Circulation, Vol 80, 234-244, Copyright © 1989 by American Heart Association
GT O'Connor, JE Buring, S Yusuf, SZ Goldhaber, EM Olmstead, RS Paffenbarger Jr and CH Hennekens
Of 22 randomized trials of rehabilitation with exercise after myocardial
infarction (MI), one trial had results that achieved conventional
statistical significance. To determine whether or not these studies, in the
aggregate, show a significant benefit of rehabilitation after myocardial
infarction, we performed an overview of all randomized trials, involving
4,554 patients; we evaluated total and cardiovascular mortality, sudden
death, and fatal and nonfatal reinfarction. For each endpoint, we
calculated an odds ratio (OR) and 95% confidence interval (95% CI) for the
trials combined. After an average of 3 years of follow-up, the ORs were
significantly lower in the rehabilitation than in the comparison group:
specifically, total mortality (OR = 0.80 [0.66, 0.96]), cardiovascular
mortality (OR = 0.78 [0.63, 0.96]), and fatal reinfarction (OR = 0.75
[0.59, 0.95]). The OR for sudden death was significantly lower in the
rehabilitation than in the comparison group at 1 year (OR = 0.63 [0.41,
0.97]). The data were compatible with a benefit at 2 (OR = 0.76 [0.54,
1.06]) and 3 years (OR = 0.92 [0.69, 1.23]), but these findings were not
statistically significant. For nonfatal reinfarction, there were no
significant differences between the two groups after 1 (OR = 1.09 [0.76,
1.57]), 2 (OR = 1.10 [0.82, 1.47]), or 3 years (OR = 1.09 [0.88, 1.34]) of
follow- up. The observed 20% reduction in overall mortality reflects a
decreased risk of cardiovascular mortality and fatal reinfarction
throughout at least 3 years and a reduction in sudden death during the 1st
year after infarction and possibly for 2-3 years. With respect to the
independent effects of the physical exercise component of cardiac
rehabilitation, the relatively small number of "exercise only" trials,
combined with the possibility that they may have had a formal or informal
nonexercise component precludes the possibility of reaching any definitive
conclusion. To do so would require a randomized trial of sufficient size to
distinguish between no effect and the most plausible effect based on the
results of this overview.
ARTICLES
An overview of randomized trials of rehabilitation with exercise after myocardial infarction
Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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