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Item Open Access Effects of Cardiac Rehabilitation in Low- and Middle-Income Countries: A systematic Review and Meta-Analysis of Randomised Controlled Trials(Progress in Cardiovascular Diseases, 2022-01) Mamataz, Taslima; Uddin, Jamal; Alam, Sayed Ibn; Taylor, Rod S.; Pakosh, Maureen; Grace, SherryObjectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there. Methods: Six electronic databases (PubMed,Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched frominception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g.,mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane’s tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI). Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to −0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI=1.13 to 9.63; I2=84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR. Conclusions: Lowtomoderate-certainty evidence establishesCRas delivered in LMICs improves functional capacity, risk factor control and QoL.Whilemore high-quality research is needed, we must augment access to CR in these settings. Systematic review registration: PROSPERO (CRD42020185296).Item Open Access The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex(Heart & Lung, 2021-07) Chowdhury, Mohiul; Heald, Fiorella Andani; Sanchez-Delgado, Juan C.; Pakosh, Maureen; Jacome Hortua, Adriana Marcela; Grace, SherryPhase III/IV cardiac rehabilitation (CR) is recommended to promote maintenance of benefits achieved during Phase II; there has been no meta-analysis to test this to date. This study determined the effects of maintenance CR on any outcome, with consideration of sex. Seven databases were searched from inception-January 2020. Randomized controlled trials on the effects of maintenance CR in cardiovascular disease patients who had graduated from CR were included. Level of evidence was evaluated with GRADEPro. 819 citations were identified, with 10 trials (21 papers) included (5238 participants; 859 [16.4%] female). Maintenance CR resulted in lower low-density lipoprotein (mean difference [MD]=-0.58; 95% confidence interval [CI]=- 1.06–-0.10, n=392) and greater quality of life (MD=0.28, 95% CI=0.05–0.52, n=118) when compared to usual care only. Outcomes for women and sex differences were mixed. In conclusion, maintenance programs appear to sustain patient’s quality of life, but more focus on women’s outcomes is needed.Item Restricted Outcomes and Cost of Women-Focused Cardiac Rehabilitation: A Systematic Review and Meta-analysis(Maturitas, 2022-06) Mamataz, Taslima; Lima de Melo Ghisi, Gabriela; Pakosh, Maureen; Grace, SherryBackground: The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost. Methods: Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception-May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. “Women-focused” CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women’s preferences. No studies were excluded based on outcome. Two independent reviewers rated citations for potential inclusion, and 1 extracted data, including quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; Certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied. Results: 3498 unique citations were identified, of which 28 (52 papers) studies were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with usual care comparisons. When compared to active comparison, women-focused CR had no meaningful effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence), and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as 7/8 SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported favorable economic impact and another reduced sick days. Conclusions: Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.