Table 1 Characteristics of included trials and their interventions
Trial details | Participant details | Outcomes reported | Exercise intervention | Usual care condition | Lipid-lowering therapy | |||||
|---|---|---|---|---|---|---|---|---|---|---|
Author, year [ref] | Country | Longest follow-up | N | Males (%) | Mean age (years) | Diagnosis | Â | Main details (what, how, where) | Â | Â |
Albus, 2009 [34] | Germany | 7Â years | 77 | 87 | 54 | Angiographically documented CAD | TM, CVM, MI, CABG, PCI | Multimodal comprehensive group behavioural intervention: residential then outpatient aerobic exercise and education, 1Â year | Standard cardiological care based on guidelines with frequent review | Guideline-based use of antiplatelet, statin, beta-blocker and anti-hypertensive therapy |
Andersen, 1981D[35] | Denmark | 3Â years | 88 | 100 | I: 52, C: 56 | Myocardial infarction | TM, CVM, MI | Outpatient aerobic (cycling, running, skipping) and resistance exercise training only, 1Â year | Usual care (not specified); some trained on own | Not reported: assume no statin use due to year of study |
Aronov, 2009R [36] | Russia | 1Â year | 392 | 94 | 52 | Myocardial infarction, unstable angina or post-PCI | CVM, MI | Group outpatient exercise (cycling and gymnastics), 1Â year | Standard cardiological care (not other specified) | Pharmacotherapy including approximately one third on statins |
Italy | 10Â years | 118 | 85 | 57 | Post-PCI | CVM, MI, CABG, PCI | Group outpatient exercise (cycling), 6Â months | Advice for daily mild physical activity but to avoid exercise training | Guideline-based pharmacotherapy but no statins started during trial | |
Bell, 1998T [39] | UK | 1 year | 353 | 79 | 59 | Myocardial infarction | TM | Two arms: (1) outpatient exercise and education (2) home-based walking exercise and education using the Heart Manual, 4–19 weeks | Usual care with basic advice on risk factors | Not reported: assume some statin therapy as participants recruited from 1994 |
Bengtsson, 1983 [40] | Sweden | 1Â year | 171 | 85 | 56 | Myocardial infarction | TM, MI | Group outpatient exercise training (aerobic high-intensity interval cycle training and callisthenics) with counselling and education, 3Â months | Usual care (not specified); 4 participants undertook cardiac rehabilitation | Not reported: assume no statin use due to year of study |
Bertie, 1992 [41] | UK | 2Â years | 110 | NR | 53 | Myocardial infarction | TM, MI, CABG# | Group outpatient aerobic exercise training (circuit-based) with reinforcement of educational information, 4Â weeks | Usual care with basic advice on risk factors | Not reported: assume no statin use due to year of study |
Bethell, 1990/99UP[42] | UK | 7Â years | 229 | 100 | I: 54; C: 53 | Myocardial infarction | TM, CVM, MI | Group aerobic exercise training at a sports centre (circuit-based), 3Â months | Usual care with exercise advice (27% exercising vigorously twice a week) | Not reported: assume no statin use due to year of study |
Blumenthal, 2005 [43] | USA | 4Â months | 134 | 69 | 63 | Documented CAD and myocardial ischemia on exercise | TM, CABG, PCI# | Outpatient aerobic exercise training (cycle, jogging, stretching), 4Â months | (1) Usual care, avoid formal exercise programs; (2) As (1) plus stress management training | Most patients treated with pharmacotherapy including statins |
Briffa, 2005 [44] | Australia | 1Â year | 113 | 73 | 61 | Myocardial infarction, unstable angina or post revascularisation | TM, CVM, MI, CABG, PCI | Group outpatient aerobic and resistance exercise training (circuit-based) with education and counselling, 6Â weeks | Standard cardiological care (9% took part in rehabilitation arm) | Individualised pharmacotherapy including statins |
Byrkjeland, 2015 [45] | Norway | 1Â year | 137 | 84 | 63 | Type 2 diabetes and angiographically documented CAD | TM, MI | Group outpatient aerobic and resistance training (circuit and high-intensity interval sessions) with one home-session each week, 1Â year | Standard care with general practitioner (not other specified) | Pharmacotherapy including statins for 94% of patients |
Carlsson, 1998 [46] | Sweden | 1 year | 235 | NR | 62 | Myocardial infarction or CABG | TM# | Group outpatient aerobic exercise (interval walking/jogging) with educational sessions (+3× pre-randomisation exercise sessions), 2–3 months | Standard cardiological care (+3 × pre-randomisation exercise sessions) | Pharmacotherapy but <30% on statins at follow-up |
