Cardiac Rehabilitation in Patients with Advanced Heart Failure

Guiding heart failure care by invasive hemodynamic measurements: Possible or useful?

The American College of Cardiology (ACC)/American Heart Association (AHA) performance measurement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement. Writing committees are instructed to consider the methodology of performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing committees also are charged with constructing measures that maximally capture important aspects of care quality, including …

The Impact of Early Cardiac Rehabilitation by using Classification of the Status on Admission for Patients with Congestive Heart Failure

RationaleTo improve the quality of exercise-based cardiac rehabilitation (CR) in patients with chronic heart failure (CHF) a practice guideline from the Dutch Royal Society for Physiotherapy (KNGF) has been developed.Guideline developmentA systematic literature search was performed to formulate conclusions on the efficacy of exercise-based intervention during all CR phases in patients with CHF. Evidence was graded (1–4) according the Dutch evidence-based guideline development criteria.Clinical and research recommendationsRecommendations for exercise-based CR were formulated covering the following topics: mobilisation and treatment of pulmonary symptoms (if necessary) during the clinical phase, aerobic exercise, strength training (inspiratory muscle training and peripheral muscle training) and relaxation therapy during the outpatient CR phase, and adoption and monitoring training after outpatient CR.Applicability and implementation issuesThis guideline provides the physiotherapist with an evidence-based instrument to assist in clinical decision-making regarding patients with CHF. The implementation of the guideline in clinical practice needs further evaluation.ConclusionThis guideline outlines best practice standards for physiotherapists concerning exercise-based CR in CHF patients. Research is needed on strategies to improve monitoring and follow-up of the maintenance of a physical active lifestyle after supervised CR.

PURPOSE Increasing caloric expenditure through physical activity is associated with reduced mortality. On the basis of observational studies, previous authors have suggested that at least 1000 kcal per week and possibly 1500 kcal per week of physical activity is necessary for health benefits. The authors have previously reported that patients in maintenance cardiac rehabilitation accumulate approximately 230 kcal per exercise session, suggesting that additional activity outside of cardiac rehabilitation is needed to achieve the goal of 1500 kcal per week. The authors estimated the amount of energy expenditure performed each week by patients in cardiac rehabilitation during both program participation and leisure time. METHODS For this study, 104 patients enrolled in a supervised maintenance cardiac rehabilitation program at both tertiary care and community settings for at least 6 months completed a self-administered physical activity questionnaire. Energy expenditure in cardiac rehabilitation and leisure time activity was measured in kilocalories. Total caloric expenditure was determined by adding up the number of kilocalories expended by the patients each week climbing stairs, walking, participating in cardiac rehabilitation, and engaging in sports. RESULTS Patients in cardiac rehabilitation expended weekly, on the average, 1504 +/- 830 kcal in physical activity, 830 +/- 428 kcal in cardiac rehabilitation, and 675 +/- 659 kcal in leisure time activity. There was a significant difference in caloric expenditure between men and women, between those with a body mass index (BMI) less than 30 and those with a BMI of 30 or more, and between those younger than 70 years and those 70 years or older. There was no difference between races. Whereas 43% of the patients accumulated 1500 kcal, 57% did not. CONCLUSIONS The findings showed that 72% of the patients in cardiac rehabilitation accumulated at least 1000 kcal of energy expenditure per week and met public health guidelines. Also, 43% of the patients in cardiac rehabilitation accumulated more than 1500 kcal of energy expenditure per week, a level identified as necessary to reduce all-cause mortality. Women of either race, patients with a BMI of 30 or more, and patients age 70 years or older are the groups least likely to achieve 1500 kcal of energy expenditure per week. The authors recommend incorporating weekly kilocalories of energy expenditure in the exercise prescription of patients to ensure achievement of maximum health benefits.

Is There a Role for Cardiac Rehabilitation After Coronary Artery Bypass Grafting? Treatment After Coronary Artery Bypass Surgery Remains Incomplete Without Rehabilitation.

