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Abstract 16963: A Novel Rehabilitation Intervention for Older Patients with Acute Decompensated Heart Failure: the REHAB-HF Pilot Study
Abstract
Introduction: Exercise training improves outcomes in patients with chronic, stable heart failure (HF). However, little is known regarding patients with acute decompensated HF (ADHF) who are typically elderly, frail, with multiple co-morbidities and frequent rehospitalizations.
Hypothesis: A novel rehabilitation intervention in older patients hospitalized for ADHF will be feasible and safe, improve physical function and reduce rehospitalizations.
Methods: This was a 3-site, randomized, attention-controlled pilot study of a tailored, progressive, multi-domain (strength, balance, mobility and endurance) rehabilitation intervention beginning in the hospital and continuing for 12 weeks post-discharge. The primary outcome was the Short Physical Performance Battery (SPPB) score, a standardized measure of physical function in frail elderly, assessed by a blinded observer; the secondary outcome was rehospitalizations.
Results: We enrolled 27 patients aged 60-98 years: 59% women, 56% African-American, 41% preserved EF. Patients had ~ 5 co-morbidities and markedly impaired physical function; > 50% were frail. Characteristics were similar between groups. Study retention (89%) and intervention adherence (93%) were excellent. Figure 1 shows change in SPPB score and 6-minute walk distance. All-cause rehospitalizations were reduced by 29% (1.16±0.35 vs. 1.64±0.39) and all-cause rehospitalization days were reduced by 47% (6.0± 2.5 vs. 11.4±2.8) at 6 month follow-up. The change in SPPB score explained 90% of the reduction in all-cause rehospitalizations. There were no adverse events related to the intervention.
Conclusions: These findings support the feasibility, safety and potential efficacy of a novel multi-domain rehabilitation intervention to improve physical function and reduce rehospitalizations in older, frail ADHF patients with multiple comorbidities. An NIH-funded multi-center trial is being launched to confirm these findings.
... The second one was a multicenter randomized controlled trial developed in the United States of America (USA) and published in 2021 [21]. The last one was a multicenter randomized controlled pilot study developed in the USA and published in 2017 [22]. The characteristics of the included studies are presented in Appendix C. ...
... The total number of participants was 547, with one study having 171 participants, with a mean age of 76 years [20], the other with 349 participants with a mean age of 73 years [21], and the last one having 27 participants with a mean age of 72 years [22]. In the study with 349 participants, 175 were randomized to the experimental group [21], and in the study with 27 participants, there were 15 in the experimental group [22]. ...
... The total number of participants was 547, with one study having 171 participants, with a mean age of 76 years [20], the other with 349 participants with a mean age of 73 years [21], and the last one having 27 participants with a mean age of 72 years [22]. In the study with 349 participants, 175 were randomized to the experimental group [21], and in the study with 27 participants, there were 15 in the experimental group [22]. In one study, 38.59% [20] of participants were women. ...
Exercise performance is an essential tool for managing heart failure. Although the benefits of exercise are well documented for people with chronic and stable heart failure, there is still no consensus on their prescription in patients hospitalized with acute heart failure undergoing clinical stabilization. The aim of this study is to identify the literature on exercise programs encompassing the components of aerobic and resistance training for hospitalized patients admitted for acute heart failure. A scoping review was conducted according to the proposed methodology of the Joanna Briggs Institute. Studies with adults over 18 years old, hospitalized, and diagnosed with acute heart failure who participated in aerobic and resistance exercise training programs during their hospital stay were included. Three studies met the inclusion criteria. One was a retrospective, observational analytical cohort study, in which the main outcome of the exercise program was improvement in the previous disabilities of the participants. The other two were multicenter randomized controlled studies that showed greater improvement in physical function, functional capacity, depression, quality of life, and frailty status in the intervention groups. The exercise prescriptions differed according to the principles of the exercise prescription-frequency of exercise, intensity of exercise, exercise time (duration), type (mode), exercise volume, and progression. It is too early to make recommendations based on evidence of the type structure of an exercise program with aerobic and strength-training components in this population. However, in the exercise programs of the reviewed studies, the predominance of light to moderate intensity and the importance of progressively increase the frequency and duration of the training sessions were demonstrated, with bicycle ergometers and walking being the most common types of aerobic exercises. It is recommended that investment and research in this area should continue with more methodologically robust studies.
... Current clinical management strategies for ADHF do not include patients with physical impairments, and these patients are usually excluded from in-patient cardiac rehabilitation programs. Recently, some studies had explored the efficacy and safety of transitional, individualized, and progressive early cardiac rehabilitation programs initiated during, or early after, hospitalization in ADHF patients [5][6][7][8]. ...
... Search results and reasons for exclusion are listed in the Preferred Reporting Items for Systematic Reviews and meta-analyses diagram (Fig. 1). A total of six trials evaluating early exercise-based rehabilitation initiated during the hospitalization [5][6][7][8]13,14] and at 6 months (n = 3) followup were included in the meta-analysis. We also included one study in which the patients in the exercise-training group and the controls were involved in the pooled analysis, but the data from the group with exercise-training receiving non-invasive devices was excluded due to our previously cited exclusion criteria (Table 1, Ref. [5][6][7][8]13,14]). ...
... A total of six trials evaluating early exercise-based rehabilitation initiated during the hospitalization [5][6][7][8]13,14] and at 6 months (n = 3) followup were included in the meta-analysis. We also included one study in which the patients in the exercise-training group and the controls were involved in the pooled analysis, but the data from the group with exercise-training receiving non-invasive devices was excluded due to our previously cited exclusion criteria (Table 1, Ref. [5][6][7][8]13,14]). ...
Background: Cardiac rehabilitation is an important part of the therapeutic regimen for chronic heart failure. Acute decompensated heart failure (ADHF) in hospitalized patients were usually excluded from cardiac rehabilitation programs. The initiation of cardiac rehabilitation with ADHF usually occurs after hospital discharge. This study included recent clinical trials in patients beginning early exercise-based rehabilitation during their hospitalization and compared the efficacy and safety of early cardiac rehabilitation to ADHF patients who didn’t receive cardiac rehabilitation. Methods: Clinical trials were searched from the EMBASE, PubMed, CENTRAL, and WAN FANG. We included randomized controlled trials (RCTs) in which early exercise-based rehabilitation started during the index hospitalization, from the establishment of the database to July 2022. RevMan 5.4 was used for the statistical analysis. Results: Six studies, with a total of 668 patients were included; 336 patients in the early rehabilitation group and 332 patients in the control group. Exercise capacity was significantly improved in the 6-minute walk distance [mean difference (MD): 32.97, 95% CI: 31.03 to 34.90, p < 0.00001], and the Short Physical Performance Battery (MD: 1.40, 95% CI: 1.35 to 1.44, p < 0.00001). The rate of all-cause rehospitalization was significantly decreased in the early rehabilitation group (OR: 0.67, 95% CI: 0.45 to 0.99, p = 0.04). Conclusions: Early exercise-based rehabilitation for eligible ADHF in-patients starting during, or early after, hospitalization could significantly improve exercise capacity. A transitional, individualized, progressive, exercise-based rehabilitation program during hospitalization combined with post-discharge clinic rehabilitation is an integrated rehabilitation strategy for acute decompensated heart failure.
... The remaining 16 full-text papers were assessed, resulting in the exclusion of another 6. Records searched manually resulted in 5 additional studies 26 In a single-center study from Bulgaria, Papathanasiou 25 randomized 120 frail patients with HF to either high-intensity aerobic interval training (HIAIT) or moderate intensity continuous exercise for 12 weeks. After 6 months, significant improvements were reported in both groups, with the HIAIT group demonstrating significantly greater improvements in 6-min walk distance and QoL. ...
... 22 Of the 4 prospective randomized studies, 1 involving patients admitted with ADHF was a small pilot randomized study aimed at assessing the safety and feasibility of conducting CR in these vulnerable patient populations. 26 Reeves et al reported a significantly greater improvement in the SPPB at 6 months in ADHF patients randomized to a 12-week multidomain physical rehabilitation program Table 5). Kato et al 31 followed 15 elderly patients (mean age 80 years) with HF who ceased attending a CR clinic for 7 weeks when the Government of Japan declared a state of emergency during the COVID-19 pandemic, then resumed CR following a lifting of the state of emergency. ...
... In contrast, 4 studies of CR in frail HF patients included in this review recruited patients during or shortly after a hospital admission for ADHF with more symptomatic HF (NYHA Class II-IV), and included a higher proportion of women and patients with HFpEF. 22-24, 26 In most studies, CR entailed a 3-month program incorporating exercise training components aimed at increasing mobility, endurance and muscle strength. Inclusion of other program elements such as nutritional supplementation/advice and psychosocial support was more variable. ...
Background:
Frailty is prevalent in patients with heart failure (HF) and associated with increased morbidity and mortality. Hence, there has been increased interest in the reversibility of frailty following treatment with medication or surgery. This systematic review aimed to assess the reversibility of frailty in patients with HF before and after surgical interventions aimed at treating the underlying cause of HF. It also aimed to assess the efficacy of cardiac rehabilitation and prehabilitation in reversing or preventing frailty in patients with HF.Methods and Results:Searches of PubMed, MEDLINE and Academic Search Ultimate identified studies with HF patients undergoing interventions to reverse frailty. Titles, abstracts and full texts were screened for eligibility based on the PRISMA guidelines and using predefined inclusion/exclusion criteria in relation to participants, intervention, control, outcome and study design. In total, 14 studies were included: 3 assessed the effect of surgery, 7 assessed the effect of rehabilitation programs, 2 assessed the effect of a prehabilitation program and 2 assessed the effect of program interruptions on HF patients.
Conclusions:
Overall, it was found that frailty is at least partially reversible and potentially preventable in patients with HF. Interruption of rehabilitation programs resulted in deterioration of the frailty status. Future research should focus on the role of prehabilitation in mitigating frailty prior to surgical intervention.