Carson, 1982 [47] | UK | 3Â years | 303 | 100 | I: 53, C: 50 | Myocardial infarction | TM, MI | Exercise training at hospital gym (circuit-based), 12Â weeks | Usual care (not other specified) | Not reported: assume no statin use due to year of study |
DeBusk, 1994 [48] | USA | 1Â year | 585 | 79 | 57 | Myocardial infarction | TM, CVM, MI, CABG, PCI | Home-based CR via nurse-led case management which included counselling for all and aerobic exercise training for 78% of group, 1Â year | Usual care with basic advice on risk factors and exercise | Physician-managed pharmacotherapy including LLT although not statin use |
Dugmore, 1999 [49] | UK | 5 years | 124 | 98 | 52–59 | Myocardial infarction | TM, MI | Aerobic (walking, jogging, cycling) and resistance exercise training, 1 year | Usual care (not other specified except to avoid formal exercise training) | Guideline pharmacotherapy but no statins used |
Finland | 5Â years | 228 | 88 | 54 | Post-CABG | TM, CABG | Intensive exercise training (aerobic and gymnastics) and education during residential stay in outpatient centre, 3Â weeks | Usual care with basic advice on risk factors and exercise | Guideline pharmacotherapy, however, is <5% using statins at any stage | |
Erdman, 1986 [52] | Netherlands | 5Â years | 80 | 100 | 51 | Myocardial infarction and anxiety or depression | TM, MI | Aerobic exercise (jogging), sports and relaxation training in a conventional gymnasium, 6Â months | Usual care with basic advice on exercise | Guideline pharmacotherapy but no statins used |
Ferreira, 2010a [53] | Portugal | 1Â year | 97 | 85 | I: 53, C: 57 | Myocardial infarction or unstable angina | TM, CVM, MI | Outpatient aerobic (cycle and treadmill) and resistance exercise training with nutritional counselling, 8Â weeks | Usual care with basic advice on risk factors and exercise | Guideline-based pharmacotherapy including statins for 97% |
Fletcher, 1994 [54] | USA | 6Â months | 88 | 100 | 62 | Diagnosed CHD and physical disability | TM# | Home-based aerobic exercise training on modified wheelchair treadmill with dietary instruction, 6Â months | Usual care with basic advice on risk factors and exercise, same dietary instruction | Not reported: assume no statin use due to year of study |
Fontes-Carvalho, 2015 [55] | Portugal | 2Â years | 188 | 82 | 56 | Myocardial infarction | TM, CVM, MI# | Outpatient aerobic (cycle and treadmill) and resistance exercise training, 8Â weeks | Standard cardiological care with advice on risk factors and exercise | Guideline based pharmacotherapy including statins for 97% |
Sweden | 5 years | 178 | 87 | 57 | Myocardial infarction | TM, MI | ‘Supportive Program’: group-based aerobic and resistance exercise, relaxation and conversation (including participant’s next-of-kin), 6 months | Usual care with basic advice on risk factors and return to work | Guideline pharmacotherapy but no statins used | |
Giallauria, 2008 [58] | Italy | 6Â months | 61 | 72 | I: 56; C: 55 | Myocardial infarction | MI# | Outpatient aerobic exercise only (cycling), 6Â months | Usual care with basic advice on risk factors and exercise | All medications in both groups titrated equally including statins for >70% |
Haglin, 2011 [59] | Sweden | 19Â years | 48 | 73 | NR | Diagnosed CHD | TM | Residential group CR program for 4Â weeks with aerobic exercise, counselling and education, followed by ongoing home maintenance exercise program with regular review | Usual care (not other specified) | Not reported: assume statin therapy due to follow-up years of study |
Haskell, 1994 [60] | USA | 4Â years | 300 | 72 | 57 | Angiographically documented CAD | TM, CVM, MI, CABG, PCI | Individual home-based aerobic exercise (cycling and walking), diet intervention and significant medication management, 4Â years | Usual care in hands of physician (not other specified) | Pharmacotherapy with LLT strategy in intervention arm although statins only available in later half of study; 31% using statins in usual care arm |
Sweden | 5Â years | 93 | 84 | 53 | Post-PCI | TM, CVM, MI, CABG, PCI | Residential group CR program for 4Â weeks with aerobic exercise, counselling and education, followed by home maintenance program for 1Â year with frequent nursing contacts | Usual care in hands of physician (not other specified) | Guideline pharmacotherapy including titration of statins in both arms during trial | |
Holmbäck, 1994 [63] | Sweden | 1 year | 69 | 97 | 55 | Myocardial infarction | TM, MI, CABG | Outpatient group exercise training (intervals of cycling, jogging callisthenics), 12 weeks | Usual care (not other specified) | Guideline pharmacotherapy but no statins used |
