Multidisciplinary Cardiac Rehabilitation and Long-Term Prognosis in Patients With Heart Failure

Frailty Test Battery Development including Physical, Socio-Psychological and Cognitive Domains for Cardiovascular Disease Patients: A Preliminary Study

Frailty is an age-related decline in physical, socio-psychological and cognitive function that results in extreme vulnerability to stressors. Therefore, this study aimed to elucidate which tests have to be selected to detect frailty in a comprehensive and feasible manner in cardiovascular disease (CVD) patients based on multivariate regression and sensitivity/specificity analyses. Patients (n = 133, mean age 78 ± 7 years) hospitalised for coronary revascularisation or heart failure (HF) were examined using the Fried and Vigorito criteria, together with some additional measurements. Moreover, to examine the association of frailty with 6-month clinical outcomes, hospitalisations and mortality up to 6 months after the initial hospital admission were examined. Some level of frailty was detected in 44% of the patients according to the Vigorito criteria and in 65% of the patients according to the Fried criteria. Frailty could best be detected by a score based on: sex, Mini Nutritional Assessment (MNA), Katz scale, timed up-and-go test (TUG), handgrip strength, Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15) and total number of medications. Frailty and specific markers of frailty were significantly associated with mortality and six-month hospitalisations. We thus can conclude that, in patients with CVD, sex, MNA, Katz scale, TUG, handgrip strength, MMSE, GDS-15 and total number of medications play a key role in detecting frailty, assessed by a new time- and cost-efficient test battery.

Efficacy and Safety of Acute Phase Intensive Electrical Muscle Stimulation in Frail Older Patients with Acute Heart Failure: Results from the ACTIVE-EMS Trial

As frailty in older patients with acute heart failure (AHF) has an adverse effect on clinical outcomes, the addition of electrical muscle stimulation (EMS) to exercise-based early rehabilitation may improve the effects of treatment. Post hoc analysis was performed on a randomized controlled study for clinical outcomes and prespecified subgroups (ACTIVE-EMS: UMIN000019551). In this trial, 31 AHF patients aged ≥ 75 years with frailty (Short Physical Performance Battery [SPPB] score 4–9) were randomized 1:1 to receive treatment with an early rehabilitation program only (n = 16) or early rehabilitation with add-on EMS therapy (n = 15) for 2 weeks. Changes in physical function and cognitive function between baseline and after two weeks of treatment were assessed. There were no adverse events during the EMS period. The EMS group showed significantly greater changes in quadriceps’ isometric strength and SPPB compared to the control group, and EMS therapy showed uniform effects in the prespecified subgroups. There were no significant differences in the changes in other indexes of physical function and cognitive function between groups. There was no significant difference in the rate of heart failure hospitalization at 90 days between groups. In conclusion, older AHF patients with frailty showed greater improvement in lower extremity function with the addition of EMS therapy to early rehabilitation without adverse events.

Association of adherence to a 3 month cardiac rehabilitation with long-term clinical outcomes in heart failure patients

Aims

Although comprehensive cardiac rehabilitation (CCR) is recommended for patients with heart failure (HF), participants often show low adherence. The aim of this study was to evaluate the association of CCR completion and response with long‐term clinical outcomes.

