Tailored cardiac rehab programme may improve physical function, QoL in older HF patients

A tailored, progressive rehabilitation programme may improve physical function in older patients hospitalized with acute decompensated heart failure (ADHF), according to results of the REHAB-HF* trial presented at ACC.21.

“Physical dysfunction, frailty, and depression are often unrecognized clinically in older patients hospitalized for HF, are generally not addressed in clinical care pathways, and probably contribute to delayed, incomplete recovery and high rates of rehospitalization, death, and long-term loss of independence after hospital discharge,” said the authors led by Professor Dalane Kitzman from the Wake Forest School of Medicine, Winston-Salem, North Carolina, US.

“The initiation of standard endurance exercise training in frail, older patients without first addressing deficits in balance and mobility can limit efficacy and increase the risk of injuries and falls,” they continued.

Study participants were 349 adults aged 60–99 years (mean age 72.7 years, 52 percent female, 49 percent non-White) hospitalized for ADHF, who were functionally independent pre-admission and could walk ≥4 m. They were randomized 1:1 to undergo a novel, transitional, tailored, progressive, multi-domain (strength, balance, mobility, endurance) rehabilitation intervention initiated soon after hospitalization plus usual care (which could include traditional cardiac rehabilitation and physical therapy) or usual care alone (control group).

The intervention was continued for 36 weeks post-discharge (three 60-minute outpatient sessions each week). These sessions were complemented by home exercise (low-intensity walking and strengthening exercises) on non-intervention days. Patient retention for the intervention was 82 percent and adherence 67 percent. Endurance, assessed by walking duration, increased between the first and last sessions (from mean 10.7 to 22.0 minutes).

Fifty-three percent of the patients had HF with preserved ejection fraction. Ninety-seven percent were considered frail or pre-frail and patients had a mean five comorbidities. Forty-five percent had prior history of hospitalization, 25 percent for HF.

Short Physical Performance Battery (SPPB) score at 3 months was significantly improved in the intervention vs control group (least-squares [LS] mean score, 8.3 vs 6.9; mean difference, 1.5, 95 percent confidence interval [CI], 0.9–2.0; p<0.001). The baseline SPPB scores were 6.0 vs 6.1. [ACC.21, abstract 21-LB-20990-ACC; N Engl J Med 2021;doi:10.1056/NEJMoa2026141]

The findings were consistent across the three components of the SPPB (balance score: 3.2 vs 2.9; 4-minute walk score: 3.0 vs 2.5; chair rise score: 2.1 vs 1.5).

All-cause hospital readmission at 6 months did not differ between the intervention and control groups (rate, 1.18 vs 1.28; rate ratio [RR], 0.93, 95 percent CI, 0.66–1.19), nor did hospital readmission for HF (94 vs 110) or death (n=21 vs 16; rate, 0.13 vs 0.10; RR, 1.17, 95 percent CI, 0.61–2.27). Fifteen and eight of the deaths in the intervention and control arms, respectively, were due to cardiovascular causes.

At 3 months, 6-minute walk distance improved with the intervention vs control (effect size, 34 m), as did gait speed (effect size, 0.12 m/second), and Kansas City Cardiomyopathy Questionnaire score (effect size, 7.1). Geriatric Depression Scale–15 score was lower with the intervention, indicating better symptoms vs control (3.3 vs 4.1), while European Quality of Life 5-Dimension 5-Level visual-analogue scale score was higher indicating better health status (71 vs 65). Fewer patients in the intervention than control group experienced falls (28 percent vs 36 percent).

“Despite many efforts to improve outcomes in patients [with HF], most studies testing a wide range of medications, devices, and strategies have been negative. This suggested to us that we were overlooking an important factor contributing to these poor outcomes, and we suspected the missing factor might be severe physical dysfunction, which is generally not addressed in HF management,” Kitzman noted.

“By improving quality of life and physical functioning, the patient feels better, which is a positive outcome for patients,” he highlighted.

The authors noted that the long-term benefits of the intervention are unclear. They also acknowledged that differences in caregiver attention could have influenced the outcomes.