... 21 From the aforementioned text, it is clear that there is potential for exercise to benefit patients with ADHF, although the available methodological rigor is limited. [22][23][24][25][26] It is therefore important to understand the trends of current research in ADHF and to develop future research priorities in this unique patient population. Therefore, the aim of this review was to assess the trends in exercise-based interventions for ADHF and to provide insight into directions for future research in this area. ...
... The literature review identified a total of 14 studies from a total of 6751 articles, of which eight were RCTs, [23][24][25][28][29][30][31][32] three retrospective studies 20,33,34 and one each of a propensity-matched trial, 35 single group pre-/post-study, 36 and case series. 37 Studies varied with time of initiation of CR (ie, during hospitalization, at discharge, or within 6 wk of discharge). ...
... 8 Despite the strong evidence to support its use in HF, the role of exercise in ADHF has not been established. This is an area in need of further research; only a few RCTs have been performed although they demonstrate benefits and feasibility in terms of both function and QoL 22,23 The current findings suggest that while there have been many studies on exercise training in stable HF, there has been minimal focus on such studies in ADHF. This is reflected by the total number of registered clinical trials. ...
Purpose:
Cardiac rehabilitation is an important intervention for patients with heart failure. However, its clinical application in acute decompensated heart failure (ADHF) remains underutilized with limited research available. An assessment of current research in this area will help guide future investigations. The aim of this review is to summarize the current research focusing on rehabilitation interventions following recovery from ADHF.
Review methods:
A systematic search was carried out on all trials registered in the clinical trial registry database of the World Health Organization-International Clinical Trial Registry Platform (WHO-ICTRP). Studies focusing on ADHF and utilizing any exercise and rehabilitation-based intervention were included.
Results:
A majority of 11 trial protocols, including 3827 participants with low ejection fraction (<40%), were identified from the WHO-ICTRP database. Majority of the protocols (64%) focused on exercise-based interventions with approximately one-quarter (29%) focusing on neuromuscular electrical stimulation and one on noninvasive ventilation during exercise. Irrespective of the mode of exercise, all protocols employed low-moderate intensity training with outcomes focusing on physical function and quality of life.
Conclusion:
Studies on rehabilitative interventions for ADHF are still in their early stages. More research is needed using innovative methodologies and testing for feasibility and fidelity.
... While acute decompensated HF (ADHF) is currently recognized as a contraindication to exercise training, the Rehabilitation Therapy in Older Acute HF Patients (REHAB-HF) Trial is currently investigating whether exercise-based rehabilitation (focusing on improved balance, strength, mobility, and endurance) commenced during an admission for ADHF, may improve physical function and reduce future re-hospitalizations in older patients (> 60 years) [23]. The REHAB-HF pilot study demonstrated the feasibility and safety of rehabilitation compared with usual care and a trend toward improved physical function and decreased hospitalizations [23]. ...
... While acute decompensated HF (ADHF) is currently recognized as a contraindication to exercise training, the Rehabilitation Therapy in Older Acute HF Patients (REHAB-HF) Trial is currently investigating whether exercise-based rehabilitation (focusing on improved balance, strength, mobility, and endurance) commenced during an admission for ADHF, may improve physical function and reduce future re-hospitalizations in older patients (> 60 years) [23]. The REHAB-HF pilot study demonstrated the feasibility and safety of rehabilitation compared with usual care and a trend toward improved physical function and decreased hospitalizations [23]. Moreover, a recent study by Delgado et al. [24] found early exercise therapy for inpatients recovering from acutely decompensated HF to be safe and efficacious for improvements in functional capacity compared with usual care. ...
Chronic heart failure (HF) is a major cause of morbidity, mortality, disability, and health care costs. A hallmark feature of HF is severe exercise intolerance, which is multifactorial and stems from central and peripheral pathophysiological mechanisms. Exercise training is internationally recognized as a Class 1 recommendation for patients with HF, regardless of whether ejection fraction is reduced or preserved. Optimal exercise prescription has been shown to enhance exercise capacity, improve quality of life, and reduce hospitalizations and mortality in patients with HF. This article will review the rationale and current recommendations for aerobic training, resistance training, and inspiratory muscle training in patients with HF. Furthermore, the review provides practical guidelines for optimizing exercise prescription according to the principles of frequency, intensity, time (duration), type, volume, and progression. Finally, the review addresses common clinical considerations and strategies when prescribing exercise in patients with HF, including considerations for medications, implantable devices, exercise-induced ischemia, and/or frailty.
... The SPPB has three sub-tests (a balance test, a gait speed test, and a chair stand test), and its use makes it possible to evaluate the comprehensive lower-extremity function of older adults within a short time and in a space-saving setting [9]. The three sub-tests of the SPPB comprise components that can be improved through rehabilitation interventions [10], and the sub-test results have been used as primary outcomes in clinical trials testing the effectiveness of cardiac rehabilitation in patients with HF [11][12][13]. ...
... The infit MnSq was 0.86-1. 13, and all three sub-tests showed adequate values to indicate that the underlying construct represented lower-limb function. The mean (SD) person fit value was 0.95 (0.9), and only 9.4% of the patients demonstrated a significant misfit to the Rasch model. ...
Purpose:
The physical function of older patients with heart failure (HF) is likely to decline, and the Short Physical Performance Battery (SPPB) is widely used for its evaluation. No study has analyzed the SPPB by using Rasch model in these patients. The aim of this study was to examine the structural validity and item response of the SPPB in older inpatients with HF.
Materials and methods:
In this multicenter cross-sectional study, we investigated 106 older inpatients with HF. We evaluated the SPPB's rating scale structure, unidimensionality, and measurement accuracy (0 = poor performance to 4 = normal performance).
Results:
The SPPB rating scale fulfilled the category functioning criteria. All items fit the underlying scale construct. The SPPB demonstrated adequate reliability (person reliability = 0.81) and separated persons into four strata: those with very low, low, moderate, and high physical performance. Item-difficulty measures were -0.59 to 0.96 logits, and regarding the person ability-item difficulty matching for the SPPB, the item was somewhat easy (the mean of person ability = 0.89 logits; mean of item difficulty = 0.00).
Conclusion:
The SPPB has strong measurement properties and is an appropriate scale for quantitatively evaluating physical function in older patients with HF.
... 8,9 In the past, most of the rehabilitation-based research work included chronic heart failure patients and excluded hospitalised patients with recently acute HF. 10,11 In the last decade, there has been an increased interest in the evaluation of the safety and e±cacy of early mobilisation programs in ADHF patients by a considerable number of studies. 7,9,[12][13][14][15][16][17][18][19][20][21][22][23][24][25] Collectively, these studies demonstrated that early structured mobilisation in stabilised patients hospitalised for acute HF was safe and e®ective in increasing functional capacity, improving ADL, shortening the hospital stay time, and reducing the re-hospitalisation rate. Nevertheless, apart from the recent randomised study by Kitzman et al. 24 there have been only four randomised controlled trials on the topic of early mobilisation in patients with acute HF, 12,14,16,21 based on a recent systematic review by Babu et al. 26 They concluded that the research work in this¯eld is still growing, and further intervention studies are to be suggested. ...
... 7,9,[12][13][14][15][16][17][18][19][20][21][22][23][24][25] Collectively, these studies demonstrated that early structured mobilisation in stabilised patients hospitalised for acute HF was safe and e®ective in increasing functional capacity, improving ADL, shortening the hospital stay time, and reducing the re-hospitalisation rate. Nevertheless, apart from the recent randomised study by Kitzman et al. 24 there have been only four randomised controlled trials on the topic of early mobilisation in patients with acute HF, 12,14,16,21 based on a recent systematic review by Babu et al. 26 They concluded that the research work in this¯eld is still growing, and further intervention studies are to be suggested. 26 Several outcome measures can be of importance when assessing the clinical bene¯ts of early mobilisation in hospitalised acute HF patients. ...
Background: Patients hospitalised for acute decompensated heart failure (ADHF) show reduced functional capacity, limited activities of daily living (ADL), and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP). The management of these patients focuses mainly on medical therapy with little consideration for in-patient cardiac rehabilitation. There has been a growing interest in evaluating the efficacy of early mobilisation, as the core for in-hospital rehabilitation, in ADHF patients in the last decade; however, the randomised trials on this topic are few.
Objective: This randomised-controlled study, therefore, aimed to further test the hypothesis that early supervised mobilisation would have beneficial effects on functional capacity, ADL, and NT-proBNP in stabilised patients following ADHF.
Methods: This is a single-centered, randomised-controlled, parallel-group trial in which 30 patients hospitalised for ADHF were randomly assigned to two groups; the study group ([Formula: see text] years, [Formula: see text]) and the control group ([Formula: see text] years, [Formula: see text]=15). Inclusion criteria were ADHF on top of chronic heart failure independent of etiology or ejection fraction, clinical/hemodynamic stability, age from 40 to 60 years old, and both genders. Exclusion criteria were cardiogenic shock, acute coronary ischemia, or significant arrhythmia. Both groups received the usual medical care, but only the study group received an early structured mobilisation protocol within 3 days of hospital admission till discharge. The outcome measures were the 6-min walk distance (6-MWD) and the rating of perceived exertion (RPE) determined from the 6-min walk test at discharge, the Barthel index (BI), NT-proBNP, and the length of hospital stays (LOS).
Results: The study group showed significantly greater improvements compared to the controls in the 6-MWD ([Formula: see text] versus [Formula: see text][Formula: see text]m, [Formula: see text]), the RPE ([Formula: see text] versus [Formula: see text], [Formula: see text]), and the LOS ([Formula: see text] versus [Formula: see text] days, [Formula: see text]) at discharge. Also, the study group showed significant improvements in the BI compared to baseline [100 (100–100) versus 41.87 (35–55), [Formula: see text]] and the controls [100 (100–100) versus 92.5(85–95), [Formula: see text]]. The mean value of NT-proBNP showed a significant reduction only compared to baseline ([Formula: see text] versus [Formula: see text][Formula: see text]pg/mL, [Formula: see text]) following the intervention. The absolute mean change ([Formula: see text]) of NT-proBNP showed an observed difference between groups in favor of the study group (i.e., [Formula: see text][Formula: see text]pg/mL in the study group versus [Formula: see text][Formula: see text]pg/mL in the control group, [Formula: see text]).
