 10.1002/14651858.CD001800.pub2.
The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health.
To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD.
RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009).
Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography.
Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information.
This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care.
AUTHORS' CONCLUSIONS: Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.
冠心病（CHD）在全球范围内造成的负担，是患者和医疗机构共同极为关注的问题之一。基于运动的心脏康复旨在使心脏病患者恢复健康。
确定基于运动的心脏康复（单独运动训练或与心理社会或教育干预相结合）对冠心病患者死亡率、发病率及健康相关生活质量的效果。
通过检索Cochrane系统评价数据库（CENTRAL）、卫生技术评估数据库（HTA）和英国图书馆护理及健康领域数据库（DARE）（使用《Cochrane图书馆》2009年第4期），以及医学索引数据库（MEDLINE，1950年至2009年12月）、荷兰医学文摘数据库（EMBASE，1980年至2009年12月）、护理学与健康领域数据库（CINAHL，1982年至2009年12月）和科学引文索引扩展版数据库（Science Citation Index Expanded，1900年至2009年12月）来识别随机对照试验（RCTs）。
所有年龄的男性和女性，曾发生过心肌梗死（MI）、接受过冠状动脉旁路移植术（CABG）或经皮冠状动脉腔内血管成形术（PTCA），或患有心绞痛或经血管造影术确诊的冠状动脉疾病。
由两名评价员独立选择研究并提取数据。如有可能，与作者联系以获取缺失信息。
本系统评价纳入了47项研究，共10794例患者被随机分配至基于运动的心脏康复组或常规治疗组。在中期至长期（即随访12个月或更长时间），基于运动的心脏康复降低了总体死亡率和心血管死亡率[相对危险度（RR）分别为0.87（95%可信区间（CI）0.75，0.99）和0.74（95%CI 0.63，0.87）]，在短期（随访<12个月）降低了住院率[RR 0.69（95%CI 0.51，0.93）]，且各试验间效应无明显异质性。心脏康复未降低总心肌梗死、冠状动脉旁路移植术或经皮冠状动脉腔内血管成形术的风险。鉴于结局指标和研究结果报告方法存在异质性，未对健康相关生活质量进行Meta分析。在10项使用有效测量工具报告健康相关生活质量的试验中，有7项显示基于运动的心脏康复组的生活质量水平显著高于常规治疗组。
基于运动的心脏康复在降低总体死亡率和心血管死亡率（中期至长期研究）以及住院率（短期研究）方面有效，但对总心肌梗死或血运重建（冠状动脉旁路移植术或经皮冠状动脉腔内血管成形术）无效。尽管纳入了更多近期试验，但本综述所研究的人群仍以男性、中年和低风险为主。因此，仍需要在更能代表常规临床实践的冠心病患者群体中开展设计良好且报告充分的随机对照试验。这些试验应包括经过验证的健康相关生活质量结局指标，需明确报告包括住院在内的临床事件，并评估成本和成本效益。