Methods and results

We screened 824 HF patients who participated in a 3 month CCR programme and underwent baseline assessment, including cardiopulmonary exercise testing (CPX). After excluding 52 participants who experienced all‐cause death or HF hospitalization within 180 days, long‐term outcomes were compared between those who attended 3 month follow‐up assessment including CPX (completers) and those who did not (non‐completers). We also compared the prognostic value of the changes in peak oxygen uptake (VO₂) vs. quadriceps muscle strength (QMS) during the 3 month CCR programme. Among the 772 study patients, there were no significant differences in baseline characteristics, including left ventricular ejection fraction, B‐type natriuretic peptide levels, and peak VO₂, between the completers (n = 561) and non‐completers (n = 211), except for a higher age (63.2 ± 14.2 vs. 59.4 ± 16.2 years; P = 0.0015) and proportion of females (27% vs. 17%; P = 0.0030) among the completers. During a median follow‐up of 55.4 months, the completers had lower rates of the composite of all‐cause death or HF hospitalization (34.4% vs. 44.6%; P = 0.0015) and all‐cause death (16.9% vs. 24.6%; P = 0.0037) than the non‐completers. After adjustment for prognostic baseline characteristics, including age and sex, CCR completion was associated with 34% and 44% reductions in the composite outcome and all‐cause death, respectively. Among the completers, peak VO₂ and QMS increased significantly (8.9 ± 15.8% and 10.5 ± 17.9%, respectively) over 3 months. Patients who had an increase in peak VO₂ ≥ 6.3% (median value) during the CCR programme had significantly lower rates of the composite outcome (27.0% vs. 33.8%; P = 0.048) and all‐cause mortality (10.0% vs. 17.4%; P = 0.0069) than those who did not. No statistically significant difference was observed in the composite outcome (30.5% vs. 30.4%; P = 0.76) or all‐cause mortality (13.0% vs. 14.4%; P = 0.39) between those with and without an increase in QMS ≥8.3% (median value).

Conclusions

In HF patients who participated in a 3 month CCR programme, its completion was associated with lower risks of subsequent HF hospitalization and death. Within the group of patients who completed the programme, the improvement in exercise capacity, but not in skeletal muscle strength, over the 3‐month period was associated with better outcomes. These findings highlight the importance of the post‐CCR follow‐up assessment, including CPX, to identify a patient's adherence and response to the CCR programme.

Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review

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.

Prognostic Effects of Cardiac Rehabilitation in Patients With Heart Failure (from a Multicenter Prospective Cohort Study)

The prognostic effects of cardiac rehabilitation (CR) are inconsistent in recent reports on heart failure (HF). Generally, participants in previous trials were relatively young and had HF with reduced ejection fraction. Herein, we examined the effects of CR on HF prognosis using a nationwide cohort study. This multicenter prospective cohort study included hospitalized patients with acute HF or worsening chronic HF. Patients who underwent CR once or more times weekly for 6 months after discharge were included in the CR group. The main study end point was a composite of all-cause mortality and HF rehospitalization during a 2-year follow-up period. We performed propensity score matching to compare the survival rates between the CR and non-CR groups. Of the 2,876 enrolled patients, 313 underwent CR for 6 months. After propensity score matching using confounding factors, 626 patients (313 pairs) were included in the survival analysis (median age: 74 years). CR was associated with a reduced risk of composite outcomes (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.48 to 0.91; p = 0.011), all-cause mortality (HR 0.53; 95% CI 0.30 to 0.95; p = 0.032), and HF rehospitalization (HR 0.66; 95% CI 47 to 0.92; p = 0.012). Subgroup analysis showed similar CR effects in patients with HF with preserved ejection fraction (≥50%) and HF with reduced ejection fraction (<40%). In the landmark analysis, CR did not reduce the aforementioned end points beyond 6 months after discharge (log-rank test: composite outcomes, p = 0.943; all-cause mortality, p = 0.258; HF rehospitalization, p = 0.831). CR is a standard treatment for HF regardless of HF type; however, further challenges may affect the long-term prognostic effects of CR.

