Objectives

To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there.

Methods

Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane’s tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI).

Results

Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO_2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I² = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I² = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I² = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m², 95% CI = -1.61 to −0.07; moderate-quality evidence; I² = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I² = 93%, low-quality evidence; mental: MD = 5.38, 95% CI = 1.13 to 9.63; I² = 84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR.

Conclusions

Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings.

Systematic review registration

PROSPERO (CRD42020185296).

中文翻译：

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心脏康复对低收入和中等收入国家的影响：随机对照试验的系统回顾和荟萃分析

 目标

鉴于先前的评论很少包括来自这些国家的试验以及那里的巨大需求，因此要评估心脏康复（CR）在低收入和中等收入国家（LMIC）的有效性。

 方法

从开始至 2020 年 5 月检索了六个电子数据库（PubMed、Medline、Embase、CINAHL、Cochrane Library 和 APA PsycINFO）。随机对照 CR（即至少初步评估和结构化练习；任何设置；一些 II 期）试验急性冠脉综合征伴或不伴血运重建或心力衰竭的任何临床结果（例如死亡率和发病率、功能能力、危险因素控制和社会心理健康）或费用，以及常规护理（UC）控制或主动比较（AC）中低收入国家的患者也被纳入其中。在数据提取和数据合成方面，两名审稿人独立审查了确定的引文并从纳入的试验中提取数据；使用 Cochrane 工具评估偏倚风险。证据的确定性是根据建议评估、制定和评价分级 (GRADE) 框架确定的。使用随机效应模型计算加权平均差和 95% 置信区间 (CI)。

 结果

纳入了 26 项试验（6380 名受试者；16.9% 为女性；中位随访 = 3 个月）。 CR 显着改善了功能能力（VO _2peak与 UC：5 项试验；平均差 [MD] = 3.13 ml/kg/min，95% CI = 2.61 至 3.65；I ² = 9.0%）；中等质量证据）、收缩压（与 UC 相比：MD = -5.29 mmHg，95% CI = -8.12 至 -2.46；I ² = 45%；低质量证据）、低密度脂蛋白胆固醇（与 UC 相比： MD = -16.55 mg/dl，95% CI = -29.97 至 -3.14；I ² = 74%；证据质量极低），体重指数（与 AC 相比：MD = -0.84 kg/m ² ，95% CI = -1.61 至 -0.07；中等质量证据；I ² = 0%）和生活质量（QoL；与 UC；SF-12/36 体检：MD = 6.05，95% CI = 1.77 至 10.34；I ² = 93%，低质量证据；心理：MD = 5.38，95% CI = 1.13 至 9.63；I ² = 84%）等。没有证据表明对死亡率或发病率有影响。定性分析显示，CR 与较低的经皮冠状动脉介入治疗、心肌梗死、更好的心血管功能和生物标志物以及恢复生活角色相关。还有其他不显着的影响。两项研究报告了家庭 CR 的成本较低。

 结论

低到中等质量的证据表明，中低收入国家提供的 CR 可以改善功能能力、风险因素控制和生活质量。虽然需要更多高质量的研究，但我们必须在这些环境中增加 CR 的获取。

系统审核注册

普洛斯彼罗 (CRD42020185296)。