Conclusion: Early structured mobilisation under the supervision of a physiotherapist could be strongly suggested in combination with the usual medical care to help improve the functional capacity and daily living activities, reduce NT-proBNP levels, and shorten the hospital stay in stabilised patients following ADHF. Trial registration number: PACTR202202476383975.
... The trial intervention (for the intervention group) was an early, transitional, tailored, progressive physical rehabilitation program that had been developed for frail, older patients with acute decompensated heart failure. 18,19 The intervention focused on four physical-function domains (strength, balance, mobility, and endurance) and progressed through four prespecified functional levels within each domain (Table S1). The progression of exercise intensity and the types of exercises at each session were individualized on the basis of the patient's performance level within each domain. ...
... On the basis of the results from a pilot study, 19 we estimated that 258 patients who could be evaluated for efficacy would provide the trial with 80% power to detect a 10% difference (equivalent to a difference of 0.6 points) between the intervention group and the control group in the score on the Short Physical Performance Battery at 3 months (the primary outcome); the enrollment of 334 patients who could be evaluated for efficacy would be needed to detect a 25% difference in the rate of rehospitalization at 6 months (the secondary outcome). We planned to enroll T h e ne w e ngl a nd jou r na l o f m e dicine 360 patients in order to allow for approximately 7% of the patients to withdraw from the trial. ...
Background
Older patients who are hospitalized for acute decompensated heart failure have high rates of physical frailty, poor quality of life, delayed recovery, and frequent rehospitalizations. Interventions to address physical frailty in this population are not well established.
Methods
We conducted a multicenter, randomized, controlled trial to evaluate a transitional, tailored, progressive rehabilitation intervention that included four physical-function domains (strength, balance, mobility, and endurance). The intervention was initiated during, or early after, hospitalization for heart failure and was continued after discharge for 36 outpatient sessions. The primary outcome was the score on the Short Physical Performance Battery (total scores range from 0 to 12, with lower scores indicating more severe physical dysfunction) at 3 months. The secondary outcome was the 6-month rate of rehospitalization for any cause.
Results
A total of 349 patients underwent randomization; 175 were assigned to the rehabilitation intervention and 174 to usual care (control). At baseline, patients in each group had markedly impaired physical function, and 97% were frail or prefrail; the mean number of coexisting conditions was five in each group. Patient retention in the intervention group was 82%, and adherence to the intervention sessions was 67%. After adjustment for baseline Short Physical Performance Battery score and other baseline characteristics, the least-squares mean (±SE) score on the Short Physical Performance Battery at 3 months was 8.3±0.2 in the intervention group and 6.9±0.2 in the control group (mean between-group difference, 1.5; 95% confidence interval [CI], 0.9 to 2.0; P<0.001). At 6 months, the rates of rehospitalization for any cause were 1.18 in the intervention group and 1.28 in the control group (rate ratio, 0.93; 95% CI, 0.66 to 1.19). There were 21 deaths (15 from cardiovascular causes) in the intervention group and 16 deaths (8 from cardiovascular causes) in the control group. The rates of death from any cause were 0.13 and 0.10, respectively (rate ratio, 1.17; 95% CI, 0.61 to 2.27).
Conclusions
In a diverse population of older patients who were hospitalized for acute decompensated heart failure, an early, transitional, tailored, progressive rehabilitation intervention that included multiple physical-function domains resulted in greater improvement in physical function than usual care. (Funded by the National Institutes of Health and others; REHAB-HF ClinicalTrials.gov number, NCT02196038.)
... The authors were able to demonstrate significant increase in the total SPPB score by 1.1 points (with the largest improvement in the Chair Stand Test), þ23 m in the Six Minute Walk Test and þ5.4 points in Quality of Life questionnaire in the exercise group compared with the control group. 10 Applying similar multimodal training into cardiac rehabilitation on top of aerobic training could yield similar benefits in elderly cardiovascular patients 1 (Figure 1). Generally, this should be applicable to everybody, yet adequate pre-and post-intervention testing would be relevant to identify patients in need and to assess the intervention efficacy. ...
... In conclusion, functional, nutritional and psychological assessments were proven to be safe and feasible in elderly patients eligible for cardiac rehabilitation. 8,10 We therefore are proponents of integrating those into cardiac rehabilitation programmes and of future studies that need to find the best blend of intervention type and intensity, primarily the resistance and balance training modalities. 1, 6,7 Author contribution TK and ML contributed to the conception and design, acquisition, analysis and interpretation of the data for the work, drafted and critically revised the manuscript, gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy. ...
... 50 The BP goals in the ACC/AHA HF guideline are similar to those in the general population, with the exception that the 2017 ACC/AHA HF guideline update recommends the lower systolic BP target of 130 mm Hg. 9,48,51 ACC/AHA HF guidelines support the use of beta-blockers, angiotensin-converting enzyme inhibitors (ACEI), T A B L E 1 Non-pharmacological interventions that were positive in HFpEF on their primary endpoints and has the potential to improve physical function and reduce rehospitalization rates. 67 A larger trial is underway to verify these findings. ...
... 27,68 This finding was confirmed in more recent analyses of Medicare beneficiaries. 67 The CARDIOMEMS device is a wireless, implanted pulmonary artery pressure monitor implanted in the distal PA during right heart catheterization. Patients transmit hemodynamic data daily using a wireless RF transmitter. ...
The majority of older patients who develop heart failure (HF), particularly older women, have a preserved left ventricular ejection fraction (HFpEF). Patients with HFpEF have severe symptoms of exercise intolerance, poor quality‐of‐life, frequent hospitalizations, and increased mortality. The prevalence of HFpEF is increasing and its prognosis is worsening. However, despite its importance, our understanding of the pathophysiology of HFpEF is incomplete, and drug development has proved immensely challenging. Currently, there are no universally accepted therapies that alter the clinical course of HFpEF. Originally viewed as a disorder due solely to abnormalities in left ventricular (LV) diastolic function, our understanding has evolved such that HFpEF is now understood as a systemic syndrome, involving multiple organ systems, likely triggered by inflammation and with an important contribution of aging, lifestyle factors, genetic predisposition, and multiple‐comorbidities, features that are typical of a geriatric syndrome. HFpEF is usually progressive due to complex mechanisms of systemic and cardiac adaptation that vary over time, particularly with aging. In this review, we examine evolving data regarding HFpEF that may help explain past challenges and provide future directions to care patients with this highly prevalent, heterogeneous clinical syndrome.
... Полученные данные согласуются с другими источниками, показавшими хорошую переносимость и безопасность ФТ у прогностически более благополучных больных с ХСН III ФК [23,25,31]. ...
Aim To assess the tolerability of an individualized physical rehabilitation program (PRP) in inotrope-dependent patients with end-stage chronic heart failure (CHF).
Material and methods This prospective randomized study included 120 men aged 18-65 years with left ventricular ejection fraction ≤30 % and blood pressure ≥90 / 60 mm Hg. Patients who have received dobutamine or dopamine for ≥2 weeks were randomized into two groups: group 1, 40 patients who participated in the PRP and group 2, 40 patients who did not participate in the PRP. Group 3 included 40 patients without inotropic support who participated in the PRP.
Results Patients of groups 1 and 3 attended >80 % of the scheduled classes without developing life-threatening adverse events (AEs) associated with exercise (E). After 6 months of the study, the exercising patients achieved a comparable (average) E intensity: 44 [35; 50]% and 45 [40;52]% of heart rate reserve and Borg scale scores 14 [12; 14] and 13 [11; 14] in groups 1 and 3, respectively (p>0.05). Initially, after 3 and 6 months at the peak of physical activity in groups 1 and 3, there was no decrease in arterial blood oxygen saturation according to pulse oximetry (SpO 2 ) <93 %. At baseline, lactate levels in central venous blood at rest were normal in all groups. After 6 months, the lactate concentration was 1.1 mmol / l in group 1, 2.3 mmol / l in group 2, and 1.4 mmol / l in group 3 (р1-2=0.005; p2-3=0.008, respectively). At the E peak at baseline, after 3 and 6 months, comparable increases in lactate not exceeding 3 mmol / l were detected in groups 1 and 3.
Conclusion The study allowed assessment of the tolerability of individualized PRP performed at the aerobic level of energy supply, in inotropic-dependent patients with CHF. Individualized 6-month PRP in inotropic-dependent patients with end-stage CHF, provided safety criteria are met, is well tolerated and does not increase the number of AEs associated with CHF and physical rehabilitation (PR). Continued inotropic support with dopamine or dobutamine should not be considered as a contraindication to PR in patients with CHF in the absence of E intolerance or life-threatening AEs.
... The important role of exercise rehabilitation in improving the quality of life for people with HF has previously been reported. 42 A pilot study 43 that provided a customized, progressive, and multidomain rehabilitation therapy for older people with AHF indicated that both intervention and control groups showed a higher Kansas City Cardiomyopathy Questionnaire score after a 3-month intervention, presenting a clinically meaningful intervention effect size of +5.4 points. We performed a meta-analysis on all studies whose quality of life was measured by the Minnesota Living with Heart Failure Questionnaire and reached the same conclusion. ...
Background:
Exercise rehabilitation is conducive to increasing functional ability and improving health outcomes, but its effectiveness in patients with acute heart failure (AHF) is still controversial.
Purpose:
In this study, our aim was to systematically examine the efficacy of exercise rehabilitation in people with AHF.
Methods:
A search was conducted for randomized controlled trial studies on exercise rehabilitation in patients with AHF up to November 2021. Two investigators conducted literature selection, quality assessments, and data extractions independently. The primary outcome was 6-minute walk distance, and the secondary outcomes were left ventricular ejection fraction, quality of life, Short Physical Performance Battery, readmission, and mortality. RevMan (version 5.3) software was used for the meta-analysis.