Hospital-Acquired Functional Decline and Clinical Outcomes in Older Cardiac Surgical Patients: A Multicenter Prospective Cohort Study

This study aimed to determine the effect of hospital-acquired functional decline (HAFD) on prognosis, 1-year post-hospital discharge, of older patients who had undergone cardiac surgery in seven Japanese hospitals between June 2017 and June 2018. This multicenter prospective cohort study involved 247 patients with cardiac disease aged ≥65 years. HAFD was defined as a decrease in the short physical performance battery at hospital discharge compared with before surgery. Primary outcomes included a composite outcome of frailty severity, total mortality, and cardiovascular readmission 1-year post-hospital discharge. Secondary outcomes were changes in the total score and sub-item scores in the Ki-hon Checklist (KCL), assessed pre- and 1-year postoperatively. Poor prognostic outcomes were observed in 33% of patients, and multivariate analysis identified HAFD (odds ratio [OR] 3.43, 95% confidence interval [CI] 1.75–6.72, p < 0.001) and low preoperative gait speed (OR 2.47, 95% CI 1.18–5.17, p = 0.016) as independent predictors of poor prognosis. Patients with HAFD had significantly worse total KCL scores and subscale scores for instrumental activities of daily living, mobility, oral function, and depression at 1-year post-hospital discharge. HAFD is a powerful predictor of prognosis in older patients who have undergone cardiac surgery.

Usefulness of the 2-year iodine-123 metaiodobenzylguanidine-based risk model for post-discharge risk stratification of patients with acute decompensated heart failure

PURPOSE

A four-parameter risk model that included cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters was recently developed for prediction of 2-year cardiac mortality risk in patients with chronic heart failure. We sought to validate the ability of this risk model to predict post-discharge clinical outcomes in patients with acute decompensated heart failure (ADHF) and to compare its prognostic value with that of the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores.

METHODS

We studied 407 consecutive patients who were admitted for ADHF and survived to discharge, with definitive 2-year outcomes (death or survival). Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk was calculated using four parameters, namely age, left ventricular ejection fraction, New York Heart Association functional class, and cardiac MIBG heart-to-mediastinum ratio on delayed images. Patients were stratified into three groups based on the 2-year cardiac mortality risk: low- (< 4%), intermediate- (4-12%), and high-risk (> 12%) groups. The ADHERE and GWTG-HF risk scores were also calculated.

RESULTS

There was a significant difference in the incidence of cardiac death among the three groups stratified using the 2-year cardiac mortality risk model (p < 0.0001). The 2-year cardiac mortality risk model had a higher C-statistic (0.732) for the prediction of cardiac mortality than the ADHERE and GWTG-HF risk scores.

CONCLUSION

The 2-year MIBG-based cardiac mortality risk model is useful for predicting post-discharge clinical outcomes in patients with ADHF.

TRIAL REGISTRATION NUMBER

UMIN000015246, 25 September 2014.

Cardiac rehabilitation for older adults: current evidence and future potential

INTRODUCTION

Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes.

AREAS COVERED

Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g. multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management.

EXPERT OPINION

Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.

Cardiac rehabilitation following coronary artery dissection: recommendations and patient considerations

INTRODUCTION

: Cardiac rehabilitation (CR) is a multidisciplinary intervention for secondary prevention, improving functional capacity, enhancing quality of life, and improving psychosocial wellbeing in broad range of cardiovascular disease. It has been well studied over a number of years and is a Class I recommendation in multiple guidelines. However, there is a paucity of data regarding the usefulness of CR in patients with spontaneous coronary artery dissection (SCAD).

AREAS COVERED

: This narrative review aims to give an overview of the evidence underpinning CR as well as the pathophysiological mechanisms of SCAD and how they relate to exercise and shear stress. Furthermore, the evidence of the usefulness of CR in the SCAD population will be reviewed.

EXPERT OPINION

: Traditional CR programs are safe and effective in SCAD cohorts, however SCAD specific CR (SCAD-CR) has significant benefits including reductions in MACE. The principles of SCAD-CR should be applied to any CR for SCAD patients for optimal outcomes and minimization of harm.

Barthel Index Score Predicts Mortality in Elderly Heart Failure - A Goal of Comprehensive Cardiac Rehabilitation

BACKGROUND

A strategy to predict mortality in elderly heart failure (HF) patients has not been established.