To describe inpatient and outpatient cardiac rehabilitation (CR) utilization patterns over time and by subgroups among patients admitted for acute heart failure (AHF) in Japan. Cardiac rehabilitation (CR) is a crucial secondary prevention strategy for patients with heart failure. While the number of older patients with AHF continues to rise, trends in inpatient and outpatient CR participation following AHF in Japan have not been described to date. We conducted a retrospective cohort study of adult patients hospitalized for AHF in Japan between April 2008 and December 2020. Using data from the Medical Data Vision database, we measured trends in inpatient and outpatient CR participation following AHF. Descriptive analyses and summary statistics for AHF patients by CR participation status were reported. The analytic cohort included 88,052 patients. Among these patients, 37,810 (42.9%) participated in inpatient and/or outpatient CR. Of those, 36,431 (96.4%) participated in inpatient CR only and 1,277 (3.4%) participated in both inpatient and outpatient CR. Rates of inpatient CR rose more than 6-fold over the study period, from 9% in 2009 to 55% in 2020, whereas rates of outpatient CR were consistently low. The rate of inpatient CR participation among AHF patients in Japan rose dramatically over a 12-year period, whereas outpatient CR following AHF was vastly underutilized. Further study is needed to assess the clinical effectiveness of inpatient CR and to create infrastructure and incentives to support and encourage outpatient CR.

A facilitated home-based cardiac rehabilitation intervention for people with heart failure and their caregivers: a research programme including the REACH-HF RCT

This randomized-controlled trial demonstrates that an exercise consultation, based on the transtheoretic model of exercise behavior change, significantly improves short-term adherence to exercise.

Heart failure

Case reportWe report the effect of a 6-week outpatient (phase II) cardiac rehabilitation in a 38-year-old man with post-stented coarctation of the aorta, moyamoya disease and hypertension. The cardiac rehabilitation programme comprised physiotherapist-guided aerobic exercises, resistance training and relaxation exercises. Clinical and functional assessment was performed before and after the cardiac rehabilitation programme.DiscussionThere is a lack of recommendations to guide cardiac rehabilitation in patients with coarctation of the aorta. This case not only had coarctation of the aorta, but also had moyamoya disease and hypertension. A cardiac rehabilitation programme after surgery provided meaningful improvements in all outcomes, including exercise capacity, clinical outcomes, quality of life and depression symptoms. Systematic cardiac rehabilitation was found to be feasible in this patient with coarctation of the aorta, and may have the potential to benefit more patients.ConclusionCardiac rehabilitation resulted in significant clinical and functional improvements in this case with coarctation of the aorta following surgery. Guidelines should be implemented to provide safe and effective cardiac rehabilitation in such patients. Furthermore, large-scale studies are needed to evaluate the clinical benefits of structured cardiac rehabilitation in patients following cardiac surgery.LAY ABSTRACTThis case report describes the effect of a 6-week outpatient cardiac rehabilitation in a 38-year-old man with coarctation of the aorta, moyamoya disease and hypertension. The cardiac rehabilitation programme comprised physiotherapist-guided aerobic exercises, resistance training and relaxation exercises. Clinical and functional assessment was performed before and after the cardiac rehabilitation programme. There is a lack of recommendations to guide cardiac rehabilitation in patients with coarctation of the aorta. Cardiac rehabilitation provided significant clinical and functional improvements, including exercise capacity, clinical outcomes, quality of life and depression symptoms, in this patient with coarctation of the aorta following surgery. Systematic cardiac rehabilitation was found to be feasible in this patient with coarctation of the aorta, and may have the potential to benefit more patients. Guidelines should be implemented to provide safe and effective cardiac rehabilitation in such patients.

Exercise and cardiac rehabilitation in hypertensive patients with heart failure with preserved ejection fraction: A position statement on behalf of the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology

Cardiac rehabilitation is a coordinated treatment approach. The interdisciplinary team aims to provide the best possible physical and psychological outcomes for patients with cardiac diseases. Patients should be enable to independently resume work and and social life. Furthermore cardiac rehabilitation wants to limit or reverse the progress of cardiac disease through sustained health-related life habits. Cardiac rehabilitation significantly contributes to long-term success based on comprehensive care of cardiac patients. Outpatient cardiac rehabilitation has shown to be effective after myocardial infarction, coronary artery bypass grafting and chronic heart failure. However randomized controlled trials were performed only in Anglo-American countries. In these trials effects were observed mainly for exercise-based cardiac rehabilitation programs. Because the results have been derived from different program settings they cannot simply be translated to German-speaking countries. However, several cohort studies predominantly performed in Germany also revealed effects of inpatient and outpatient cardiac rehabilitation programs for German-speaking countries. The most recent results demonstrated a significant reduction of recurrent events in patients after inpatient cardiac rehabilitation. Following the current evidence concerning the effect of inpatient and outpatient cardiac rehabilitation programs particularly after myocardial infarction international guidelines provide Class I (USA) and IIa (Europe) recommendation for this treatment intervention.In contrast to Anglo-American countries cardiac rehabilitation in Austria, Germany and Switzerland was established at its beginning exclusively for inpatient programs. In addition more and more outpatient programs were introduced in the last decades. Nevertheless inpatient cardiac rehabilitation is still the most common program in German-speaking countries.Future challenges of cardiac rehabilitation should not address the competition between inpatient and outpatient programs but provide answers to the question "which patient needs which program?" Future cardiac rehabilitation will offer patient-tailored programs. In German-speaking countries inpatient cardiac rehabilitation has long been well established whereas treatment potential of outpatient programs have increased. Outpatient cardiac rehabilitation is more flexible, close to home and it can be done part-time. Furhtermore, outpatient cardiac rehabilitation programs can take on important tasks in long-term cardiac care and thus provide relief to inpatient programs. The initiation of such programs is a challenge and can add to better future development of comprehensive cardiac rehabilitation.