Finland | 15Â years | 375 | 80 | 54 | Myocardial infarction | TM, CVM, MI | Outpatient group exercise (gymnastics, cycling, walking), education and counselling with ongoing home-based maintenance for 3Â years: 2 sites in WHO study program | Usual care in hands of physician with basic advice on risk factors | Pharmacotherapy including non-statin LLT for 28% of intervention arm and 11% of usual care arm | |
Kovoor, 2006 [66] | Australia | 6Â months | 142 | 87 | 56 | Myocardial infarction with low further risk | MI, CABG, PCI | Outpatient exercise training (circuit-based), counselling and education, 5Â weeks | Usual care with return to work in 2Â weeks, basic advice on risk factors and exercise | Pharmacotherapy at discretion of cardiologist; < 33% on statins, similar proportions in each trial arm |
KrasnitskiÄ, 2010R[67] | Russia | 1Â year | 100 | 93 | I: 55, C:54 | Post-PCI | TM, CVM, PCI | Group outpatient exercise (cycling) with educational sessions, 6Â weeks | Standard cardiological care (not other specified) | Maintenance pharmacotherapy for all participants; >80% on statins |
La Rovere, 2002 [68] | Italy | 10Â years | 95 | 100 | 52 | Myocardial infarction | CVM, MI, CABG | Outpatient exercise training (cycling and callisthenics) and education, 4Â weeks | Usual care with same education on risk factors diet and smoking as intervention group | Guideline pharmacotherapy but no statins used |
Lear, 2014 [69] | Canada | 16Â months | 78 | 85 | I: 62, C: 58 | Acute coronary syndrome, PCI or CABG with low to moderate risk | TM | Virtual, individual, home-based program with education, support, monitoring and exercise program delivered exclusively via the Internet, 4Â months | Usual care with basic advice on risk factors and exercise as well as internet resources | Not reported: assume statin therapy as recruited participants from 2009 onwards |
Leizorovicz, 1991 (PRECOR) [70] | France | 2Â years | 182 | 100 | 50 | Myocardial infarction | TM, CVM, MI, CABG | Outpatient group exercise training (cycling, walking, gymnastics), education and relaxation, 6Â weeks | (1) Usual care of physician (not other specified); (2) as for (1) with personalised risk factor education | Guideline pharmacotherapy but no statins used |
Marchionni, 2003 [71] | Italy | 14Â months | 270 | 71 | 3 age groups: 57, 70, 80 | Myocardial infarction | TM, MI | Two arms: education and counselling with either (1) outpatient exercise training or (2) home individual exercise training (both cycling, stretching, flexibility), 8Â weeks | Usual care of physician with one session of risk factor education | Not reported: assume statin therapy as recruited participants from 1998 onwards |
Miller, 1984 [72] | USA | 6 months | 203 | 100 | 52 | Myocardial infarction | CVM, MI, CABGb | Four arms: (1) short (8 weeks), home-based exercise training (cycling); (2) long (23 weeks), home-based exercise training (cycling); (3) short, gym-based exercise training (walking); (4) long, gym-based exercise training (walking) | Usual Care (not other specified: many walking 30–45 min daily) | Guideline pharmacotherapy but no statins used |
Spain | 10Â years | 190 | 100 | C: 53, I: 50 | Myocardial infarction with low further risk | TM, CVM, MI, CABG, PCI | Outpatient aerobic exercise (cycling) and callisthenics training, counselling and education, 3Â months | Usual care with basic risk factor advice | Pharmacotherapy at discretion of cardiologist; assume no statin therapy due to year of study | |
Munk, 2009 [75] | Norway | 1.5Â years | 40 | 83 | 59 | Post-PCI | MI, CABG, PCI# | Outpatient group-based high intensity interval training (cycling and running), 6Â months | Usual care (not other specified) | Maintenance pharmacotherapy for all participants including statins for 95% |
Mutwalli, 2012 [76] | Saudi Arabia | 6Â months | 49 | 100 | 57 | Post-CABG | TM, CVM, MI | Individual, home walking program with group outpatient education sessions and telephone support | Usual Care with basic risk factor advice | Not reported: assume statin therapy as recruited participants from 2008 onwards |
Oerkild, 2012 [77] | Denmark | 5.5Â years | 40 | 58 | 77 | Older than 65Â years with myocardial infarction, PCI or CABG | TM | Individual home-based walking program with support, dietary counselling and smoking education | Standard cardiological care (medication adjustment, frequent review by cardiologist) | Guideline-based pharmacotherapy including statins for all participants |
