Evidence summary (Updated 2022)
A large body of good quality randomised controlled data shows consistent reduction in all-cause mortality and cardiac mortality from cardiac rehabilitation(CR). The majority of studies demonstrated this effect in all-cause mortality beyond 12 months(1,2) whereas others demonstrated this regardless of study periods and duration of cardiac rehabilitation(3–5). In recent meta-analyses measuring cardiac mortality, there was a significant reduction across all studies(1,3–6). While the overwhelming majority of studies found positive outcomes, the evidence is not uniformly consistent largely owing due to high heterogeneity and some paucity of evidence. A Cochrane review in 2018 found that exercise-based cardiac rehabilitation had an uncertain effect on all-cause mortality in patients with stable angina.(7)
Dibben et al in 2021 published a further Cochrane review (85 trials, n=23,430) looking at exercise-based cardiac rehabilitation and found a small reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence) in a 6-12 moth follow-up period. At medium to long-term follow-up there is a large reduction in cardiovascular mortality.(8)
A large meta-analysis of over 1000 participants who underwent PCI followed by exercise interventions for cardiovascular disease showed that risk of cardiac death, chest pain and future myocardial infarction was significantly reduced .(9) This was confirmed by Ji et al who found a significantly lower mortality in the CR group (HR=-0.47; 95% CI=-0.56 to -0.39, p<0.05) and improved cardiac mortality.(10)
Kraus et al published a large umbrella review composed of 13 reviews with a follow-up period of 3.8 to more than 20 years. The group reported a significant inverse relationship across varying physical activity groups and all-cause mortality/CVD mortality/incidence of CVD. Compared with the inactive participants, the hazard ratio (HR) for all-cause mortality was 0.66 (95%CI, 0.62–0.72) in insufficiently active participants who reported 1 to 2 sessions per week, 0.70 (95%CI, 0.60–0.82) in weekend warrior participants, and 0.65 (95%CI, 0.58–0.73) in regularly active participants.(11)
Considering individual interventions yoga was found no have no effect on all-cause mortality (RR, 1.02; 95%CI, 0.75-1.39).(12)
While several papers reported on mortality reductions, the work by Wewege specifically looked at the risk of HIIT training in individuals with cardiovascular disease. In 11 333 training hours of HIIT only 1 non-fatal cardiovascular event was reported, meaning the benefits outweigh the risks of adverse events.(13)
Quality of evidence
B – Moderate quality
Strength of recommendation
1 – Strong
Overall, there is a large amount of high-quality evidence supporting reductions in all-cause mortality, in groups with higher levels of physical activity. However, this has not been found to be consistent across all types of exercise/ physical activity interventions and review studies and high heterogeneity is present.
- Taylor. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. (ue 7. Art. No: CD001800).
- Clark. Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease. Ann Intern Med. 143(9):659–672.
- Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta-analysis. J Am Coll Cardiol. 67:1–12.
- Lawler. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Hear J Oct. 162:571–584.
- Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 116:682–692.
- Dorn J, Naughton J, Imamura D, Trevisan M. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP. Circ United States. 100(17):1764–1769.
- Long L, Anderson L, Dewhirst AM, He J, Bridges C, Gandhi M, et al. Exercise-based cardiac rehabilitation for adults with stable angina. Cochrane database Syst Rev [Internet]. 2018 Feb 2 [cited 2022 Oct 7];2(2). Available from: https://pubmed.ncbi.nlm.nih.gov/29394453/
- Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane database Syst Rev [Internet]. 2021 Nov 6 [cited 2022 Oct 8];11(11). Available from: https://pubmed.ncbi.nlm.nih.gov/34741536/
- Zhang H, Chang R. Effects of Exercise after Percutaneous Coronary Intervention on Cardiac Function and Cardiovascular Adverse Events in Patients with Coronary Heart Disease: Systematic Review and Meta-Analysis. J Sports Sci Med [Internet]. 2019 [cited 2022 Oct 7];18(2):213. Available from: /pmc/articles/PMC6543998/
- Ji H, Fang L, Yuan L, Zhang Q. Effects of Exercise-Based Cardiac Rehabilitation in Patients with Acute Coronary Syndrome: A Meta-Analysis. Med Sci Monit [Internet]. 2019 Jul 7 [cited 2022 Oct 7];25:5015–27. Available from: https://pubmed.ncbi.nlm.nih.gov/31280281/
- Kraus WE, Powell KE, Haskell WL, Janz KF, Campbell WW, Jakicic JM, et al. Physical Activity, All-Cause and Cardiovascular Mortality, and Cardiovascular Disease. Med Sci Sports Exerc [Internet]. 2019 Jun 1 [cited 2022 Oct 6];51(6):1270–81. Available from: https://pubmed.ncbi.nlm.nih.gov/31095084/
- Li J, Gao X, Hao X, Kantas D, Mohamed EA, Zheng X, et al. Yoga for secondary prevention of coronary heart disease: A systematic review and meta-analysis. Complement Ther Med [Internet]. 2021 Mar 1 [cited 2022 Oct 6];57. Available from: https://pubmed.ncbi.nlm.nih.gov/33338581/
- Wewege MA, Ahn D, Yu J, Liou K, Keech A. High-Intensity Interval Training for Patients With Cardiovascular Disease-Is It Safe? A Systematic Review. J Am Heart Assoc [Internet]. 2018 Nov 1 [cited 2022 Oct 6];7(21). Available from: https://pubmed.ncbi.nlm.nih.gov/30376749/