A novel physical rehabilitation program for patients with advanced heart failure (HF) that aimed to improve their ability to exercise before focusing on endurance was successful in a randomized trial in ways that seem to have eluded some earlier exercise-training studies in the setting of HF.
The often frail patients following the training regimen, initiated before discharge from hospitalization for acute decompensation, worked on capabilities such as mobility, balance, and strength deemed necessary if exercises meant to build exercise capacity were to succeed.
A huge percentage stayed with the 12-week program. They benefited with gains in balance, walking ability, and strength, which were followed by significant gains in 6-minute walk distance (6MWD) and measures of physical functioning, frailty, and quality of life. The patients then continued elements of the program at home out to 6 months.
At that time, death and rehospitalizations did not differ between those assigned to the regimen and similar patients who had not participated in the program, although the trial wasn’t powered for clinical events.
The rehab strategy seemed to work across a wide range of patient subgroups by age, sex, symptom severity, ejection fraction, and whether or not they were obese or had comorbidities such as ischemic heart disease, diabetes, or chronic kidney disease.
There was also evidence that the benefits were more pronounced in patients with HF and preserved ejection fraction (HFpEF) compared to those with HF and reduced ejection fraction (HFrEF), observed Dalane W. Kitzman, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Kitzman presented results from the REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) trial during the all-virtual American College of Cardiology (ACC) 2021 Scientific Session and is lead author on its same-day publication in the New England Journal of Medicine.
An earlier pilot program unexpectedly demonstrated that such patients recently hospitalized with HF “have significant impairments in mobility and balance,” he explained. “If so, “it would be hazardous to subject them to traditional endurance training, such as walking-based treadmill, or even bicycle.”
The unusual program, said Kitzman, looks to those issues before engaging the patients in endurance exercise by addressing mobility, balance, and basic strength — enough to repeatedly stand up from a sitting position, for example. “If you’re not able to stand with confidence, then you’re not able to walk on a treadmill.”
This model of exercise rehab, Kitzman said, “is used in geriatrics research, and enables them to safely increase endurance. It’s well known from geriatric studies that if you go directly to endurance in these, frail, older patients, you have little improvement and often have injuries and falls.”
The functional outcomes examined in REHAB-HF “are the ones that matter to patients the most,” observed Eileen M. Handberg, PhD, Shands Hospital at the University of Florida, Gainesville, at a presentation on the trial for the media.
“This is about being able to get out of a chair without assistance, not falling, walking farther, and feeling better as opposed to the more traditional outcome measure that has been used in cardiac rehab trials, which has been the exercise treadmill test — which most patients don’t have the capacity to do very well anyway,” said Handberg, who is not a part of REHAB-HF.
“This opens up rehab, potentially, to the more sick, who also need a better quality of life,” she said.
“I was really very impressed that you had 83% adherence to a home exercise 6 months down the road, which far eclipses what we had in HF-ACTION,” said Vera Bittner, MD, University of Alabama, Birmingham, as the invited discussant following Kitzner’s formal presentation of the trial. “And it certainly eclipses what we see in the typical cardiac rehab program.”
Both Bittner and Kitzner participated in HF-ACTION, a randomized exercise-training trial for patients with chronic, stable HFrEF who were all-around less sick than those in REHAB-HF.
Of the 349 patients in REHAB-HF, those assigned to the program scored significantly higher on the 3-component Short Physical Performance Battery (SPPB) at 12 weeks (8.3 vs 6.9; P < .001), compared to those assigned to a usual care approach that included, for some, more conventional cardiac rehabilitation.
The SPPB, validated in trials as a proxy for clinical outcomes, Kitzner and colleagues report, includes tests of balance while standing, gait speed during a 4-minute walk, and strength. The latter is the test that measures time needed to rise from a chair 5 times.
In subgroup analyses, the intervention was successful against the standard-care approach in both men and women, at all ages and regardless of ejection fraction; symptom status; and whether the patient had diabetes, ischemic heart disease, or atrial fibrillation or was obese.
Many patients who were invited to participate in the trial could not because they lived too far away from the program, observed Handberg.
“It would be nice to see if the lessons from COVID-19 might apply to this population” by making participation possible remotely, “perhaps using family members as rehab assistance,” she said.
Supported by research grants from the National Institutes of Health, the Kermit Glenn Phillips II Chair in Cardiovascular Medicine, and the Oristano Family Fund at Wake Forest School of Medicine.
American College of Cardiology (ACC) 2021 Scientific Sessions. Abstract 406-09. Presented May 16, 2021.
N Engl J Med. Published online May 16, 2021. Abstract
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