How can HF patients boost their daily physical activity engagement?

Physical activity (PA) interventions targeted at patients with heart failure (HF) can be especially effective if delivered by a physiotherapist in a centre-based setting and in group format, according to the results of a meta-analysis.

Understanding how to improve PA engagement in HF patients is critical to the success of cardiac rehabilitation (CR) and other exercise-based programmes, which help to improve quality of life and reduce hospitalization in HF, the investigators said. [Open Heart 2015;2:e000163; ACC Heart Fail 2019;7:691-705; Eur J Prev Cardiol 2015;22:1504-1512]

“The uptake of CR remains suboptimal. Therefore, it is essential to evaluate the efficacy of alternative interventions, as well as CR, and identify content and features that are likely to be successful in promoting PA,” they added.

In the study, the investigators pooled data from 20 randomized controlled trials evaluating a total of 21 PA interventions in HF. The trials included a total of 6,277 participants, with the majority (69.49 percent) being men and their mean age ranging from 54 to 80 years. Efficacy was assessed in terms of general approach (eg, CR), strategies used (eg, action planning), setting (eg, centre based), mode of delivery (eg, face to face or online), facilitator (eg, nurse), contact time, and behavioural change theory use.

PA interventions had a significant overall benefit as assessed postcompletion compared with education only (standardized mean difference [SMD], 0.54, 95 percent confidence interval [CI], 0.13–0.95; p<0.0005). Furthermore, the combination of an exercise programme with behavioural change intervention was effective at boosting PA engagement (SMD, 1.26, 95 percent CI, 0.26–2.26; p<0.05). [Open Heart 2021;8:e001687]

Efficacy also showed a significant association with centre-based (SMD, 0.98, 95 percent CI, 0.35–1.62) and group-based (SMD, 0.89, 95 percent CI, 0.29–1.50) delivery by a physiotherapist (SMD, 0.84, 95 percent CI, 0.03–1.65).

Intervention strategies identified as efficacious included prompts/cues (SMD, 3.29, 95 percent CI, 1.97–4.62), credible source (SMD, 2.08, 95 percent CI, 0.95–3.22), addition of objects to the environment (SMD, 1.47, 95 percent CI, 0.41–2.53), generalization of the target behaviour (SMD, 1.32, 95 percent CI, 0.22–2.41), monitoring of behaviour by others without feedback (SMD, 1.02, 95 percent CI, 0.05–1.98), self-monitoring of outcomes of behaviour (SMD, 0.79, 95 percent CI, 0.06–1.52), graded tasks (SMD, 0.73, 95 percent CI, 0.22–1.24), behavioural practice/rehearsal (SMD, 0.72, 95 percent CI, 0.26–1.18), action planning (SMD, 0.62, 95 percent CI, 0.03–1.21), and goal setting behaviour (SMD, 0.56, 95 percent CI, 0.03–1.08).

“The present review provides moderate evidence that an exercise programme combined with a behavioural change intervention is a promising approach to increasing PA in HF,” the investigators said.

In light of the present data, the investigators stressed the importance of additional training for physiotherapists in delivering behavioural change interventions that will include the identified efficacious strategies.

“Practical limitations of the identified efficacious strategy need to be considered when designing interventions. [For example], adding objects to the environment to support [a] physically active[e] lifestyle (eg, a treadmill) may not be affordable or practical, and does not satisfy the principle of health equity,” they added. [https://www.who.int/sdhconference/en/]

The investigators also stressed the need to determine how best to promote a physically active lifestyle in the older HF population, given that these patients have a significantly worse prognosis and a larger number of comorbidities than younger patients. [Can J Cardiol 2016;32:1140-1147]

“Only five trials assessed PA at 6-month and 12-month follow-ups. Long-term efficacy was not supported. Thus, it is important to investigate how sustained PA improvements can be established,” they said.