This review concluded that home-based exercise increased exercise capacity safely, but did not improve quality of life in patients with chronic heart failure. The authors suggested that home-based exercise could be used to improve the management of patients who had limited access to hospital-based exercise. The authors’ conclusions appear reasonable, but variability between studies needs to be investigated further.

To determine the effectiveness and safety of home-based exercise in improving exercise capacity and quality of life in people with chronic heart failure.

English language trials were identified through a computerised bibliographic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Register of Controlled Trials, PEDro, Chinese Electronic Periodical Service (CEPS) and MD Consult for studies published between January 1980 and July 2006. The references of retrieved articles were searched for additional studies, conference abstracts were searched and expert advice sought. Search terms were reported.

Randomised controlled trials (RCTs) of home-based exercise in adults with chronic heart failure (three or more months duration) were eligible for inclusion. Chronic heart failure was based on clinical presentation or left ventricular ejection fraction. The home-based exercise protocol could be aerobic exercise with or without resistance exercise. Studies of simultaneous supervised and home-based exercise, respiratory muscle training or training of a single muscle were excluded. Studies were required to report at least one of the following outcomes: exercise capacity measured at the impairment level by peak VO₂ (oxygen uptake) and at the activity level by a graded exercise test or the six-minute walk test; health-related quality of life (QOL) measured using disease-specific scales; and adverse events including all-cause mortality, cardiac death and hospitalisation for heart failure.

Participants in the included studies were predominantly men. Most patients were clinically stable. All programs included aerobic exercise (walking or cycling) with some resistance. The duration of home-based exercise ranged from six weeks to nine months. Most included studies compared the home-based exercise intervention with usual activity. Two reviewers independently assessed eligibility.

The quality of studies was independently assessed by two reviewers using the PEDro scale to assign a score out of 10. The following variables were included: random allocation; allocation concealment; similarity at baseline; participant blinding; therapist blinding; assessor blinding; less than 15 per cent drop-outs; intention to treat; between-group differences reported; point estimate and variability reported. Disagreements were resolved by consensus.

Data on numbers of events in each group were used to derive the odds ratio (OR) and 95% confidence intervals (CIs) for dichotomous outcomes. Continuous variables were reported as mean (SD) or median (range). Data extraction was performed by one reviewer and checked by another. Study authors were contacted to provide additional information where necessary.

For dichotomous outcomes, the pooled odds ratio (OR) and corresponding 95% CIs were calculated. For continuous outcomes, pooled weighted mean differences (WMD) or standard mean difference (SMD) and corresponding 95% CIs were calculated. Statistical heterogeneity was assessed (method not reported): in the absence of heterogeneity, studies were pooled in a fixed-effect meta-analysis; where there was statistical heterogeneity, a random effects-model was used.

Ten RCTs (n=648) were included in the review. PEDro scores ranged from 4 to 7 (median was 5.5) out of 10. Three studies investigated two weeks of hospital-based exercise before home-based exercise. Two studies investigated three months of supervised exercise before home-based exercise. The remaining five studies investigated home-based exercise alone. Most studies were of low to moderate intensity exercise (40 to 70 per cent of maximum heart rate or 70 per cent peak VO₂).

Home-based exercise increased peak oxygen uptake (seven trials, WMD 2.7 mL/kg/min, 95%CI: 0.7, 4.7) and increased six-minute walk test distance by 41 metres in (five trials, 95%CI: 19, 63) compared to usual activity. Home-based exercise did not increase the odds of hospitalisation compared to usual activity (two trials, OR 0.75, 95%CI: 0.19, 2.92). A random-effects model was used for the peak oxygen uptake analysis as there was statistically significant heterogeneity; a fixed-model was used for the home-based exercise analysis, presumably because the test of heterogeneity was not significant at 5 per cent level (p=0.06, I² = 55%).

Quality of life was measured in three trials using the Minnesota Heart Failure Questionnaire, which had a maximum possible score of 105 points. Home-based exercise did not improve quality of life (WMD 0.5 points, 95%CI: -4.4, 5.4) compared to usual activity. Using the Chronic Heart Failure Questionnaire, one study reported significant improvement in quality of life and the other did not.

Home-based exercise increased exercise capacity safely, but did not improve quality of life in patients with chronic heart failure. Home-based exercise could be used to improve management of people with chronic heart failure who do not have access to hospital-based exercise.

This review addressed a clear question in terms of participants, inclusion criteria, study design and outcomes of interest. A number of relevant electronic databases were searched. Search terms were reported. There were no language restrictions. The potential influence of publication bias was not considered in the report. Steps were taken to minimise bias and errors in searching for relevant trials, selection of included trials and data extraction. Validity assessment was carried out, but did not appear to be considered in the interpretation of results. Heterogeneity was assessed and a random-effects model used where evidence of heterogeneity was found, but possible sources of heterogeneity (oxygen uptake analysis and the suggestion of heterogeneity in the walk test) were not investigated.

The authors’ conclusions appeared reasonable, but variability between studies needs to be investigated further.

Practice: The authors stated that home-based exercise could be used to improve the management of patients who have limited access to hospital-based exercise.

Research: The authors stated that further studies on safety were needed because most trials included in this review were not designed to assess safety and data were scarce.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.