METHODS AND RESULTS

We retrospectively enrolled 413 HF patients aged ≥65 years (mean age 78 years) who had received comprehensive cardiac rehabilitation (CR) during hospitalization. Basic activities of daily life were assessed before discharge using the Barthel index (BI). Of 413 HF patients, 116 (28%) died during a median follow-up period of 1.90 years (interquartile range 1.20-3.23 years). An adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increased in an almost linear manner as the BI score decreased, and that a BI score of 85 corresponded to an HR of 1.0. Kaplan-Meier survival curves showed that the survival rate was lower for patients with a low BI (<85) than for those with a high BI (≥85; 65% vs. 74%, respectively; P=0.007). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjusting for predictors, including B-type natriuretic peptide. Inclusion of the BI into the adjusted model improved the accuracy of the prediction of mortality.

CONCLUSIONS

A BI score <85 at the time of discharge is associated with increased mortality independent of known prognostic markers, and achieving functional status with a BI score ≥85 by comprehensive CR during hospitalization may contribute to favorable outcomes in elderly HF patients.

Effects of Cardiac Rehabilitation With Lumbar-Type Hybrid Assistive Limb on Muscle Strength in Patients With Chronic Heart Failure - A Randomized Controlled Trial

BACKGROUND

Aiming to establish an effective tool in new cardiac rehabilitation programs, we investigated the use of a lumbar-type hybrid assistive limb (HAL) in patients with heart failure (HF) who had difficulty in walking at the usual speed of healthy subjects (≈80 m/min).

METHODS AND RESULTS

We randomly assigned 28 HF patients (age, 73.1±13.8 years) to perform a sit-to-stand exercise with or without HAL. The sit-to-stand exercise was repeated as many times as possible as cardiac rehabilitation therapy over a period of 6-10 days. We measured 5 parameters before and after the completion of cardiac rehabilitation: B-type natriuretic peptide, Short Physical Performance Battery (SPPB), 6-min walking distance (6MWD), 30-s chair-stand test (CS-30), and isometric knee extensor muscle strength. The SPPB and 6MWD were significantly improved, and the CS-30 score was somewhat improved, after the exercise therapy in both the HAL and non-HAL groups. The knee extensor muscle strength improved significantly in the HAL group (0.29±0.11 to 0.35±0.11 kgf/kg, P<0.01), but showed no change in the non-HAL group (0.35±0.11 to 0.35±0.13 kgf/kg, P=0.40).

CONCLUSIONS

The improved knee extensor muscle strength in the HAL group suggests that the lumbar-type HAL may be an effective tool for cardiac rehabilitation in HF patients with frailty, which is a predictor of poor prognosis in HF.

Prevention and Reversal of Frailty in Heart Failure - A Systematic Review

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.

Relationship between high-sensitivity cardiac troponin T, B-type natriuretic peptide, and physical function in patients with heart failure

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.

Current conditions and significance of outpatient cardiac rehabilitation and home nursing-care services in heart failure patients with mid-range or preserved ejection fraction: post-hoc analysis of the REAL-HF registry