Results:
Twelve studies with 1215 participants were included. Exercise rehabilitation significantly improved the 6-minute walk distance (mean difference [MD], 33.04; 95% confidence interval [CI], 31.37-34.70; P < .001; I2 = 0%), quality of life (MD, -11.57; 95% CI, -19.25 to -3.89; P = .003; I2 = 98%), Short Physical Performance Battery (MD, 1.40; 95% CI, 1.36-1.44; P < .001; I2 = 0%), and rate of readmission for any cause (risk ratio, 0.48; 95% CI, 0.26-0.88; P = .02; I2 = 7%), compared with routine care. However, no statistically significant effects on left ventricular ejection fraction (MD, 0.94; 95% CI, -1.62 to 3.51; P = .47; I2 = 0%) and mortality (risk ratio, 1.07; 95% CI, 0.64-1.80; P = .79; I2 = 0%) were observed.
Conclusions:
Compared with routine care, exercise rehabilitation improved functional ability and quality of life, reducing readmission in patients with AHF.
... [5,6] Malnutrition is closely associated with poor prognosis. [7,8] Recent randomised controlled trials (RCTs) have revealed that nutritional support [9] or exercise training [10,11] would be preferable for improving mortality or physical performance in patients hospitalized with heart failure. Therefore, evaluation of and intervention for malnutrition are essential issues. ...
Background
Although nutritional assessment and education are important for patients hospitalized with heart failure, the extent of their implementation in real-world clinical practice is unknown. Therefore, in this study, we aimed to investigate the evaluation and management of nutrition during hospitalization for heart failure using a questionnaire survey for cardiologists.
Methods
In this cross-sectional multicenter survey, 147 cardiologists from 32 institutions completed a web-based questionnaire (response rate, 95%).
Results
The survey showed that 78.2% of the respondents performed a nutritional assessment for hospitalized patients, whereas 38.3% used objective tools. In contrast, only 9.5% of the respondents evaluated the presence or absence of cardiac cachexia. Most respondents (89.8%) reported providing nutritional education to their patients before hospital discharge. However, compared with the number of respondents who provided information on sodium (97.0%) and water (63.6%) restrictions, a limited number of respondents provided guidance on optimal protein (20.5%) and micronutrient (9.1%) intake as part of the nutritional education. Less than 50% of the respondents provided guidance on optimal calorie intake (43.2%) and ideal body weight (34.8%) as a part of the nutritional education for patients identified as malnourished.
Conclusions
Although nutritional assessment is widely performed for hospitalized patients with heart failure, most assessments are subjective rather than objective. Nutritional education, frequently provided before hospital discharge, is limited to information on water or salt intake restrictions. Therefore, more comprehensive and individualised nutritional assessments and counselling with a scientific basis are required.
... Many cardiac patients, particularly those who are elderly, are at risk of frailty, poor mobility and falls. The addition of targeted strength and balance training to augment cardiac rehabilitation may help to further improve physical function and has been seen to improve functional capacity in heart failure [140,141] and after cardiac surgery [142]. ...
... In previous studies that sought to predict frailty improvement among older patients with heart failure, investigators mostly focused on conditions at admission without considering changes during hospitalisation. 41 The present results indicate that, despite the presence of poor conditions at admission, patients can recover from frailty by improving physical function during hospitalisation; therefore, rehabilitation is essential during hospitalisation. Resistance training is known to improve singleleg standing time among older individuals. ...
Introduction:
There are no clinical prediction models to predict the prognosis of pre-frailty or frailty in patients with heart failure. We aimed to develop prediction models for the prognosis of pre-frailty and frailty in older patients with heart failure using the classification and regression tree (CART) method; we then tested the predictive accuracies of the developed models.
Methods:
Patients with pre-frailty or frailty at admission were divided into improved and non-improved groups. The CART method was used to establish two models: A, which predicted the presence or absence of pre-frailty improvement during hospitalisation; and B, which predicted the presence or absence of frailty improvement during hospitalisation.
Results:
Patients with heart failure complicated by pre-frailty (n=28) or frailty (n=156) were included. In model A, the accuracy of predicting pre-frailty improvement was high; the best predictor was single-leg standing time at admission, followed by left ventricular ejection fraction at admission. In model B, the accuracy of predicting frailty improvement was moderate; the best predictor was hand grip strength at admission, followed by estimated glomerular filtration rate at admission, haemoglobin level at admission, and change in single-leg standing time during hospitalisation. The areas under the receiver operating characteristic curves of the CART models were 0.96 and 0.84 in models A and B, respectively.
Conclusion:
Although conditions at admission may predict the improvement of pre-frailty and frailty during hospitalisation, cardiac rehabilitation that improves single-leg standing time may help to improve frailty, particularly when conditions at admission are poor.
... This could be attributable, in addition to advanced age and the presence of comorbidi-ties, to the presence of logistical problems 36 . To attempt this difficulty, the scientific community lately is focusing on the development of home rehabilitation programs, which have been shown to be comparable to programs carried out in-presence, in terms of improving quality of life and involvement in home physical activity 37,38 . ...
Objective:
The advent of the SARS-CoV-2 pandemic has resulted in an increase in sedentary behavior, with consequences on cardiopulmonary capacity, especially in the elderly population. Prehabilitation is a strategy usually used before a surgical procedure to improve functional capacity; however, it can be used for non-surgical patients and not in the acute phase of disease. The purpose of this study is to evaluate the effectiveness of a prehabilitation program, using telerehabilitation, in frail elderly patients with chronic heart failure.
Patients and methods:
This is a randomized, controlled, single-blind study. Fifteen patients with chronic heart failure were randomized into three groups: two active groups (telerehabilitation and in-person) and the control group. Patients in the active groups underwent a rehabilitation program divided into two 4-week periods, for 45-60 minutes per day, 2 days per week.
Results:
In the Study Group, the quality of life significantly improved (EQoL-5D), and between the two groups a statistically significant difference in the motor dimension of SF-36 was identified.
Conclusions:
The telerehabilitation prehabilitation program for patients with chronic heart failure was confirmed to be effective and not inferior to a prehabilitation program performed in-person, avoiding the worsening of some domains of quality of life and motor performance, and leading to the improvement of others.
... If the covariate variables did not follow a normal distribution, we performed a log-transformation and used it for multivariate analysis. Multivariate analyses were adjusted for log BNP in Model 2 [25], Model 2 plus SPPB [26] in Model 3 and Model 3 plus log length of hospital stay [27] in Model 4. Statistical significance was defined as a p value of less than 0.05. Statistical analyses were performed using the Statistical Package for the Social Sciences software (version 26.0; ...
The clinical importance of nutritional management in activities of daily living (ADL) among older inpatients with heart failure (HF) is greatly increasing. We determined the optimal nutritional assessment tool that can predict ADL decline among older inpatients with HF. We prospectively investigated 91 inpatients aged ≥ 65 years with HF in an acute hospital. We measured their nutritional status at admission using nutrition indices: the controlling nutritional status (CONUT), the geriatric nutritional risk index, the prognostic nutritional index, and the mini nutritional assessment. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships between the malnutrition status assessed by each nutritional index category and the ADL decline measured by the Barthel index (BI) in the univariate and multivariate analyses. Among the participants, 28.6% (n = 26; median age 81.5 years; 69.2% men) of the participants were included in the Reduced BI group and 71.4% (n = 65; median age 79.0 years; 67.7% men) in the Maintained BI group. The Reduced BI group showed a significantly higher CONUT value than the Maintained BI group, but there were no significant differences in other nutritional indices. In the multivariate logistic regression analysis, a higher CONUT score was associated with a significantly elevated risk of Reduced BI (adjusted OR 0.24; 95%CI 0.08-0.75; p = 0.014). We found that CONUT is an appropriate nutritional assessment tool for predicting ADL decline among older inpatients with HF in the early phase of hospitalization.
... Os eventos adversos tiveram uma baixa frequência, havendo apenas uma interrupção da realização do protocolo devido à instabilidade clínica, com melhora após repouso. Em estudos que avaliaram o efeito de protocolo de exercícios, incluindo o resistido, apenas em um estudo teve um caso de efeito adverso que poderia ter relação com o exercício e os outros não apresentaram efeito adverso 11,15,16 . ...
Introdução: O processo de envelhecimento associado à hospitalização prolongada gera diminuição de massa e de força muscular dos membros inferiores, sendo necessárias intervenções para minimizar esses efeitos deletérios, como o treinamento de sentar-levantar. Este treinamento utiliza o peso do próprio corpo e é um movimento essencial para a manutenção da independência funcional. As respostas cardiovasculares agudas estão relacionadas com a segurança da atividade, por isso é imprescindível a monitorização constante. Objetivo: Avaliar a segurança e a viabilidade da realização do protocolo de sentar-levantar, observando os efeitos hemodinâmicos agudos em idosos hospitalizados. Materiais e métodos: Em uma amostra composta de idosos com estabilidade clínica, realizou-se um protocolo de sentar-levantar progressivo, com oito níveis em apenas uma sessão. Avaliaram-se variáveis hemodinâmicas, como pressão arterial sistólica e diastólica, pressão arterial média, frequência cardíaca e duplo produto, em repouso e após 1 min, 10 min e 30 min, sendo analisados e comparados médias e desvio-padrão. Resultados: Observou-se um leve aumento nas variáveis pressão arterial sistólica, na frequência cardíaca e duplo produto, com normalização nos minutos seguintes ao protocolo. A pressão arterial diastólica e a arterial média apresentaram uma discreta diminuição no decorrer das mensurações. Observaram-se poucos eventos adversos na amostra, os quais foram solucionados após o repouso. Houve significância estatística entre a maior parte das variáveis, porém não houve significância clínica. Conclusão: O protocolo de sentar-levantar é viável e seguro em idosos hospitalizados, desde que seja realizado de acordo com os critérios de elegibilidade e monitorados.
... Efficacy of rehabilitation intervention in older patients with heart failure, adapted from Reeves et al.32) . ...
... [1][2][3] With advances in HF treatment and management, the target population is becoming progressively older; hence, sarcopenia and frailty are becoming major issues. 4,5 Therefore, if it is possible to evaluate physical dysfunction using indicators that are frequently used in clinical practice, the identification of patients with sarcopenia and frailty may become easier. ...
