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Canadian Journal of Cardiology

The Paucity of Data Addressing the Effects of Cardiac Rehabilitation on Mortality and Morbidity in Women

Published:November 03, 2017DOI:https://doi.org/10.1016/j.cjca.2017.11.001
      To the Editor:
      Approximately 2.4 million Canadians live with ischemic heart disease, with approximately 50% being women. Participation in cardiac rehabilitation (CR), an outpatient chronic disease management model for secondary prevention, is associated with 20% reductions in mortality and morbidity.
      • Anderson L.
      • Oldridge N.
      • Thompson D.R.
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease cochrane systematic review and meta-analysis.
      However, in this latest Cochrane review,
      • Anderson L.
      • Oldridge N.
      • Thompson D.R.
      • et al.
      Exercise-based cardiac rehabilitation for coronary heart disease cochrane systematic review and meta-analysis.
      only 66% of CR trials included women, and women accounted for < 15% of total participants. Although it is expected that women would achieve benefits from CR participation comparable to those seen in men, it is known that there are some sex differences regarding the pathophysiology of cardiovascular disease, the burden of risk factors, and access to and impact of acute reperfusion therapies, in addition to the fact that women are less likely to adhere to CR programs (if they do access them).
      • Pilote L.
      • Dasgupta K.
      • Guru V.
      • et al.
      A comprehensive view of sex specific issues related to cardiovascular disease.
      Therefore, we set out to undertake a meta-analysis of the effects of CR on mortality and morbidity in women.
      Randomized controlled trials from the 2 most recent systematic reviews
      • Pilote L.
      • Dasgupta K.
      • Guru V.
      • et al.
      A comprehensive view of sex specific issues related to cardiovascular disease.
      • van Halewijn G.
      • Deckers J.
      • Tay H.Y.
      • et al.
      Lessons from contemporary trials of cardiovascular prevention and rehabilitation: a systematic review and meta-analysis.
      were considered for inclusion. The trials had to include women attending comprehensive CR programs and report the outcomes of mortality and morbidity (hospitalization, myocardial infarction, and revascularization). An updated search of the literature was performed from the end date of the last review (July 2014) through July 2017, based on the Cochrane strategy. Authors were contacted to request results in women when not reported.
      As shown in Figure 1, 80 unique trials were included in the reviews, plus 1 trial was identified through the updated search. Of 31 potential trials meeting inclusion criteria, data for women were reported in none. On contacting authors, many reported that the data were no longer available, but data were provided for 2 trials. Therefore it was deemed inappropriate to undertake a meta-analysis.
      Figure thumbnail gr1
      Figure 1Flow diagram of study selection process. CR, cardiac rehabilitation; RAMIT, Rehabilitation After Myocardial Infarction Trial; UK, United Kingdom; VHSG, Vestfold Heartcare Study Group.
      In conclusion, this review corroborates the dearth of data on CR participation in women. Currently, there are insufficient data available to quantify the benefit of CR participation on mortality and morbidity in women, despite the fact that it is the leading cause of death in this population. Given the totality of evidence, however, including reductions in mortality and morbidity in nonrandomized studies, and evidence of benefit for other important outcomes such as functional capacity and quality of life, it is maintained that CR does improve outcomes in women.
      • Benett A.L.
      • Lavie C.J.
      • Grace S.L.
      Cardiac rehabilitation following acute coronary syndrome in women.
      Therefore, women should continue to be referred and encouraged to enroll and adhere to these programs. Ethically conducted trials are needed to rigorously establish the benefits of CR on mortality and morbidity in women.

      Disclosures

      The authors have no conflicts of interest to disclose.

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