Background Kidney dysfunction is considered one of the most prevalent comorbidities in patients with heart failure (HF). A combination of HF and kidney dysfunction is associated with peripheral muscle impairment, exercise intolerance, and poor prognosis. Conversely, cardiac rehabilitation (CR) for HF patients has been recognized to improve their clinical outcomes. However, the impact of kidney function on responses to CR in patients with HF is still unclear. Purpose This study aimed to investigate the associations between baseline kidney function and outcomes following CR including changes in physical function and prognosis in HF patients. Methods We reviewed a total of 3,727 patients who were admitted for HF treatment and underwent comprehensive CR during hospitalization. In addition to clinical characteristics, we assessed the kidney function using estimated glomerular filtration rate (eGFR) based on serum creatinine level at hospital discharge as baseline. The quadriceps strength (QS) and 6-minute walk distance (6MWD) were measured as muscle strength and functional capacity, respectively, at baseline. We also remeasured these parameter 5 months after hospital discharge in patients who participated in outpatient CR. The association between participation in outpatient CR and composite outcome of all-cause death and/or unplanned readmission were assessed using the multivariate Cox proportional hazard models in a subgroup of baseline eGFR. We also compared the changes in QS and 6MWD (ΔQS and Δ6MWD) between the eGFR stages. Results During the median follow-up period of 1.9 years, all-cause death/readmission occurred in 1604 (43.0%) patients, and their rate of incidence was 20.9/100 person-years. Out of studied patients, 1,585 (42.5%) patients participated in outpatient CR that was significantly associated with lower incidences of all-cause clinical events in patients with both eGFR ≥60 (adjusted hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.60–0.89, P=0.002) and eGFR <60 (adjusted HR: 0.88, 95% CI: 0.78–0.99, P=0.045), but those with an eGFR <60 showed significant interaction between CR participation and adverse clinical events (interaction P<0.035, Figure 1). Among the outpatient CR participants, QS and 6MWD were significantly higher after 5-month CR than those at baseline (P<0.001, respectively), but the low baseline eGFR correlated with low ΔQS and Δ6MWD (trend P<0.001, respectively) even after adjustment for clinical confounding factors (Figure 2). Conclusions Although the outcomes following CR is affected by baseline kidney function, outpatient CR is significantly associated with the positive change in physical function and better prognosis in HF patients with low kidney function. Funding Acknowledgement Type of funding sources: None.

ObjectiveTo investigate the effect of sacubitril/valsartan (ARNI) combined with cardiac rehabilitation (CR) in patients with heart failure (HF) after acute myocardial infarction (AMI).MethodsA total of 118 patients with HF after AMI were screened and randomly divided into an experimental group and a control group. The control group was given ARNI. The experimental group received CR treatment in addition to the control treatment. The primary endpoint was cardiorespiratory fitness as measured by the cardiopulmonary exercise test (CPET). The secondary endpoints included cardiac remodeling detected by NT-ProBNP and cardiac ultrasound. All participants were assessed by CPET, NT-ProBNP, and cardiac ultrasound at baseline and after treatment.ResultsAfter treatment, the changes in the left ventricular ejection fraction (LVEF), anaerobic threshold (AT), oxygen uptake peak (VO2 peak), and metabolic equivalents (METs) in the experimental group were significantly greater than those in the control group (all P < 0.05). However, there was no significant difference in BNP, Left atrial diameter (LA) or Left ventricular end diastolic diameter (LVD) between the two groups (P > 0.05).ConclusionsPatients with HF after AMI could benefit from combined ARNI and CR.Trial registrationhttp://www.chictr.org.cn, ChiCTR2400093772 (11/12/2024). Retrospectively registered.