The effects of outpatient cardiac rehabilitation (OCR) implementation and home nursing-care services (HNS) use are not well defined in patients with heart failure (HF) with mid-range or preserved left-ventricular ejection fraction (EF) (HFmrEF or HFpEF). Through a post-hoc analysis of the HF registry in Hiroshima Prefecture of Japan (REAL-HF), we investigated the current conditions and significance of OCR and HNS in HFmrEF or HFpEF patients. The REAL-HF enrolled adult patients hospitalized with HF in eight regional core hospitals. Patients discharged home were followed for conditions of OCR and HNS and the primary endpoints (all-cause death or unscheduled readmission) for 1 year. The patients were classified into HF with reduced EF (< 40%) (HFrEF) or HFmrEF (40% ≤ EF < 50%) or HFpEF (EF ≥ 50%) group. We followed 195 HFrEF and 381 HFmrEF or HFpEF patients. OCR was generally underutilized, especially in HFmrEF or HFpEF patients (rate of completion [5-month program], 3.2%), whereas HFmrEF or HFpEF patients were more likely to use HNS after discharge home than HFrEF patients (44.1% vs. 27.2%, P < 0.0001). Patients with the use of HNS generally had lower scores of Mini-Mental State Examination and EuroQol 5 dimensions than those without. Multivariate analysis adjusted for medical and social factors showed that the completion of OCR was a strong negative predictor of the primary endpoints both in HFrEF (hazard ratio [HR] 0.10; 95% confidence interval [CI] 0.01-0.75; P = 0.025) and HFmrEF or HFpEF (HR 0.11; 95% CI 0.01-0.78; P = 0.028) patients, whereas the use of HNS was a positive predictor only in HFmrEF or HFpEF patients (HR 1.41; 95% CI 1.00-1.97; P = 0.047). In conclusion, continuous OCR, despite its inadequate implementation, was associated with favorable overall outcomes, while the necessity for HNS related to impaired cognitive function and quality of life was associated with poorer overall outcomes in HFmrEF or HFpEF patients discharged home. Further study is warranted to fully consider the factors related to OCR implementation and HNS use.

Left Atrial Myopathy in Heart Failure With Preserved Ejection Fraction

The left atrium (LA) plays an important role in facilitating left ventricular (LV) filling by acting as a reservoir, passive conduit, and active booster pump, as well as a regulator of blood volume through A-type natriuretic peptide secretion in response to stimulation by mechanical stretch of the cavity. LA myopathy has emerged as one of the most important non-LV contributors to disease progression in heart failure with preserved ejection fraction (HFpEF). LA dysfunction is common in HFpEF and is associated with more severe pulmonary vascular disease and right ventricular dysfunction, and increases the risk of incident atrial fibrillation or atrial functional mitral regurgitation, leading to limitations in cardiac output reserve and reduced exercise capacity. LA deformation assessed by 2-dimensional speckle-tracking echocardiography is useful for estimating abnormal hemodynamics or exercise capacity, discriminating HFpEF from non-cardiac dyspnea and is an independent predictor of adverse outcome in HFpEF. Thus, interventions directly targeting LA myopathy may improve outcomes in HFpEF with LA myopathy. This review provides information regarding the physiology of the LA in patients with HFpEF and discusses the importance of evaluation of LA function, management issues, and future directions through ongoing trials of medical interventions.

Prevalence and impact of fracture on postmenopausal women with aortic stenosis who underwent transcatheter aortic valve replacement

Information regarding fracture in patients with transcatheter aortic valve replacement (TAVR) is limited. We investigated the prevalence and impact of fracture in patients with severe aortic stenosis who had undergone TAVR. Of 913 consecutive patients with symptomatic, severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute between October 2013 and April 2020, 633 women were enrolled. The primary endpoint was all-cause mortality following TAVR. Patients with a history of fracture displayed smaller body mass indices, increased frailty, a higher prevalence of osteoporosis, and stroke history. Notably, 61.7% of patients with a history of fracture reported to have not taken any osteoporosis medications. Estimated all-cause mortality survival rates post-TAVR were significantly lower in patients with fractures than those without fractures. In the multivariate analysis, history of fracture was independently associated with all-cause mortality following TAVR. Furthermore, fracture prevalence was significantly greater in those who had a higher clinical frailty scale score were slower in the 5-m walk test, had more severe dementia as per the revised Hasegawa dementia scale, and performed poorly in the hand grip strength test. History of fracture was an independent predictor for all-cause mortality in patients undergoing TAVR. In addition, our study demonstrated that osteoporotic fracture may be under-treated in this population. History of fracture may be one of the phenotypes of frailty given its significant relationship with frailty markers in this population.

