乌鸦传媒

A physical rehabilitation program tailored to people diagnosed with acute decompensated heart failure appeared to improve physical functioning, quality of life, and even depression, researchers reported.

After 3 months, patients who were classified as frail or pre-frail improved by an average 1.5 units in the Short Physical Performance Battery compared with patients who were not involved in the program (95% CI 0.9-2.0, P<0.001), a significant and clinically meaningful improvement, said Dalane Kitzman, MD, of Wake Forest School of Medicine in Winston-Salem, North Carolina.

In a presentation at the virtual meeting, Kitzman noted that at baseline, patients' average score on the battery was 6.1 – about what is found in a nursing home population.

He reported that the group receiving the tailored rehabilitation program were able to add 34 more meters to their 6-minute walk test versus controls, a meaningful finding as patients in the study could not achieve 200 meters in the test prior to beginning rehabilitation. While both groups improved, the patients in the rehab program did significantly better (P=0.007).

Additionally, patients in the rehab program saw their Modified Fried Frailty Criteria scores decrease by 0.6 points versus controls (P=0.028), had a 7.1-unit improvement on the Kansas City Cardiomyopathy Questionnaire scores compared with the control group (P=0.007), and had a 0.7-unit reduction in their Geriatric Depression Scale score (P=0.013).

Kitzman said that while the improvements were encouraging, the trial -- Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) -- was a phase II study, and longer follow-up is needed to confirm the results, which were published simultaneously in the . He also noted that the personalized rehabilitation program was expensive, and there are questions as to whether it could be reimbursed if further testing proves the long-term value in these patients.

To change guidelines, he explained, studies would have to show an impact on outcomes, such as hospitalization, and this study was not powered to show that impact, and it was not seen in any case, although there were signals of benefit in subgroup analyses that are still being explored.

"These patients have persistently poor outcomes with frequent rehospitalizations, poor quality of life, high rates of dying, and high healthcare costs," Kitzman said at a press conference. "Despite many efforts to improve outcomes in these patients, most studies testing a wide range of medications, devices, and strategies have been negative. This suggested to us that we were overlooking an important factor contributing to these poor outcomes, and we suspected the missing factor might be severe physical dysfunction, which is generally not addressed in heart failure management."

The study's discussant, Eileen Handberg, PhD, of University of Florida Health in Gainesville, said: "This work is extremely important because the domains that were evaluated are the ones that mean the most to patients. This is about being able to get out of a chair without assistance; walking farther and feeling better, as opposed to the traditional method of testing patients on a treadmill, which is difficult for these patients to do very well. This is a real-world intervention that allows us to look at the impact -- and the impact was significant."

She noted that many patients in the study were unable to participate because they lived too far from the centers and suggested that the lessons learned about telemedicine from COVID-19 might be applied here as well.

Hospitalization for heart failure speeds the downward spiral for these patients, Kitzman said. "Even before they are hospitalized, these patients already have lower physical functioning due to both aging and their chronic heart failure, and when their heart failure worsens, their physical function deteriorates further and this can then be exacerbated by the hospital experience and bed rest."

"This sequence of events leading to marked impairments in all domains of physical function and its impact on patient outcomes has been largely overlooked," he continued, adding that with these insights, the REHAB-HF intervention was developed and designed to correct deficits in balance, mobility, and strength.

A total of 349 patients were enrolled in the study. Their average age was 73, 51% were women, and 49% were non-white. Participants had at least five comorbidities, and 97% were considered frail or pre-frail with marked physical dysfunction. The patients were recruited from seven hospitals, including four community hospitals.

Kitzman noted that unlike traditional cardiac rehab programs that typically start 6 weeks after hospitalization, the REHAB-HF program started early -- during the patient's hospital stay if possible -- and transitioned to three outpatient sessions per week for 12 weeks following hospital discharge.

Kitzman told 乌鸦传媒 that one exercise to improve balance was to have patients stand in front of the instructor, feet together, and then gradually spread the feet wide, while being gently challenged.

"It was a surprise to us that patients with heart failure who did not have a stroke had significant balance problems," Kitzman said. "This is dramatically different than standard cardiac rehabilitation."

Comment