Cardiac rehabilitation programs aid recovery from cardiac events such as heart attacks, coronary stent placement, and bypass surgery and reduce the likelihood of further illness. Cardiac rehabilitation programs vary, but usually include one or more of the following: exercise, education, and psychological counselling/support. Despite the benefits of cardiac rehabilitation, not everyone agrees to participate and, of those who do, many people do not adhere to the program recommended. This review updates a previously published Cochrane review that evaluated trials of strategies to promote the uptake of or adherence to cardiac rehabilitation.
We searched a wide variety of scientific databases for randomised controlled trials (studies that allocate participants to one of two or more treatment groups in a random manner) in adults (over 18 years of age) who had a heart attack, coronary artery bypass graft (a surgical procedure that diverts blood around narrowed or clogged sections of the major arteries to improve blood flow and oxygen supply to the heart), percutaneous transluminal coronary angioplasty (a procedure that opens up blocked coronary arteries), heart failure, angina, or coronary heart disease who were eligible for cardiac rehabilitation. The search was current to January 2013.
We found 18 trials that were suitable for inclusion (10 trials of interventions to improve uptake and eight trials of interventions to improve adherence). The studies evaluated a variety of techniques to improve uptake or adherence and, in many studies, a combination of strategies was employed.
Strategies to increase uptake were generally effective and included regular nurse- or therapist-led visits, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. We assessed few studies as having low risk of bias (low risk of arriving at wrong conclusions because of favoritism by the researchers). Only a small number of studies demonstrated an improvement in adherence with effective interventions including: daily self monitoring of activity, action planning, and adherence facilitation by cardiac rehabilitation staff. However, the risk of bias in these studies was high. We found no evidence that these interventions improved health-related quality of life or reduce cardiovascular events or total mortality. We found no evidence to suggest that interventions to promote uptake or adherence to cardiac rehabilitation cause harm. We found no studies providing information about costs or resource implications.
Quality of the evidence
There was only weak evidence to suggest that interventions to increase uptake of cardiac rehabilitation were effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Further high-quality research is needed, particularly in under-represented groups of people such as women, ethnic minorities, older patients, patients with heart failure, and people with co-morbidities (presence of one or more diseases or conditions other than those of primary interest).