Review of Recent Cardiac Rehabilitation Research Related to Enrollment/Adherence, Mental Health, and Other Populations

This review overviews three topic areas observed to be highly active in the cardiac rehabilitation (CR) research literature published in 2019 and 2020. Topics summarized were enrollment or adherence in CR programs; mental health, particularly depression, stress, and anxiety of patients participating in CR programs; and patients participating in CR programs with diagnoses other than coronary artery bypass graft, myocardial infarction, or percutaneous coronary interventions.

Association between Big Five Personality Traits and Participation in Cardiac Rehabilitation in Japanese Patients with Cardiovascular Disease: A Retrospective Cohort Study

Cardiac rehabilitation (CR) remains underutilised, despite its established clinical benefit. A personality traits assessment may help promote CR implementation, as they are determinants of health-related behaviour. This study aimed to examine the association between the Big Five personality traits and outpatient CR participation in patients with cardiovascular disease (CVD) after discharge. This retrospective cohort study included 163 patients aged <80 years, who underwent inpatient CR when hospitalised for CVD. The Big Five personality traits (conscientiousness, neuroticism, openness, extraversion, and agreeableness) of each patient were evaluated at discharge, using the Japanese version of the Ten-Item Personality Inventory. We examined the relationship of each personality trait with non-participation in outpatient CR and dropout within three months, using logistic regression analysis. Out of 61 patients who initiated the outpatient CR, 29 patients dropped out, leaving us with 32 subjects. The logistic regression analysis results showed that high conscientiousness was associated with non-participation in CR. The primary reason for this was a lack of motivation. Conversely, low conscientiousness and high openness were predictors of dropout. This study suggests that the assessment of the Big Five personality traits, especially conscientiousness and openness, can help improve health communication with patients to promote outpatient CR participation after discharge.

The Future of Exercise-Based Cardiac Rehabilitation for Patients With Heart Failure

Cardiac rehabilitation (CR) is a comprehensive program that includes exercise training, titration of medical therapy, lifestyle modification, educational support, and psychosocial assessment. All these components are safe and beneficial resulting in significant improvements in quality of life, functional capacity, mortality, and hospital readmission. Current guidelines support its use in a broad spectrum of cardiac disease. This review focuses on exercise-based CR for heart failure (HF) patients in whom CR is a recommended treatment. Exercise should be prescribed according to a personalized approach, optimizing, and tailoring the rehabilitative program to the patient's characteristics. Specific CR programs are dedicated to older patients, those with HF and preserved ejection fraction, and recipients of cardiac implantable electronic devices or left ventricular assistance device. Telemedicine may increase CR participation and overcome some of the barriers that limit its utilization.

Difference in Prognosis between Continuation and Discontinuation of A 5-Month Cardiac Rehabilitation Program in Outpatients with Heart Failure with Preserved Ejection Fraction

Background: Cardiac rehabilitation (CR) is a requisite component of care for patients with heart failure (HF). We aimed to evaluate the clinical outcomes in outpatients with HF with preserved ejection fraction (HFpEF) compared to those in patients with non-HFpEF who did and did not continue a 5-month CR program. Methods: 173 outpatients with HF who participated in a 5-month CR program were registered. We divided them into two groups: HFpEF (n = 84, EF 63 ± 7%) and non-HFpEF (n = 89, EF 31 ± 11%). We further divided the patients into those who continued the CR program (continued group) and those who did not (discontinued group) in the HFpEF and non-HFpEF groups. The clinical outcomes at 5 months were compared among the groups. Results: There were no significant differences in patient characteristics at baseline between the continued and discontinued groups in the HFpEF and non-HFpEF groups except for % diabetes mellitus in the non-HFpEF group. The rates of all-cause death and hospital admissions in the continued group in both the HFpEF and non-HFpEF groups were significantly lower than those in the discontinued group. The all-cause death and hospital admissions in each group were independently associated with the continuation of the CR program. Conclusions: The continuation of a 5-month CR program was associated with the prevention of all-cause death and hospital admissions in both the HFpEF and non-HFpEF groups.