Oldridge, 1991 [78] | USA | 1Â year | 201 | 88 | 53 | Myocardial infarction with depression or anxiety | TM | Outpatient group aerobic exercise training (cycle, treadmill and arm ergometry) with cognitive therapy and counselling | Usual care of physician with 50% provided referral to similar CR program | Not reported: assume no statin use due to year of study |
USA | 5Â years | 93 | NR | I: 57, C: 62 | Angiographically documented CAD | TM, CVM, MI, CABG, PCI | Individual home-based aerobic exercise training (walking), relaxation and intensive diet plan; group outpatient counselling sessions, 4Â years | Usual care (not other specified) | Some participants in usual care arm began statins during trial (up to 60%). No statins started in intervention arm. | |
Reid, 2012 [81] | Canada | 1Â year | 223 | 84 | 56 | Post-PCI | TM, CABG# | Individual, home-based exercise training delivered via Internet with online behaviour change tutorials, 6Â months | Usual care of physician with exercise advice and education booklet | Not reported: assume statin therapy as recruited participants from 2004 onwards |
Román, 1983 [82] | Chile | 9 years | 193 | 90 | 55 | Myocardial infarction | TM, CVM, MI, CABG | Outpatient group exercise training (walking, ergometry and callisthenics), 42 months | Standard cardiological care (not other specified) | Guideline pharmacotherapy but no statins used |
Germany | 6Â years | 113 | 100 | 54 | Angiographically documented CAD | TM, CVM, MI, CABG, PCI# | Combination of individual home-based exercise (cycle) and group outpatient exercise training with diet plan and group education, 6Â years | Usual care with basic risk factor and diet advice | Pharmacotherapy as required; no statins at beginning but 41% usual care and 20% intervention arm on statins at end trial | |
USA | 19Â years | 651 | 100 | 52 | Myocardial infarction | TM, CVM, MI, CABG | Outpatient aerobic exercise training (circuit-based) for 8Â weeks and then ongoing maintenance exercise in a gymnasium | Usual care (not specified but avoid formal exercise program) | Guideline pharmacotherapy but no statins used | |
Sivarajan, 1982 [87] | USA | 6Â months | 258 | 80 | 56 | Myocardial infarction | TM, CVM, CABG | Two arms: (1) individual home-based callisthenics and walking program with outpatient group education; (2) Individual home-based callisthenics and walking program only, both 12Â weeks | Standard cardiological care: many exercising on own when surveyed | Not reported: assume no statin use as recruited participants before 1980 |
Specchia, 1996 [88] | Italy | 3Â years | 256 | 91 | 53 | Myocardial infarction | CVM, CABG, PCI | Residential-based group exercise training (cycling and callisthenics) with education for 4Â weeks then home maintenance walking program | Usual care with group education sessions | Guideline pharmacotherapy but no statins used |
Sweden | 4.4Â years | 109 | 80 | 71 | Myocardial infarction or unstable angina and >65Â years old | ACM, CABG, PCI# | Group-based outpatient aerobic interval training of large muscle groups to music with relaxation and option to go to education sessions, 12Â weeks | Usual care with basic exercise advice and option to go to same education sessions | Increase in statin use from 10 to 20% of participants in trial after 1Â year | |
Stern, 1983 [91] | USA | 1Â year | 106 | 86 | 54 | Myocardial infarction with decreased fitness or anxiety or depression | TM, MI, CABG | Outpatient aerobic exercise training (circuit-based high-intensity intervals), 12Â weeks | (1) Group counselling and education; (2) usual care of physician but avoid formal exercise or counselling | Not reported: assume no statin use due to year of study |
Toobert, 2000 [92] | USA | 2Â years | 28 | 0 | 64 | Diagnosed CAD, myocardial infarction, CABG or PCI | TM, CVM, MI# | Group aerobic exercise training, diet, relaxation and counselling at initial 7-day retreat, with decrease in continuing outpatient attendance frequency over a 2-year period | Usual care (not other specified) | Pharmacotherapy as required: 45% of usual care arm and 29% of intervention group on statin therapy |
Vecchio, 1981I [93] | Italy | 1Â year | 50 | 100 | 51 | Myocardial infarction | CVM, CABG | Residential exercise training (cycling and callisthenics), counselling and education, 6Â weeks | Usual care and exercise less than 3 METS at home | Not reported: assume no statin use due to year of study |
Vermeulen, 1983 [94] | Netherlands | 5Â years | 98 | 100 | 49 | Myocardial infarction | TM, CVM, MI | Outpatient group-based exercise training (cycling), counselling and psychological advice | Usual care (not other specified) | Not reported: assume no statin use due to year of study |
