Abstract
Background: The safety of exercise therapy (ET) in patients with an implantable cardioverter defibrillator (ICD) remains unclear. We sought to explore the current state of evidence and conduct a systematic review on the safety of ICDs during ET. Methods: A systematic review was performed using CINAHL, Cochrane Library, EMBASE, Google Scholar, MEDLINE, PubMed (excluding Medline records), and Web of Science databases searched through April 2015. Studies that quantitively assessed adverse events during ET and after ET in ICD patients compared to one of two control groups (non-ICD ET or non-ET ICD patients) were included. The primary outcome was adverse events during ET. Secondary outcomes were events during ET and follow-up. Results: Meta-analyses were performed on ten eligible studies. During ET, ICD patients experienced an increased risk of adverse events [relative risk (RR)=2.63, 95% confidence interval (CI) (1.71-4.05), P=0.01] compared to non-ICD controls. There was no significant increase risk of adverse events compared to non-ET ICD controls [RR=0.99, 95% CI (0.11-8.95), P=0.99]. ET-ICD patients had fewer adverse events during follow-up compared to non-ET ICD populations [RR=0.90, 95% CI (0.82- 0.99), P=0.02]. A sensitivity analysis including only randomized trials showed similar findings showed no difference in the primary outcome. Conclusions: Our analysis showed increased adverse event during exercise in ICD patients as compared with non-ICD patients. Comparative adverse event rates between exercising and sedentary ICD patients were similar during ET and lower after ET, suggesting that exercise can be safe and potentially protective among ICD patients. More rigorous data from larger randomized trials is needed to further quantify the incremental risk of exercise in high-risk ICD populations.
Highlights
Implantable cardioverter defibrillators (ICDs) result in significant survival benefit in patients with heart failure, high-risk arrhythmias, and survivors of sudden cardiac arrest [1,2]
Exercise and cardiac rehabilitation has established benefits in survival, health status, and quality of life in both high and low risk cardiac patients, including those with and without an ICD [4,5,6,7,8]. Those with an ICD are underrepresented in cardiac rehabilitation, typically report low levels of exercise [9,10] and are often reluctant to participate in exercise programs due to fear of exercise-induced shocks [11,12]
(629 from PubMed, 170 from MEDLINE, 2363 from Web of Knowledge, 467 from EMBASE, 3227 from CINAHL, 5820 from Google Scholar, and 1942 from the Cochrane Library), and five studies were added after hand-searching in-text citations (Figure 1). 15 (3573 participants) [9,18,19,20,28,29,30,31,32,33,34,35,36,37,38] studies collected data relevant to our outcomes of interest, safety and/or adverse events during and/or after exercise therapy (ET)
Summary
Implantable cardioverter defibrillators (ICDs) result in significant survival benefit in patients with heart failure, high-risk arrhythmias, and survivors of sudden cardiac arrest [1,2]. As such, their use worldwide is increasing for both primary and secondary prevention of sudden cardiac death [3]. Exercise and cardiac rehabilitation has established benefits in survival, health status, and quality of life in both high and low risk cardiac patients, including those with and without an ICD [4,5,6,7,8].
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