Aims
High-sensitivity cardiac troponin T (hs-cTnT) and B-type natriuretic peptide (BNP) are associated with prognosis and severity in patients with heart failure (HF); however, their association with physical function is unclear. This study aimed to investigate whether hs-cTnT and BNP levels are associated with physical function in patients with HF.
Methods and results
Hs-cTnT, BNP, and physical function (maximal quadriceps isometric strength [QIS], usual gait speed, and 6-min walk distance [6MWD]) were evaluated in 363 consecutive patients with HF (median age, 70 [60–78] years). Patients were divided into four groups according to their median hs-cTnT and BNP levels. After adjusting for demographic characteristics, laboratory levels, and HF severity, higher hs-cTnT and BNP levels were significantly associated with lower physical function (log hs-cTnT, β = −0.162, P = 0.001, for maximal QIS; β = −0.175, P = 0.002, for usual gait speed, and β = −0.129, P = 0.004, for 6MWD; log BNP, β = −0.090, P = 0.092, for maximal QIS, β = 0.038, P = 0.516, for usual gait speed, and β = −0.108, P = 0.023, for 6MWD). In addition, the high hs-cTnT and high BNP group had significantly lower physical function (all P < 0.05) than the low hs-cTnT and low BNP group.
Conclusions
Higher hs-cTnT and BNP levels are both associated with lower physical function in patients with HF, but hs-cTnT levels showed a more consistent association. The combination of hs-cTnT and BNP may be effective for the stratification of physical function in patients with HF.
... 32 In the REHAB-HF pilot study, a 12-week rehabilitation programme focused on improving strength, balance, mobility, and endurance showed a trend towards improved physical function and decreased hospitalizations in acute HF patients. 33 Recent evidence suggests that exercise training, combined with nutritional support (e.g. protein/amino acid supplementation, preventing vitamin/ mineral deficiencies), has shown considerable benefit in chronic HF patients. ...
Background:
Muscle wasting and unintentional weight loss (cachexia) have been associated with worse outcomes in heart failure (HF), but timely identification of these adverse phenomena is difficult. Spot urinary creatinine may be an easily accessible marker to assess muscle loss and cachexia. This study investigated the association of urinary creatinine with body composition changes and outcomes in patients with new-onset or worsening HF (WHF).
Methods:
In BIOSTAT-CHF, baseline spot urinary creatinine measurements were available in 2315 patients with new-onset or WHF in an international cohort (index cohort) and a validation cohort of 1431 similar patients from Scotland.
Results:
Median spot urinary creatinine concentrations were 5.2 [2.7-9.6] mmol/L in the index cohort. Median age was 69 ± 12 years and 73% were men. Lower spot urinary creatinine was associated with older age, lower height and weight, worse renal function, more severe HF, and a higher risk of >5% weight loss from baseline to 9 months (odds ratio = 1.23, 95% CI = 1.09-1.39 per log decrease; P = 0.001). Spot urinary creatinine was associated with Evans criteria of cachexia (OR = 1.26 per log decrease, 95% CI = 1.04-1.49; P = 0.016) and clustered with markers of heart failure severity in hierarchical cluster analyses. Lower urinary creatinine was associated with poorer exercise capacity and quality of life (both P < 0.001) and predicted a higher rate for all-cause mortality [hazard ratio (HR) = 1.27, 95% CI = 1.17-1.38 per log decrease; P < 0.001] and the combined endpoints HF hospitalization or all-cause mortality (HR = 1.23, 95% CI = 1.15-1.31 per log decrease; P < 0.001). Significance was lost after addition of the BIOSTAT risk model. Analyses of the validation cohort yielded similar findings.
Conclusions:
Lower spot urinary creatinine is associated with smaller body dimensions, renal dysfunction, and more severe HF in patients with new-onset/WHF. Additionally, lower spot urinary creatinine is associated with an increased risk of weight loss and a poorer exercise capacity/quality of life. Urinary creatinine could therefore be a novel, easily obtainable marker to assess (risk of) muscle wasting in HF patients.
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
Introdução: Os doentes com insuficiência cardíaca descompensada caracterizam-se por apresentar elevada intolerância à atividade, associada a dispneia e edemas. O treino de exercício físico permite promover um aumento da tolerância ao esforço, assim como melhoria da função cardíaca.
Objetivo: Identificar sinais de modulação cardíaca e consequente melhoria da capacidade funcional após a implementação de um plano de exercício físico estruturado.
Método: Relato de caso de abordagem quantitativa. Pessoa com insuficiência cardíaca descompensada de etiologia isquémica e valvular, manifestando elevado grau de intolerância à atividade assim como descompensação hemodinâmica.
Foram avaliados parâmetros fisiológicos como FC, TA, PSE pela escala de Borg e a sua tolerância à atividade, no momento da admissão e ao longo das sessões de treino. O T6MM foi aplicado em 2 momentos distintos: ao 4º dia de internamento e à data da alta, como forma de avaliar a evolução da capacidade funcional. O doente em questão encontra-se inserido num ensaio clínico randomizado onde se pretende avaliar a eficácia e segurança do exercício físico, sendo utilizados como instrumentos de avaliação a escala de LCADL, o Índice de Barthel, assim como do T6MM.
Resultados: Verificou-se uma melhoria da capacidade funcional da pessoa, avaliada pelo teste dos 6 minutos de marcha (T1: 210m, T2: 295m), assim como uma redução da frequência cardíaca em repouso (85 bpm vs 68 bpm) e de treino (145bpm vs 94bpm). Não foram verificados eventos adversos durante as sessões de treino.
Conclusões: A intervenção implementada nesta situação clínica revelou-se segura, sendo igualmente eficaz na melhoria da capacidade funcional e modulação da frequência cardíaca em repouso e durante o treino.
... 114 Limited data exists regarding cardiac rehabilitation in AHF, however, small studies have demonstrated an improvement in physical function and reduced re-hospitalization. 115 Similarly, in-hospital followed by outpatient cardiac rehabilitation have demonstrated improved function and QoL. 116 Finally, post-discharge early cardiac rehabilitation was shown to improve the 1-year urgent heart transplant-free survival of AHF J o u r n a l P r e -p r o o f patients. ...
Acute heart failure (AHF) is a complex, heterogeneous clinical syndrome with high morbidity and mortality, incurring significant healthcare costs. Patients transition from home to the emergency department, the hospital and home again, and require decisions surrounding diagnosis, treatment and prognosis at each step of the way. The purpose of this review is to examine the epidemiology, etiologies and classifications of AHF, and specifically focus on practical information relevant to the clinician. We examine the mechanisms of decompensation relevant to clinical presentations, including precipitating factors, neuroendocrine interactions and inflammation, along with how consideration of these factors these may help select therapies for an individual patient. The prevalence and significance of end-organ manifestations like renal, gastrointestinal, respiratory and neurologic manifestations are discussed. We also highlight how the development of renal dysfunction relates to the choice of a variety of diuretics that may be useful in specific circumstances and review guideline-directed medical therapy. We discuss the practical use (and pitfalls) of a variety of evidence-based clinical scoring criteria available to risk stratify patients with AHF. Finally, evidence-based management of AHF is discussed, including both pharmacologic and nonpharmacologic therapies, including the lack of evidence for using old and new vasodilators and the recent evidence regarding initiation of newer therapies in hospital. Overall, we suggest that clinicians consider implementing the newer data in AHF and subject existing practice patterns and treatments to the same rigor as new therapies.
... In addition, increased physical function after 5-month CR was associated with reduced risk of adverse clinical events in older HF participants with sinus rhythm or AF. Some recent studies revealed increased physical function because of exercise training as an indicator of decreased rehospitalization in older individuals with HF [25,26], which is consistent with our findings. Conversely, increased 6MWD and QS were significantly associated with reduced clinical events in participants with sinus rhythm, those with AF showed a significant association between increased 6MWD and decreased clinical events but not increased QS. ...
Background:
Although the coexistence of heart failure (HF) with atrial fibrillation (AF) exhibits poor outcomes, the correlation between AF status and outcomes after exercise-based cardiac rehabilitation (CR) remains unclear in older individuals with HF.
Objective:
This retrospective study aimed to investigate the impact of AF on changes in physical function and prognosis after CR in older individuals with HF.
Methods:
We enrolled consecutive individuals with HF who were ≥60 years old who received 5-month CR. Exercise-based CR involved moderate-intensity aerobic exercises tailored to each participant. Isometric quadriceps strength (QS) and 6-min walk distance (6MWD) were measured as physical function, at baseline and 5 months thereafter. We compared QS and 6MWD changes from baseline to the 5-month observation period (⊿QS and ⊿6MWD) between sinus rhythm and AF. We examined composite incidence of all-cause death or unplanned readmission after 5-month CR and analysed the association of ⊿QS and ⊿6MWD with clinical events, estimating adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).
Results:
Of the 764 participants, 476 (62%) had sinus rhythm, and 288 (38%) had AF. AF was associated with lower QS and 6MWD at baseline. The 2 groups did not differ in ⊿QS and ⊿6MWD after adjusting for clinical confounders. With sinus rhythm, greater change in QS and 6MWD was significantly associated with reduced incidence of clinical events (⊿QS tertile: aHR 0.75 [95% CI 0.60-0.92]; ⊿6MWD tertile: aHR 0.59 [95% CI 0.46-0.76]); however, with AF, this association was observed for only 6MWD and not QS (⊿QS: aHR 0.92 [95% CI 0.72-1.17]; ⊿6MWD: aHR 0.73 [95% CI 0.54-0.98]).
Conclusion:
AF in older individuals with HF is associated with reduced physical function at baseline but not response to exercise-based CR. Furthermore, positive response of physical function after CR is associated with better prognosis regardless of AF, which suggests that exercise-based CR is potentially effective in older individuals with HF and AF.
... 35 On the other hand, outpatient cardiac rehabilitation participation was associated with reduced risks of all-cause death and HF rehospitalization in frail patients with HF. 36 A new trial, the REHAB-HF study, is currently underway, and this pilot study has shown that rehabilitation therapy beginning in the hospital improved 6MWD and SPPB score, with the strongest trend seen with chair stands, in hospitalized older patients with HF, and the change in SPPB score was strongly related to all-cause rehospitalization. 37 Tissue oxygenation is decreased by anaemia and hypoxia, which may lead to functional impairment of muscle. A previous longitudinal study showed that anaemia preceded the occurrence of frailty, 38 and a meta-analysis indicated that the odds of frailty are more than doubled by the presence of anaemia in older individuals. ...
