Effectiveness and safety of out-of-hospital cardiac rehabilitation: a living systematic review (Update report)

Background: Cardiac rehabilitation (CR) is a key component of secondary prevention for patients with ischemic heart disease or heart failure. However, access to hospital-based cardiac rehabilitation (HBCR) remains limited for many patients. Out-of-hospital cardiac rehabilitation (OHCR), particularly home-based programs, offers a potentially more accessible alternative. The comparative effectiveness and safety of OHCR versus HBCR, particularly for critical outcomes such as mortality, cardiac events, and health-related quality of life (HRQoL), remains a priority for decision-makers.Objective: To assess the effectiveness and safety of OHCR compared to HBCR in patients with ischemic heart disease or heart failure, with a focus on critical outcomes (all-cause mortality, cardiac events, and HRQoL) and to determine whether a living evidence approach remains warranted.Methods.Design: We are conducting a Living Evidence Synthesis; this is the first update report since our previous baseline evidence synthesis report completed on 10/07/2023. Based on its conclusions we activated the evidence monitoring to identify emerging studies that inform on critical outcomes such as all-cause mortality, cardiac events and HRQoL that were unresolved by the available evidence and require a living evidence approach.Evidence identification, screening and selection: We conducted a living systematic review following a registered protocol and the methodological standards proposed by the Cochrane Collaboration and the GRADE Working Group. Searches were performed using the Epistemonikos database and managed through the L·OVE (Living OVerview of Evidence) platform, which supports automated retrieval and continuous surveillance. Study selection, data extraction, and risk of bias assessments were conducted independently by two reviewers.Synthesis and assessment: We conducted meta-analyses using random-effects models. Effect estimates were expressed as risk ratios for dichotomous outcomes and mean or standardized mean differences for continuous outcomes. Subgroup and meta-regression analyses were used to explore heterogeneity. Certainty of evidence was assessed using GRADE.Results: The updated synthesis found no meaningful differences between OHCR and HBCR in terms of all-cause mortality, cardiac events, or HRQoL. The certainty of the evidence for critical outcomes was rated as moderate at best, mainly due to risk of bias and inconsistency. No significant effect modifiers were identified in subgroup or meta-regression analyses.Conclusions: Overall, evidence of moderate certainty suggests that OHCR, particularly home-based CR, is as effective as HBCR for improving critical outcomes in patients with ischemic heart disease or heart failure. Given the minimal new evidence identified and the stability of findings, we have decided to discontinue the living mode for this question as of 22/11/2024, with no further updates planned in the near future.