Cardiac rehabilitation programs and their core components for coronary heart disease: A systematic review and network meta-analysis.

Background. Although earlier reviews establish that patients with coronary heart disease (CHD) respond well to cardiac rehabilitation (CR), the comparative effectiveness of different CR programs or their individual core components of CR have not been evaluated. Methods. A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of CR (nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. The core components were evaluated individually and as part of broader CR treatment categories ("exercise-only" CR programs, "comprehensive" CR programs, and "secondary prevention programs without exercise"). Published RCTs were identified from database inception dates (Medline, Medline In-Process, the Cochrane database, Embase, CINAHL, Sci-Expanded, PsychINFO, the Web of Science) to July 2014. Endpoints included measures of mortality (all-cause and CV) and morbidity (myocardial infarction (MI), revascularization, and hospitalization). Hazard ratios (HR) and 95% credible intervals (CrIs) were used as summary measures. Findings. 136 trials (50,054 participants) and 169 trials (62,149 participants) were included for the NMAs of the overall CR treatment strategies and for the core components of CR respectively. "Exercise-only" and "comprehensive" CR programs significantly reduced the hazards of all-cause mortality, CV mortality, total MI, fatal MI, non-fatal MI, revascularization, total and CV hospitalization by 25-54% when compared to usual care, and significantly reduced the hazard of all-cause mortality by 23%-26% when compared to "secondary prevention programs without exercise". "Secondary prevention programs without exercise" significantly reduced the hazards of all-cause and CV mortality, total MI, non-fatal MI, all-cause and CV hospitalization by 20%-43% when compared to usual care. The core component of PM significantly reduced the hazards of all-cause mortality, all-cause and CV hospitalization by 31%, 33% and 50% respectively. RFM and PE significantly reduced the hazards of total MI and all-cause hospitalization by 37% and 23% respectively. Interpretation. These findings confirm the central role of CR in patients with CHD, emphasize the central role of exercise training in CR, elevate the role of other key CR core components, especially psychosocial management, and establish the superiority of exercise-based CR programs to "secondary prevention programs without exercise". (PsycINFO Database Record (c) 2017 APA, all rights reserved)