Aims
There have been no investigations of the prevalence and clinical implications of coexistence of anaemia and frailty in older patients hospitalized with heart failure (HF) despite their association with adverse health outcomes. The present study was performed to determine the prevalence and prognostic value of the coexistence of anaemia and frailty in hospitalized older patients with HF.
Methods and results
We performed post hoc analysis of consecutive hospitalized HF patients ≥65 years old enrolled in the FRAGILE‐HF, which was the prospective, multicentre, observational study. Anaemia was defined as haemoglobin < 13 g/dL in men and <12 g/dL in women, and frailty was evaluated according to the Fried phenotype model. The study endpoint was all‐cause mortality. Of the total of 1332 patients, 1217 (median age, 81 years; 57.4% male) were included in the present study. The rates of anaemia and frailty in the study population were 65.7% and 57.0%, respectively. The patients were classified into the non‐anaemia/non‐frail group (16.6%), anaemia/non‐frail group (26.4%), non‐anaemia/frail group (17.7%), and anaemia/frail group (39.3%). A total of 144 patients died during 1 year of follow‐up. In multivariate analyses, only the anaemia/frail group showed a significant association with elevated mortality rate (adjusted hazard ratio, 1.94; 95% confidence interval, 1.02–3.70; P = 0.043), compared with the non‐anaemia/non‐frail group after adjusting for other covariates.
Conclusions
Coexistence of anaemia and frailty are prevalent in hospitalized older patients with HF, and it has a negative impact on mortality.
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
Enquadramento: A acessibilidade constitui um elemento crucial na qualidade de vida das pessoas com mobilidade condicionada, sendo imprescindível para o exercício dos seus direitos. A sua efetividade envolve uma equipa multidisciplinar, que deverá incluir o Enfermeiro Especialista em Enfermagem de Reabilitação, dado que a este compete capacitar a pessoa com mobilidade condicionada para a reinserção e exercício da cidadania.
Objetivos: Refletir sobre os direitos das pessoas com mobilidade condicionada; compreender a intervenção do Enfermeiro Especialista em Enfermagem de Reabilitação na promoção da acessibilidade e na inclusão social.
Principais tópicos em análise: Legislação e planos de promoção da acessibilidade e da inclusão social; e a intervenção do Enfermeiro Especialista em Enfermagem de Reabilitação no âmbito destas problemáticas.
Conclusão: As condições de acessibilidade constituem um dos fatores discriminatórios para as pessoas com mobilidade condicionada. Assim, compete ao Enfermeiro Especialista em Enfermagem de Reabilitação paralelamente com as entidades competentes, encarar esta problemática como uma urgente oportunidade para a mudança.
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
Introdução: A Doença Pulmonar Obstrutiva Crónica é prevenível e tratável, com manifestações respiratórias persistentes, nas quais as intervenções do ER podem contribuir para melhorar a capacidade funcional e emocional, o conhecimento, promover o autocuidado, a adesão ao regime terapêutico e a comportamentos saudáveis.
Objetivo: Sintetizar evidência científica sobre impacto da intervenção do ER na Pessoa com DPOC.
Métodos: Estabeleceu-se como pergunta de investigação “Qual o impacto da intervenção do Enfermeiro de Reabilitação na Pessoa com Doença Pulmonar Obstrutiva Crónica?”, adotando-se a metodologia do The Joanna Briggs Institute para revisão sistemática. Definiram-se critérios de inclusão e a pesquisa booleana, na EBSCOhost.
Resultados: Incluíram-se 6 artigos, que retratam a componente educacional e suporte do ER. O ER tem impacto positivo na vida da pessoa com DPOC, verificando-se melhores resultados no controlo sintomático/dispneia, na redução das admissões e tempo de internamento, no aumento da perceção da doença e da qualidade de vida. Tem impacto na melhoria das atividades de vida diária e na redução dos custos.
Conclusões: Os estudos evidenciaram variedade nas formas de atuação do ER, mas impacto positivo associado. Salienta-se pouca investigação sobre resultados das intervenções.
... 28 Reeves et al showed success in a pilot study employing a novel rehabilitation intervention in older adults with heart failure and a high burden of frailty, and a larger study is under way. 29 There are also ongoing studies testing novel rehabilitation strategies in patients undergoing TAVR, including ACTIVE AFTER TAVR (NCT03270124) and PERFORM-TAVR (NCT03522454). Other strategies that may improve postprocedure resilience and outcomes include prehabilitation (preprocedure conditioning), less procedural sedation, early postprocedure ambulation, and shorter hospital stays. ...
Background
Gait speed is a reliable measure of physical function and frailty in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Slow gait speed pre‐TAVR predicts worse clinical outcomes post‐TAVR. The consequences of improved versus worsened physical function post‐TAVR are unknown.
Methods and Results
The REPRISE III (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System–Randomized Clinical Evaluation) trial randomized high/extreme risk patients to receive a mechanically‐expanded or self‐expanding transcatheter heart valve. Of 874 patients who underwent TAVR, 576 with complete data at baseline and 1 year were included in this analysis. Slow gait speed in the 5‐m walk test was defined as <0.83 m/s. A clinically meaningful improvement (≥0.1 m/s) in gait speed 1 year after TAVR occurred in 39% of patients, 35% exhibited no change, and 26% declined (≥0.1 m/s). Among groups defined by baseline/1‐year post‐TAVR gait speeds, 1‐ to 2‐year mortality or hospitalization rates were as follows: 6.6% (normal/normal), 8.0% (slow/normal), 20.9% (normal/slow), and 21.5% (slow/slow). After adjustment, slow gait speed at 1 year (regardless of baseline speed) was associated with a 3.5‐fold increase in death/hospitalization between 1 and 2 years compared with those with normal baseline/1‐year gait speed. Patients whose slow gait speed normalized at 1 year had no increased risk. One‐year, but not baseline, gait speed was associated with death or hospitalization between 1 and 2 years (adjusted hazard ratio, 0.83 per 0.1 m/s faster gait; 95% CI, 0.74–0.93, P =0.001).
Conclusions
Marked heterogeneity exists in the trajectory of physical function after TAVR and this, more than baseline function, has clinical consequences. Identifying and optimizing factors associated with physical resilience after TAVR may improve outcomes.
Registration
URL: https://www.clini caltr ials.gov ; Unique identifier: NCT02202434.
... Tradicionalmente, as diretrizes de treinamento para pacientes com IC recomendam exercícios aeróbicos de grande massa muscular (caminhada e ciclismo) e o treinamento muscular localizado pode ser um tipo importante de treinamento para melhorar o transporte de O 2 na IC, particularmente útil em pacientes gravemente incapacitados com capacidade de reserva mínima. 60 Reeves et al., 61 realizou o estudo REHAB-HF que sugeriu a segurança e a eficácia de uma reabilitação física de múltiplos domínios de intervenção para melhorar a função física e reduzir a hospitalização em pacientes idosos e frágeis com descompensação aguda IC com múltiplas comorbidades. Em pessoas com IC combinada com perda muscular significativa, o treinamento deve concentrar-se inicialmente no aumento da massa e força muscular aplicando principalmente treinamento de força durante as sessões da primeira semana. ...
A reabilitação cardiovascular com ênfase nos exercícios físicos tem sido documentada em pacientes com insuficiência cardíaca, demonstrando diminuição da morbimortalidade cardiovascular, bem como redução da taxa de hospitalizaçãoe melhora na qualidade de vida.No mundo, o sedentarismo tem forte correlação com o aparecimento de doença cardiovascular e morte súbita. Por outro lado, a prática de exercício físico regular está associada a um melhor estilo de vida, redução da incidência de doenças cardiovasculares, resultando em menor mortalidade. O objetivo do presente estudo foi abordar as diferentes fases da reabilitação cardiovascular baseada em exercício físico, incluindo treinamento da musculatura inspiratória e suas particularidades na insuficiência cardíaca.
... It is postulated that these patients may be excellent candidates for exercise intervention, as was done with the HF-ACTION Trial, and with the recently completed REHAB-HF study, to improve functional status and quality of life. (4,5) COVID-19 is not a short term acute healthcare problem that will go away and not return. COVID-19 is here today, and has caused enormous fatigue on our patients and healthcare providers in this three-month acute phase. ...
... Regular moderate-intensity aerobic exercise training is the most promising treatment approach with the potential to improve or reverse the frailty phenotype in older adults with cardiovascular disease, 19,20 mostly through improvements in cardiorespiratory fitness. Recently, we reported that cardiorespiratory fitness (peak oxygen consumption [VO 2peak ]) was 36% less than predicted normative values (19.2 mL.kg −1 .min ...
Objective
To evaluate whether 5-m gait speed, an established marker of frailty, is associated with post-operative events following elective proximal aortic surgery.
Methods
A retrospective review of 435 patients >60 years of age who underwent elective proximal aortic surgery, defined as surgery on the aortic root, ascending aorta, and/or aortic arch through median sternotomy. Patients completed a 5-m gait speed test within 30-days prior to surgery. We evaluated the association between categorical (slow, ≤0.83 m/s and normal, >0.83 m/s) and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for EuroSCORE II. The composite outcome included in-hospital mortality, renal failure, prolonged ventilation, and discharge location. Secondary outcomes were 1-year mortality and 5-year survival.
Results
Of the study population, 30.3% (132/435) were categorized as slow. Slow walkers were significantly more likely to suffer in-hospital mortality, prolonged ventilation, renal failure, and were less likely to be discharged home (p’s<0.05). The composite outcome was 2 times more likely to occur for slow walkers (gait speed-categorical adjusted odds ratio (OR), 2.08; 95% confidence interval (CI), 1.27-3.40; p=0.004). Moreover, a unit (1m/s) increase in gait speed (continuous) was associated with 73% lower risk of experiencing the composite outcome (OR 0.27, 95% CI: 0.11-0.68; p=0.006).
