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Q Is exercise based cardiac rehabilitation effective in patients with coronary heart disease (CHD)?
Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ IM/Ambulatory care ★★★★★☆☆ Cardiology ★★★★★☆☆
METHODS
Data sources:
previously published systematic reviews and meta-analyses; Medline, EMBASE/Excerpta Medica, CINAHL, and SciSearch (to March 2003); the Cochrane Library; specialised rehabilitation databases; health technology assessment web sites; clinical trial registries; bibliographies of selected articles; and contact with experts and agencies.
Study selection and assessment:
randomised controlled trials (RCTs) comparing exercise based cardiac rehabilitation (alone or combined with psychosocial or educational interventions) with usual care that did not include any form of structured exercise training or advice in patients with CHD and had ⩾6 month follow up. Study quality was assessed in terms of the method of randomisation, allocation concealment, blinding of outcome assessment, and loss to follow up.
Outcomes:
all cause mortality, cardiac mortality, non-fatal myocardial infarction (MI), revascularisation, change from baseline in modifiable cardiac risk factors (lipid concentrations, triglyceride concentrations, blood pressure, and smoking), and health related quality of life (HRQOL).
MAIN RESULTS
48 RCTs (8940 patients, mean age 55 y) met the inclusion criteria. The median intervention duration was 3 months (range 0.25–30 mo) and the median follow up was 15 months (range 6–72 mo). Patients who received exercise based cardiac rehabilitation had less all cause and cardiac mortality than did patients who received usual care (table). Groups did not differ for rates of non-fatal MI (odds ratio [OR] 0.79, 95% CI 0.59 to 1.09), coronary artery bypass grafting (OR 0.87, CI 0.65 to 1.06), or percutaneous coronary intervention (OR 0.81, CI 0.49 to 1.34). Cardiac rehabilitation was associated with reductions in total cholesterol and triglyceride concentrations (table); no differences were seen in low or high density lipoprotein concentrations. Systolic blood pressure and patient reported smoking were also reduced with cardiac rehabilitation. HRQOL was assessed in 12 RCTs: all trials showed an improvement in HRQOL in both cardiac rehabilitation and usual care groups, with greater improvement with cardiac rehabilitation seen in only 2 RCTs.
Exercise-based cardiac rehabilitation v usual care in coronary heart disease at mean 15 months*
CONCLUSION
In patients with coronary heart disease, exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors.
Abstract and commentary also appear in ACP Journal Club.
Commentary
Impetigo is a common skin infection. It is usually a minor illness that may be self limiting. Unless severe, it is managed in primary care. For many children, the problem (or perceived benefit!) is that it is contagious and necessitates a minimum of 2 days off school. The more visible, but often less serious, non-bullous form, which typically forms yellow crusts on exposed surfaces, is more commonly encountered.
Management guidance and high quality research have been in short supply. The updated systematic review by Koning et al and a recent review by George and Rubin1 have been published in an attempt to address these deficiencies. These 2 reviews were similarly elegant and rigorous, with high concordance between chosen studies, despite minor differences in inclusion criteria. The conclusions were similar.
Mupirocin and fusidic acid appear to be the most effective topical antibiotics. They seem preferable to erythromycin in localised disease, based on both efficacy and side effects.
There are, of course, further twists! Placebo response rates are high (suggesting natural resolution). Fusidic acid is most commonly used in orthopaedics, and as bacterial resistance develops rapidly and in clusters, there is some concern about the implications for its use in orthopaedics. As mupirocin is recommended for control of methicillin resistant Staphylococcus aureus in the UK, increased use for impetigo could reduce its effectiveness in this important area. Flucoxacillin is listed as the first choice for widespread disease in the British National Formulary, but evidence for its use in preference to topical treatment or alternative oral antibiotics is scanty, and definitions of widespread disease are also lacking.1 Thus, the usefulness of erythromycin or non-antibiotic disinfecting agents cannot be discounted despite their disadvantages.
Both reviews indicate that more research, properly powered and assessing a single disease, is needed. Studies should be targeted at relevant outcomes (clinical, yes, but what about length of contagiousness?) and primary care, where the action happens! In the meantime, I’ll use more fusidic acid, perhaps mupirocin, and fewer oral antibiotics for localised disease.
References
Footnotes
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For correspondence: Dr R S Taylor, University of Birmingham, Edgbaston, Birmingham, UK. r.s.taylorbham.ac.uk
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Sources of funding: Canadian Coordinating Office for Health Technology Assessment; British Heart Foundation; UK Physiotherapy Research Foundation.