Early cardiac rehabilitation for acute decompensated heart failure safely improves physical function (PEARL study): a randomized controlled trial

BACKGROUND

Improvements in the Short Physical Performance Battery (SPPB) rather than exercise tolerance reportedly lead to favorable prognosis in elderly patients with acute decompensated heart failure (ADHF). However, about 50% of heart failure shows heart failure with preserved ejection fraction, safe and effective interventions to improve SPPB for these types remain unclear. In addition, although a standard cardiac rehabilitation (CR) program for heart failure is widely used in Japan, whether this is sufficient to improve SPPB in elderly patients with ADHF remains unclear.

AIM

This study was to evaluate whether the addition of multidisciplinary physical interventions to the standard CR program would prove effective for improving SPPB among elderly patients with ADHF regardless types of heart failure.

DESING

Randomized, prospective study.

SETTING

Patients admitted to our hospital due to ADHF in Japan.

POPULATION

Elderly patients with ADHF between March 2019 and March 2020 were randomized to two groups, an Intervention group and a Control group.

METHODS

The Control group performed standard CR. The Intervention group received balance training and resistance training and used a cycling ergometer in addition to the standard CR program. The primary outcome was the improvement in SPPB after CR.

RESULTS

Seventy-five patients with ADHF were divided into the two groups (Intervention group, n=36; Control group, n=39). At baseline, both groups showed low physical performance and a high prevalence of frailty. Intervention size effect was an improvement in SPPB score of +2.2 (+3.7±1.1 vs. +1.5±1.7; p<0.001). Of the 3 components of SPPB, both gait speed and timed repeated chair rise were significantly improved in the Intervention group compared to the Control group, with intervention size effect of +0.76 and +0.94, respectively (p<0.001). Subgroup analysis of heart failure with preserved ejection fraction showed significant improvement in SPPB score in the Intervention group compared to the Control group (p<0.001).No adverse events were observed during the study period.

CONCLUSIONS

A multi-faceted intervention in addition to standard CR improved physical performance among elderly patients with ADHF regardless types of heart failure.

CLINICAL REHABILITATION IMPACT

We believe that use of a cycling ergometer and loadspecific resistance training provide specific CR for patients with ADHF during acute hospitalization and highlight the need for active intervention.

Associations between kidney function and outcomes of comprehensive cardiac rehabilitation in patients with heart failure

AIMS

To investigate the impact of baseline kidney function on outcomes following comprehensive cardiac rehabilitation (CR) in patients with heart failure (HF).

METHODS

We reviewed a total of 3,727 patients who were admitted for HF treatment. Estimated glomerular filtration rate (eGFR), quadriceps strength (QS), and 6-min walk distance (6MWD) were measured at hospital discharge as a baseline and 5 months thereafter in participants of outpatient comprehensive CR. The association between outpatient CR participation and all-cause events was evaluated using propensity score-matched analysis in subgroups across eGFR stages. The changes in QS and 6MWD following 5-month CR were compared between eGFR stages.

RESULTS

Out of the studied patients, 1585 (42.5%) participated in outpatient CR. After propensity matching for clinical confounders, 2680 patients were included for analysis (pairs of n = 1340 outpatient CR participants and nonparticipants). The participation in outpatient CR was significantly associated with low clinical events in subgroups of eGFR ≥ 60 [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.51-0.84] and eGFR 45-60 (HR: 0.71, 95% CI: 0.55-0.92), but not in eGFR 30-45 (HR: 0.83, 95% CI: 0.64-1.08) and eGFR < 30 (HR: 0.88, 95% CI: 0.69-1.12). QS and 6MWD were significantly higher after 5-month CR than those at baseline (P < 0.001, respectively), but lower baseline eGFR correlated with lower changes in QS and 6MWD (trend P < 0.001, respectively).

CONCLUSIONS

Although low baseline kidney function attenuates the outcomes of CR, outpatient CR seems to be associated with a better prognosis and positive change in physical function in HF patients with low kidney function.