Conclusion
Slow gait speed is a preoperative indicator of risk for post-operative events following elective proximal aortic surgery. Gait speed may be an important tool to complement existing operative risk models, and its application may identify patients who may benefit from pre- and post-surgical rehabilitation.
... The average walked distance on the first test performed by the patients of this study was about 178 m, and at discharge was 287.6 m, which is considerably high in comparison to other studies involving the same type of patients. 26 In a systematic review of adults with multiple pathologies, the MCID has a range from 14.0 m to 30.5 m, 18 in a study on patients with coronary artery disease, the MCID was 25 m 16 and for chronic HF patients was 30.1 m. 28 In our study the difference between the first test and the discharge test was, on average, 109.6 m. If the findings of those previous studies are applied to our population, the improvement in the 6MWT distance difference appears clinically significant in this sample of patients. ...
Background
Decompensated heart failure patients are characterised by functional dependence and low exercise tolerance. Aerobic exercise can improve symptoms, functional capacity and an increase in exercise tolerance. However, the benefits of early rehabilitation have not yet been validated.
Objective
To evaluate the safety and feasibility of an aerobic exercise training programme in functional capacity of decompensated heart failure patients.
Methodology
A single centre, parallel, randomised controlled, open label trial, with 100 patients. The training group (TG, n=50) performed the training protocol and the control group (CG, n=50) performed the usual rehabilitation procedures. The London chest activity of daily living (LCADL) scale, the Barthel index (BI) and the 6 minute walking test (6MWT) at discharge were used to evaluate the efficacy of the protocol. Safety was measured by the existence of adverse events.
Results
The mean age of the patients was 70 years, 20% were New York Heart Association (NYHA) class IV and 80% NYHA class III at admission. The major heart failure aetiology was ischaemic (35 patients) and valvular disease (25 patients). There were no significant differences between groups at baseline in terms of sociodemographic or pathophysiological characteristics. There was a statistically significant difference of 54.2 meters for the training group ( P=0.026) in the 6MWT and at LCADL 12 versus 16 ( P=0.003), but the BI did not: 96 versus 92 ( P=0.072). No major adverse events occurred.
Conclusions
The training protocol demonstrated safety and efficacy, promoting functional capacity. This study elucidated about the benefits of a systematised implementation of physical exercise during the patient’s clinical stabilisation phase, which had not yet been demonstrated. Trial registration: Clinicaltrials.gov NCT03838003, URL: https://clinicaltrials.gov/ct2/show/NCT03838003 .
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
Context: Regular use of school backpacks presents risks during a child's growth period. The weight percentage of the backpack recommended is not unanimous, and this multifactorial problem deserves further literature review.
Objectives: to map the evidence regarding the maximum backpack weight recommended for children from 6 to 12 years in school context.
Method: Suggested by Joanna Briggs Institute. Primary fulltext studies in portuguese, english and spanish published in scientific databases, international guidelines and gray literature will be included. The analysis of the relevance of the articles, the extraction and synthesis of the data will be developed by two independent reviewers.
Presentation and discussion of the results: the extracted data will be presented in a PRISMA diagram, allowing the interpretation and dissemination of the available evidence.
Conclusion: The results are expected to summarize the best evidence on the maximum backpack weight recommended for children (6-12 years) in school settings.
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
RESUMO
Implementámos um Programa de Estimulação Multissensorial (PEM) a doentes com alterações severas do estado de consciência, integrado num projeto de melhoria contínua da qualidade dos cuidados de enfermagem: “Avaliação e estimulação do doente com alterações do estado de consciência” (1). Tivemos como objetivo geral promover a melhoria do estado de consciência destes doentes. Foi aplicado a 22 pessoas com média de idade de 57,95 anos (+17,27), sendo 63,64% homens. A tipologia de doentes foi maioritariamente AVC Hemorrágico (59,09%), seguida de Traumatismo Crânio-Encefálico (31,82%). Escolhemos a Escala de Coma de Glasgow (ECG) e a Rancho los Amigos Levels of Cognitive Functioning Scale (LCSF) para avaliar o doente. Dos resultados destacamos: mais de metade dos doentes evoluíram no estado de consciência, 63,64% melhoraram o
Score na ECG e 54, 55% progrediram no nível LCFS; os que tiveram a família envolvida evoluíram seis vezes mais em média na ECG. Concluímos que com a aplicação do nosso PEM poderemos contribuir para a melhoria do estado de consciência da maioria destes doentes.
Descritores: Enfermagem de Reabilitação; Estado de Consciência; Reabilitação Cognitiva; Programa de Estimulação multissensorial; Alterações severas do estado de consciência.
... Relativamente à capacidade funcional, a diferença de 85 metros na distância percorrida entre os 2 testes realizados pelo doente traduzem uma melhoria considerável, que podemos classificar como sendo clinicamente significativa (35)(36)(37)(38) . A capacidade de marcha é aceite como um excelente indicador para inferir autonomia na realização das AVD e consequentemente inferir sobre a sua capacidade funcional. ...
Objetivo: analisar os focos/diagnósticos de enfermagem documentados pelos enfermeiros especialistas em enfermagem de reabilitação, durante o processo de morrer em contexto hospitalar.
Método: estudo descritivo, retrospetivo e quantitativo realizado numa instituição hospitalar do norte de Portugal em fevereiro de 2017. Os dados sobre a documentação dos focos/diagnósticos de enfermagem identificados nos clientes que morreram no ano de 2016 foram recolhidos por meio de dois sistemas de informação: SClínico e BICUcare.
Resultados: nos 4115 registos efetuados por 148 enfermeiros especialistas em enfermagem de reabilitação, constatamos que apesar da evolução ocorrida durante a última década, na documentação dos cuidados de enfermagem, sobressaem algumas inquietações sobre qual a prática de cuidados que a mesma evidencia. Decorrente da ênfase colocada na documentação das alterações no domínio da função, os enfermeiros especialistas em enfermagem de reabilitação tendem a subestimar o registo das alterações e das necessidades que emergem das transições vivenciadas pelas pessoas, especificamente durante a morte e os processos de morrer.
Conclusão: Atendendo a que a informação registada contribui para a visibilidade dos cuidados prestados, emerge a necessidade de se adotarem estratégias que resolvam o problema da subdocumentação, nomeadamente perante a morte e os processos de morrer.
Background:
People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting.
Objectives:
To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure.
Search methods:
We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers.
Selection criteria:
We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF.
Data collection and analysis:
We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence.
Main results:
We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes.
Authors' conclusions:
This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
Introdução: Apesar dos avanços no tratamento, a insuficiência cardíaca é uma doença crónica, cuja incidência aumenta com a idade. Os internamentos por descompensação mantêm-se elevados, pelo que é crucial priorizar estratégias para a autogestão, tais como o ensino, o acompanhamento e os programas de reabilitação cardíaca. Face ao exposto, este estudo teve como objetivo verificar o impacto do programa REPIC na qualidade de vida, nível de conhecimentos e adesão ao exercício físico. Metodologia: Estudo quantitativo com desenho antes-após de grupo único realizado numa amostra de 110 pessoas com insuficiência cardíaca, sujeitos a um programa de reabilitação e educação para a saúde durante o internamento e com follow-up telefónico, ao final de um mês, seis meses e um ano após a alta clínica. Resultados e Discussão: A maioria dos participantes são do sexo masculino (66%) e a amplitude da idade varia entre 30 e 89, com uma média de 64,3 anos e um desvio padrão de 14,4. A análise dos dados evidenciou uma melhoria estatisticamente significativa no conhecimento sobre a doença, bem como na perceção da qualidade de vida nas dimensões mobilidade, cuidados pessoais, atividades habituais e nível geral de saúde (p=0,01). O incremento no tempo de exercício físico após o programa REPIC foi confirmado com resultado estatisticamente significativo [t (109)=6,03; p=0,019]. Os resultados obtidos demonstram os benefícios da educação para a saúde e do acompanhamento telefónico de enfermagem, nomeadamente a melhoria no nível de conhecimentos sobre a doença, na qualidade de vida e na adesão ao exercício físico. Conclusão: O programa REPIC permitiu reforçar o processo educativo, potenciar os comportamentos de autogestão, melhorar a qualidade de vida e aumentar a duração do exercício físico.
https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_CJ-22-0234/_article
Electrical muscle stimulation (EMS) is expected to be considered as an add-on therapy for the usual rehabilitation of patients with chronic heart failure (HF). However, it remains unclear whether EMS can reduce muscle volume loss in patients with acute HF (AHF) immediately after hospitalization. Therefore, the aim of this study was to investigate if EMS could reduce the lower-limb muscle volume loss in patients with AHF. In this single-center, retrospective, observational study, lower-limb skeletal muscle volume, quadriceps muscle layer thickness, and clinical events (worsening HF or kidney function) were evaluated in 45 patients with AHF (mean age, 77.4 ± 11.6 years, 31 males). All patients underwent EMS on the right leg, in addition to usual rehabilitation, for 20 minutes per day, 5 days per week, for 2 weeks. A two-factor (time × leg) analysis of variance was performed to compare the difference between the right leg (usual rehabilitation and EMS) and left leg (usual rehabilitation only). The skeletal muscle mass decreased by 11.6% ± 19.7% from baseline in the right leg and by 20.4% ± 16.1% in the left leg (interaction; F = 4.54, P = 0.036). The quadriceps muscle layer thickness decreased by 10.2% ± 7.1% from baseline in the right leg and by 13.5% ± 6.0% in the left leg (interaction; F = 10.50, P = 0.002). No clinical events were related to EMS. Results showed that EMS combined with usual rehabilitation for patients with AHF has the potential to inhibit muscle volume loss.
