People with heart failure have low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. A Cochrane review in 2018 found that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control improved HRQoL and hospital admissions, as well as a possible reduction in mortality. However, the RCTs included disproportionately represented populations, and were mostly conducted in a hospital or centre-based setting. This systematic review aimed to assess the effects of ExCR on mortality, hospital admissions, and health-related QoL in adults with heart failure.

This review included randomised controlled trials (RCTs) comparing ExCR with a follow-up of six months or longer versus a no-exercise control in people ≥18 years with heart failure (either heart failure with reduced (<45%) ejection fraction (HFrEF) or heart failure with preserved (≥45%) ejection fraction (HFpEF)). Six databases and two trial registers were searched for RCTs. There were no language or date restrictions. The exercise-based interventions were either given alone or as part of comprehensive cardiac rehabilitation in hospital or centre-based settings, as well as including alternative modes of delivery including home‐based and digitally‐supported programs. Usual care consisted of active interventions such as education or psychological intervention or usual medical care alone. The primary outcomes were all‐cause mortality, heart failure mortality, number of participants who experienced an all‐cause hospital admission, number of participants who experienced a heart failure‐related hospital admission, and HRQoL assessed by a validated outcome measure. Data was processed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and The Cochrane Risk of Bias 1.0 tool was used to assess the level of bias. Data was pooled from trials using a random effects model, and a meta-analysis was performed. GRADE was used to assess the certainty of the evidence.

Sixty trials, involving 8,728 participants, were included with a median of six months follow-up. Aerobic exercise was included in all trials, with 21 trials also including resistance training. The exercise dosage across trials varied: time 8-120 minutes duration, frequency 1-7 sessions a week, intensity 40-80%, maximal heart rate to 50-85% maximal oxygen uptake (Vo2 max), and duration 8-120 weeks. The overall risk of bias was low or unclear, with the main issues found in trials to be poorly reported details surrounding random sequence generation, allocation concealment, and blinding.

There was no evidence of a difference in the short term (up to 12 months’ follow‐up) in the pooled risk of all‐cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93; 95% confidence interval (CI) 0.71 to 1.21; p=0.95; I²=0%; 34 trials, 3941 participants; low certainty evidence). Only one trial reported heart failure‐specific mortality with one death due to heart failure in the high‐intensity interval training arm, and no heart failure‐specific deaths in either the moderate continuous training or control arms. Participation in ExCR versus usual care likely reduced the risk of all‐cause hospital admissions (RR 0.69; 95% CI 0.56 to 0.86; p=0.14, I²=24%; 23 trials; 2283 participants; moderate certainty evidence) and heart failure‐related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; p=0.41; I²=4%; 10 trials; 911 participants; moderate certainty evidence) in the short term. ExCR may improve HRQoL in the short term, but the evidence is very uncertain (standardised mean difference (SMD) −0.52; 95% CI −0.70 to −0.34; 33 trials; 4769 participants; very low certainty evidence).

Compared to no-exercise control, there was no evidence of a difference in all-cause mortality following ExCR in people with heart failure. ExCR likely reduced all-cause hospital admissions and heart failure-related hospital admissions and may result in improvements in HRQoL.

Molloy C, Long L, Mordi IR, Bridges C, Sagar VA, Davies EJ, Coats AJS, Dalal H, Rees K, Singh SJ, Taylor RS. Exercise‐based cardiac rehabilitation for adults with heart failure. Cochrane Database of Systematic Reviews 2024, Issue 3. Art. No.: CD003331. DOI: 10.1002/14651858.CD003331.pub6.

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PEDro acknowledges Dr Renae McNamara, Clinical Specialist Physiotherapist, Prince of Wales Hospital and Katie Warren, Masters of Physiotherapy Student, University of Technology Sydney for preparing the summary.

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