Characteristics of Elderly Patients with Heart Failure and Impact on Activities of Daily Living: A Registry Report from Super-Aged Society

BACKGROUND

To assess the health care burden of elderly patients with heart failure (HF) in an aging Japanese community-based hospital, we investigated the outcomes of cardiac rehabilitation.

METHODS AND RESULTS

We enrolled all patients with HF aged ≥65 years admitted to 3 hospitals in the Niigata Prefecture. We prospectively collected data on their hospital stays and for 2 years postdischarge. The cohort comprised 617 patients (46.5% men; mean age 84.7 years), 76.2% of whom were aged ≥80 years. Among these patients, 15.6% were nursing home residents, 57.7% required long-term care insurance, only 37.6% could walk unaided at the time of admission, and 70.5% required cardiac rehabilitation; age had no significant rehabilitative effect on the degree of improvement in activities of daily living (ADLs). Two years postdischarge, all-cause mortality, and HF rehospitalization were 41.1% and 38.6%, respectively. The ADL score at discharge was an independent prognostic factor for mortality. The incidence of mortality and rehospitalization was lower in elderly patients with preserved ADLs at discharge.

CONCLUSIONS

Elderly patients with HF in our super-aged society were mainly octogenarians who required disease management and personalized care support. Although their ADL scores increased with comprehensive cardiac rehabilitation, improved scores at discharge were closely associated with prognosis.

Multidomain Frailty in Heart Failure: Current Status and Future Perspectives

PURPOSE OF REVIEW

With a worldwide aging population, frailty and heart failure (HF) have become issues that need to be addressed urgently in cardiovascular clinical practice. In this review, we outline the clinical implications of frailty in HF patients and the potential therapeutic strategies to improve the clinical outcomes of frail patients with HF.

RECENT FINDINGS

Frailty has physical, psychological, and social domains, each of which is a prognostic determinant for patients with HF, and each domain overlaps with the other, although there are no standardized criteria for diagnosing frailty. Frailty can be targeted for treatment with various interventions, and recent studies have suggested that multidisciplinary intervention could be a promising option for frail patients with HF. However, currently, there is limited data, and further research is needed before its clinical implementation. Frailty and HF share a common background and are strongly associated with each other. More comprehensive assessment and therapeutic interventions for frailty need to be developed to further improve the prognosis and quality of life of frail patients with HF.

Current Status and Effect of Outpatient Cardiac Rehabilitation After Percutaneous Coronary Intervention in Japan

Background: Although cardiac rehabilitation (CR) has been reported to be associated with better clinical outcomes in patients with cardiovascular diseases, there are few nationwide studies about CR participation by patients with coronary artery disease in Japan.

Methods and Results: We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan between April 2014 and March 2018. Patients were divided into 2 groups (acute coronary syndrome [ACS] and stable coronary artery disease [sCAD]), and the rates of participation in in- and outpatient CR after percutaneous coronary intervention (PCI) were investigated. Propensity score-matched analysis was performed and the association between outpatient CR participation and all-cause mortality 3 months after PCI was examined. Overall, 616,664 patients (ACS, n=202,853; sCAD, n=413,811) were analyzed. The participation rates of CR increased annually. The participation rate was higher for inpatient than outpatient CR in both the ACS (52% vs. 9%, respectively) and sCAD (15% vs. 3%, respectively) groups. Prognosis was better for patients with than without outpatient CR in both the ACS (hazard ratio [HR] 0.52; 95% confidence interval [CI] 0.47–0.59) and sCAD (HR 0.72; 95% CI 0.65–0.80) groups.

Conclusions: Outpatient CR was associated with a better prognosis in patients with ACS or sCAD. The participation rates of outpatient CR following PCI were extremely low in Japan.

Prevalence and prognostic value of the coexistence of anaemia and frailty in older patients with heart failure

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.