Return to Sport from Viral Myocarditis in A Previously Healthy Collegiate Athlete: A Case Report
The objective of this paper is to present the case of a healthy, nineteen-year-old female collegiate soccer player who presented with acute pulmonary edema and acute heart failure in recovery status post hip labrum arthroscopic surgery. The patient's initial diagnosis, of negative pressure pulmonary edema in direct relation to extubation, was questioned when the patient became hemodynamically unstable. After receiving the results of a cardiac biopsy, the final diagnosis was determined to be acute pulmonary edema and heart failure secondary to viral myocarditis. The patient was treated and discharged ten days after admission. Specific and substantiated return to play guidelines after a cardiac event, specifically viral myocarditis, have been sparse. The inter-professional collaboration between athletic trainers and cardiologists is a key dynamic in the clinical decision-making process of a safe return to competitive athletic participation following a cardiac event.
With the aging of the world’s population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.
Objectives
The purpose of this study was to assess temporal trends and factors associated with cardiac rehabilitation (CR) enrollment and participation among Medicare beneficiaries after the 2014 Medicare coverage expansion.
Background
CR improves exercise capacity, quality of life, and clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). In 2014, Medicare coverage for CR was expanded to include chronic HFrEF.
Methods
Among Medicare beneficiaries from quarter (Q) 1 2014 to Q2 2016, 11,696 patients from 14,258 hospitalizations with primary discharge diagnosis of HF were identified. Patients with HF with preserved ejection fraction were excluded. Quarterly CR participation rates among hospitalized HF patients within 6 months of discharge were identified through outpatient administrative claims. The predictors of CR participation were assessed with the use of a multivariable logistic regression model that included patient- and hospital-level characteristics. A secondary analysis to assess participation rates of CR after outpatient encounters for HF was performed.
Results
Overall, only 611 (4.3%) and 349 (2.2%) eligible patients participated CR after primary hospitalization or outpatient visit for HF, respectively. There was a modest, statistically significant increase in CR participation after HF admissions (2.8% in Q1 2014; 5.0% in Q2 2016; p < 0.001) without significant increase after outpatient visits for HF (2.6% to 3.8%; p = 0.21). Younger age, male sex, nonblack race, previous cardiovascular procedures, and hospitalization at hospitals with available CR facilities were all independently associated with CR participation.
Conclusion
s: CR participation among eligible Medicare beneficiaries with HFrEF was low with minimal increase since 2014 Medicare coverage decision. Sex, race, and institution-dependent variables were independent predictors of CR participation.
Background
We will undertake an individual patient data (IPD) meta-analysis to assess the impact of exercise-based cardiac rehabilitation in patients with heart failure with preserved ejection fraction (HFpEF) on mortality and hospitalization and quality of life of exercise-based cardiac rehabilitation according to patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischemic etiology, ejection fraction, and exercise capacity. Despite emerging evidence supporting exercise training in HFpEF, uncertainties remain in the interpretation and understanding of this evidence base. Clinicians and health care providers seek definitive estimates of impact on mortality, hospitalization and health-related quality of life (HRQoL). This work is, therefore, important as HFpEF treatment options are evolving; however, efficacy of some medications is equivocal, so optimizing exercise rehabilitation is vital.
Methods
We conducted a systematic search to identify randomized trials of exercise training for at least 3 weeks compared with no exercise control with 6-month follow up or longer, providing IPD time to event on mortality or hospitalization (all-cause or heart failure-specific). IPD will be combined into a single dataset. We will use Cox proportional hazards models to investigate the effect of exercise-based cardiac rehabilitation and the interactions between exercise-based cardiac rehabilitation and participant characteristics. We will use a mix of one-stage and two-stage models. Original IPD will be requested from the authors of all eligible trials; we will check original data and compile a master dataset. IPD meta-analyses will be conducted using a one-step approach where the IPD from all studies are modeled simultaneously while accounting for the clustering of participants with studies.
Results
We expect our analyses to show improved mortality, hospitalization, cardiorespiratory fitness, and health-related quality of life.
Conclusion
This work will clarify exercise-based rehabilitation delivery methods to optimize benefits for people with HFpEF.
Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Exercise training and other components of cardiac rehabilitation (CR) are safe and beneficial and result in significant improvements in quality of life, functional capacity, exercise performance, and heart failure (HF)–related hospitalizations in patients with HF. Despite outcome benefits, cost-effectiveness, and strong practice guideline recommendations, CR remains underused. Clinicians, health care leaders, and payers should prioritize incorporating CR as part of the standard of care for patients with HF.
Background:
Although hospitalized patients with acute decompensated heart failure (ADHF) have severe physical dysfunction, little data are available on the comparative effectiveness of early versus late rehabilitation. This study examined the relationship between early compared to late rehabilitation and physical function among older patients hospitalized for ADHF.
Methods:
In a retrospective cohort study, independent patients aged ≥65years at baseline who were hospitalized for ADHF from 2012 to 2014 and underwent inpatient rehabilitation were identified using Emergency Department visit data and electronic medical records at two hospitals. Patients were classified into those who underwent early rehabilitation (initiated within 72hours of admission) and late rehabilitation (after 72hours). Primary outcome was length of time from admission until the patient was able to walk independently. Multivariable competing-risk regression with death as the competing event was used to adjust for potential confounding factors, and multiple imputation (MI) analysis was performed.
Results:
Of 259 individuals, 30 (11.6%) commenced rehabilitation within 72hours after admission while 229 (88.4%) did so 72hours after admission. Patients who received early rehabilitation had a higher rate of unassisted walking for at least 40m by 30days after admission (hazard ratio: 8.03; 95% confidence interval: 2.15 to 29.98; P=.002 in the multivariable adjusted model) than those who received late rehabilitation. Similar findings were observed on MI analysis.
Conclusion:
Early rehabilitation therapy commenced within 72hours of admission was associated with a higher rate of recovery of an activity of daily living (independent walking on a level surface).
Cultural factors – language barriers, beliefs, values, education, psychosocial aspects, availability of food, eating patterns, physical activity behaviors, and socioeconomic status, among others – are potent modifiers of the response to lifestyle interventions. Ideally, lifestyle medicine interventions must be based on the best evidence available and culture must be recognized and effectively incorporated in the health system. Transcultural medicine – a component of precision medicine – includes ethno-cultural elements in the dynamic encounter between a healthcare professional and a patient. Effective evidence-based interventions result from the transculturalization of information from one culture to another. This is a stepwise process that involves clinical practice guidelines, transcultural adaptation, implementation, and finally outcomes, which are followed. The transcultural adaptation process applies ecological validity model dimensions. The transcultural Diabetes Nutrition Algorithm (tDNA) – a portable tool developed to facilitate the delivery of lifestyle modifications and nutrition therapy to people with prediabetes and type 2 diabetes in different countries and cultural settings – is an example. Various approaches to lifestyle medicine using the chronic disease model are discussed. The components to prepare a Lifestyle Medical Center to provide transculturalized care are presented. These culturally sensitive elements include staff and communication strategies that consider cultural competence knowledge, attitudes and skills, infrastructure/services, information/software, and important administrative/organizational aspects. A formal survey to capture relevant social determinants of disease is critical for every patient encounter. Clinical examples weave through the discussion: an Arab patient evaluated by a Hispanic doctor in a healthcare center in Miami, a Japanese patient evaluated in Brazil for diabetes risk screening, and an African American female referred to a lifestyle medicine center in the USA. These case studies are platforms to deliver didactic applications of transcultural concepts.
Purpose of review:
ICU survivors frequently suffer significant, prolonged physical disability. 'ICU Survivorship', or addressing quality-of-life impairments post-ICU care, is a defining challenge, and existing standards of care fail to successfully address these disabilities. We suggest addressing persistent catabolism by treatment with testosterone analogues combined with structured exercise is a promising novel intervention to improve 'ICU Survivorship'.
Recent findings:
One explanation for lack of success in addressing post-ICU physical disability is most ICU patients exhibit severe testosterone deficiencies early in ICU that drives persistent catabolism despite rehabilitation efforts. Oxandrolone is an FDA-approved testosterone analogue for treating muscle weakness in ICU patients. A growing number of trials with this agent combined with structured exercise show clinical benefit, including improved physical function and safety in burns and other catabolic states. However, no trials of oxandrolone/testosterone and exercise in nonburn ICU populations have been conducted.
Summary:
Critical illness leads to a catabolic state, including severe testosterone deficiency that persists throughout hospital stay, and results in persistent muscle weakness and physical dysfunction. The combination of an anabolic agent with adequate nutrition and structured exercise is likely essential to optimize muscle mass/strength and physical function in ICU survivors. Further research in ICU populations is needed.
A consensus conference on frailty in solid‐organ transplantation took place on February 11, 2018 to discuss the latest developments in frailty, adopt a standardized approach to assessment and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation’s Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging‐associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex co‐morbidities. However, outcomes data in the pre‐transplant setting, particularly for younger patients, is limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes and help distinguish frailty phenotypes amenable to intervention.
Introduction:
Patients with decompensated heart failure are characterized by low exercise tolerance associated with dyspnea and edema. Exercise training promotes exercise tolerance as well as an improvement in ventricular function.
Objective:
To identify signs of cardiac modulation and consequent improvement of functional capacity after the implementation of a structured exercise plan.
Method:
It is a quantitative approach case report, about a patient with decompensated heart failure of ischemic and valvular etiology, manifesting a high degree of activity intolerance as well as hemodynamic decompensation.
Physiological parameters such as Heart Rate, Blood Pressure, Subjective perception of effort evaluated by the Borg scale and the tolerance of the patient to activity at baseline and throughout the training sessions. The 6MWT was applied at two different moments: on the 4th day of hospitalization and at discharge, as a way to evaluate the evolution of functional capacity. This patient is enrolled on randomized clinical trial that aims to evaluate the feasibility and safety of exercise, being used as assessment tools the LCADL scale, the Barthel Index, as well as the 6MWT.
Results:
There was an improvement in the patient’s functional capacity, assessed by the 6-minute walk test (T1: 210m, T2: 295m), as well as a reduction in resting heart rate (85 bpm vs 68 bpm) and training heart rate (145bpm vs 94bpm). No adverse events occured during training sessions.
Conclusions:
The intervention implemented in this clinical situation proved to be safe and equally effective in improving functional capacity and modulating heart rate at rest and during exercise training.
ResearchGate has not been able to resolve any references for this publication.