Vestfold Heart Care Group, 2003 [95] | Norway | 2Â years | 199 | 82 | I: 54, C: 55 | Myocardial infarction, unstable angina, PCI or CABG | TM, MIUP, CABGUP, PCIUP | Outpatient aerobic interval training of large muscle groups set to beat of music, counselling, education and relaxation (6Â weeks) then 9Â weeks exercise in gym | Standard cardiological care with basic risk factor advice | Guideline based pharmacotherapy for all participants including statins for >90% |
Wang, 2012 [96] | China | 6 months | 160 | 83 | I: 57, C: 58 | Myocardial infarction | TM | Individual, home-based exercise training, education and relaxation plan for 6 weeks based on, and culturally adapted from, the ‘Heart Manual’ | Usual care with basic risk factor advice | Pharmacotherapy as required including statin therapy for two thirds of participants |
West, 2013 [97] | UK | 9 years | 1813 | 74 | I: 64, C: 65 | Myocardial infarction | TM, MI, CABG, PCI | Outpatient cardiac rehabilitation as delivered in several UK centres (all include exercise training, education and counselling), 6–8 weeks | Usual care of health system (GP review, basic risk factor education) | Pharmacotherapy including statin therapy for 60% |
WHO Balatonfured, 1983 [98] | Hungary | 3Â years | 160 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 6Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Brussels, 1983 [98] | Belgium | 3Â years | 166 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 8Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Bucharest, 1983 [98] | Romania | 3Â years | 129 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise (cycling) with educational sessions and counselling, 12Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Budapest, 1983 [98] | Hungary | 3Â years | 200 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 8Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Dessau, 1983 [98] | Germany | 3Â years | 54 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise (cycling) with educational sessions and counselling, 6Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Erfurt, 1983 [98] | Germany | 3Â years | 119 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise (cycling) with educational sessions and counselling, 5Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Ghent, 1983 [98] | Belgium | 3Â years | 168 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise (cycling and gymnastics) with educational sessions and counselling, 6Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Kaunas, 1983 [98] | Lithuania | 3 years | 115 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 8–16 weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Prauge, 1983 [98] | Czech Republic | 3Â years | 112 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 3Â years | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Rome, 1983 [98] | Italy | 3Â years | 63 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 8Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Tel Aviv, 1983 [98] | Israel | 3Â years | 114 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 20Â weeks | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
WHO Warsaw, 1983 [98] | Poland | 3Â years | 79 | 100 | 53 | Myocardial infarction | TM, CVM, MI | Group outpatient CR at local centre: exercise for most participants with educational sessions and counselling, 3Â years | Usual care of local health system (not other specified) | Not reported: assume no statin use as recruited participants before 1980 |
Wilhelmsen, 1975 [99] | Sweden | 4Â years | 315 | 89 | 51 | Myocardial infarction | TM, CVM, MI | Outpatient exercise training (individualised high-intensity intervals, callisthenics, running, cycling), 1Â year | Standard cardiological care with basic advice on physical activity | Guideline pharmacotherapy but no statins used |
Yu, 2004 [100] | Hong Kong | 2Â years | 269 | 76 | 64 | Myocardial infarction or post-PCI | TM | Outpatient aerobic and resistance exercise training, vocational training and education with maintenance program offered, 8Â weeks | Standard cardiological care with one education session about risk factors and physical activity | Guideline-based pharmacotherapy including statin therapy for >56% participants |
Zwistler, 2008 [101] | Denmark | 3 years | 446 | 63 | 66 | Myocardial infarction, angina, PCI or CABG | TM, MI, CABG, PCI | Outpatient group-based aerobic and resistance exercise training, education and psychological advice | Standard cardiological care (not other specified) | Guideline-based pharmacotherapy; including statin therapy for 50–60% participants |