Developing the evidence base for

cardiac rehabilitation:

a 30 year & 6 cities journey

Rod Taylor MSc, PhD Professor of Health Services Research

& Director of Exeter Clinical Trials Unit

University of Exeter Medical School. Exeter, UK

& Adjunct Professor, University of Southern Denmark

June 9th 2017, REHPA, Nyborg, Denmark.

2

“The treatment

itself has no

side effects -

but the number

of statisticians

needed to prove

its value may

cause dizziness

and nausea”

2016 1948 1980-1984 1985-1997

PhD - “Physical Training in Middle Aged Men”

• Examine the physiological effect of a comparatively strenuous program of strenuous program of endurance training in group of middle aged men

• Assessments at prior to training (T1) and after 15 (T2) and 30 wks (T3) training

• 53 sedentary males; aged 35-50 yrs

Results

2016 1948 1985-1997 1998-2000

JAMA 1988;260:

945-50.

Exercise-Based CR for CHD

• 36 RCTs in 8440 post MI and revascularisation patients

• Compared to control, CR reduced risk of all cause death by 19% (Odds Ratio: 0.81, 95% 0.72, 0.91)

• Improvements in lipids, and BP

• Limited data on HRQoL

• Quality of reporting poor

Cochrane CR ‘Portfolio’ Title Version Publication status

Exercise based rehabilitation for…. CHD [9811] Stable angina [1612] Heart failure [0025] Atrial fibrillation [1401] Post valve surgery [1301] Implantable cardiac defibrillators [1409] Cardiac transplantation [1506]

v3 v1 v3 v1 v1 v1 v1

Jan 2016 Ongoing (Q2 2017) Ongoing (Q4 2017) Feb 2017 Mar 2016 Ongoing (Q3 2017) Apr 2017

Psychological interventions for CHD [0010] v3 Mar 2017

Educational interventions for CHD [1005] v2 2017 (in press)

Home vs centre based interventions [0802] v2 2017 (in press)

Interventions to increase uptake & adherence [0422]

v3 Ongoing (Q4 2017)

2016 1948 1998-2000 2000-2005

2016 1948 2000-2005 2006-2017

Cardiac Rehabilitation: The

evidence from the Cochrane

Reviews

Rod Taylor, MSc PhD

Dept of Public Health & Epidemiology,

University of Birmingham

Hjerterehbilitering I Denmark, Copenhagen,

28th October 2004

2016 1948 7 2006-2017

Evidence synthesis

Research gap identification

Clinical Trial

Priority setting

NICE CG 108 (2011)

28th July 2014!

REACH HF • Funded by NIHR Programme Grant, 2012-7

• Programme consists of linked work packages to:

• develop, a home based, self-help CR programme ('the

HF Manual') for people with HF and their caregivers

• pilot trial assess feasibility of definitive trial of the HF

Manual in HFPEF

• multi-centre RCT to assess effectiveness and cost

effectiveness of HF Manual vs. usual care in people with

HFREF and their caregivers

• evidence synthesis/modelling of the effectiveness and

cost effectiveness of the HF Manual vs. centre-based CR in HFREF and HFPEF

REACH-HF contributors

York

Professor Patrick Doherty

Dr Russell Davis

Birmingham

Professor Kate Jolly

Gwent

Dr Jackie Austin

Edinburgh

Exeter Professor Charles

Abraham

Professor Nicky Britten

Dr Colin Greaves

Dr Colin Green

Professor Rod Taylor

Truro Dr H Dalal

Dr Jenny Wingham

Dr Robin Van Lingen

Kevin Paul (PPI)

Heart Manual office

Dundee

Prof Chim Lang

Dr Karen Smith

Truro

Dundee

Edinburgh

York

Birmingham

Gwent

Exeter

REACH HF PROGRAMME

Updated Cochrane

review

of RCTs of CR for HF

Development of home-based

intervention for HFrEF & HFPEF

Development of caregiver

resource

Pilot RCT of HF Manual

versus usual care in

HFpEF

Feasibility study of HF Manual

versus usual care in HFrEF

Full multicenter RCT of HF

Manual versus usual care

with parallel process and

economic evaluations

in HFrEF

Decision analytic

economic modelling

REACH HF intervention model

0

10

20

30

40

50

60

Jul-

15

Aug

-15

Sep-

15

Oct

-15

No

v-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun

-16

No

. of

par

tici

pan

ts

Month

Target versus actual number of participants randomised for WP2 Pilot trial

Target randomised

Actual randomised

The researches of many

commentators have already

thrown much darkness on this

subject, and it is probable that

if they continue, we shall soon

know nothing at all about it.

Mark Twain

And the next (last) 5 yrs…

• Danish Heart Foundation – Review of reviews [Sept!]

• UK MRC Global Challenges – Implementing cost-effective CR in Bangladesh &

Malaysia [Q1 2018]

• REACH-HFpEF – Full trial application to NIHR HTA [Q3 2017]

• REACH-AF • UK NIHR Programme Grant Application [Q3 2017]