Physical Rehabilitation for Older Patients Hospitalized for Heart Failure

Risk Factors and Cardiovascular Disease in the Elderly

Age is associated with increased cardiovascular risk factors and cardiovascular disease, which constitutes the leading cause of morbidity and mortality in elderly population. In this text we thoroughly review current evidence regarding the impact on cardiovascular disease of the most important cardiovascular risk factors, especially prevalent and common in the elderly population. Diagnosis and treatment approaches are also addressed, also highlighting the importance of adequate primary and secondary prevention and management. Also, the relationship between cardiovascular disease and some comorbidities and geriatric conditions, such as frailty, particularly common in the elderly, is reviewed, together with some other issues, less often addressed but closely related to ageing, such as genetics, structural and electrical heart changes and oxidative stress. All such questions are of great importance in the comprehensive approach of risk factors and cardiovascular disease in the elderly.

Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction

Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.

Digital Technologies to Support Better Outcome and Experience of Care in Patients with Heart Failure

PURPOSE OF REVIEW

In this article, we review a range of digital technologies for possible application in heart failure patients, with a focus on lessons learned. We also discuss a future model of heart failure management, as digital technologies continue to become part of standard care.

RECENT FINDINGS

Digital technologies are increasingly used by healthcare professionals and those living with heart failure to support more personalised and timely shared decision-making, earlier identification of problems, and an improved experience of care. The COVID-19 pandemic has accelerated the acceptability and implementation of a range of digital technologies, including remote monitoring and health tracking, mobile health (wearable technology and smartphone-based applications), and the use of machine learning to augment data interpretation and decision-making. Much has been learned over recent decades on the challenges and opportunities of technology development, including how best to evaluate the impact of digital health interventions on health and healthcare, the human factors involved in implementation and how best to integrate dataflows into the clinical pathway. Supporting patients with heart failure as well as healthcare professionals (both with a broad range of health and digital literacy skills) is crucial to success. Access to digital technologies and the internet remains a challenge for some patients. The aim should be to identify the right technology for the right patient at the right time, in a process of co-design and co-implementation with patients.

Prognostic value of functional capacity after transitional rehabilitation in older patients hospitalized for heart failure

BACKGROUND

Poor functional status is highly prevalent among older patients hospitalized for HF and marks a downward inflection point in functional and prognostic trajectories. We assessed the prognostic value of 6-min walk test after transitional cardiac rehabilitation in older patients hospitalized for heart failure (HF).

METHODS

We studied 759 patients aged ≥60 years who had been transferred to six inpatient rehabilitation facilities (IRF) from acute care hospitals after a hospitalization for acute HF. The primary outcome was 3-year all-cause mortality. We used multivariable Cox analysis to determine the association between 6-min walk distance (6MWD) at discharge from the IRFs and the primary outcome, adjusting for established predictors of death. The optimal cutoff for 6MWD was considered as the one that maximized the chi-square statistic.

RESULTS

Mean age was 75 ± 8 years. 6MWD significantly increased from admission to discharge (145 to 210 m; p < 0.001). The optimal cutoff for 6MWD was 198 m. After full adjustment, the hazard ratio for each 50 m-increase in discharge 6MWD was 0.90 (0.87-0.94; p < 0.001) and that for discharge 6MWD dichotomized at the optimal cutoff 0.48 (0.38-0.60; p < 0.001). The incidence rate of death/100 person-years for the patients who walked >198 m was 13.0 (10.0-15.5) compared with 30.8 (26.9-35.4) for those who walked <198 m. A statistically significant interaction of discharge 6MWD with left ventricular ejection fraction (EF) on the risk of death was observed (p value for interaction 0.047).

CONCLUSIONS

A rehabilitation intervention provided in the critical hospital-to-home transition period to older patients hospitalized for HF resulted in improved functional capacity. Increasing levels of functional capacity following rehabilitation were closely associated with decreasing risk of death; this association was significantly stronger for the subgroup with preserved EF.

Cardiovascular prevention in elderly patients

In recent decades, life expectancy has been increasing significantly. In this scenario, health interventions are necessary to improve prognosis and quality of life of elderly with cardiovascular risk factors and cardiovascular disease. However, the number of elderly patients included in clinical trials is low, thus current clinical practice guidelines do not include specific recommendations. This document aims to review prevention recommendations focused in patients ≥ 75 years with high or very high cardiovascular risk, regarding objectives, medical treatment options and also including physical exercise and their inclusion in cardiac rehabilitation programs. Also, we will show why geriatric syndromes such as frailty, dependence, cognitive impairment, and nutritional status, as well as comorbidities, ought to be considered in this population regarding their important prognostic impact.

Frailty Status Modifies the Efficacy of Exercise Training Among Patients With Chronic Heart Failure and Reduced Ejection Fraction: An Analysis From the HF-ACTION Trial

BACKGROUND

Supervised aerobic exercise training (ET) is recommended for stable outpatients with heart failure (HF) with reduced ejection fraction (HFrEF). Frailty, a syndrome characterized by increased vulnerability and decreased physiologic reserve, is common in patients with HFrEF and associated with a higher risk of adverse outcomes. The effect modification of baseline frailty on the efficacy of aerobic ET in HFrEF is not known.

METHODS

Stable outpatients with HFrEF randomized to aerobic ET versus usual care in the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial were included. Baseline frailty was estimated using the Rockwood frailty index (FI), a deficit accumulation-based model of frailty assessment; participants with FI scores >0.21 were identified as frail. Multivariable Cox proportional hazard models with multiplicative interaction terms (frailty treatment arm) were constructed to evaluate whether frailty modified the treatment effect of aerobic ET on the primary composite end point (all-cause hospitalization and mortality), secondary end points (composite of cardiovascular death or cardiovascular hospitalization, and cardiovascular death or HF hospitalization), and Kansas City Cardiomyopathy Questionnaire score. Separate models were constructed for continuous (FI) and categorical (frail versus not frail) measures of frailty.

RESULTS

Among 2130 study participants (age, 59±13 years; 28% women), 1266 (59%) were characterized as frail (FI>0.21). Baseline frailty burden significantly modified the treatment effect of aerobic ET (P interaction: FI × treatment arm=0.02; frail status [frail versus nonfrail] × treatment arm=0.04) with a lower risk of primary end point in frail (hazard ratio [HR], 0.83 [95% CI, 0.72-0.95]) but not nonfrail (HR, 1.04 [95% CI, 0.87-1.25]) participants. The favorable effect of aerobic ET among frail participants was driven by a significant reduction in the risk of all-cause hospitalization (HR, 0.84 [95% CI, 0.72-0.99]). The treatment effect of aerobic ET on all-cause mortality and other secondary endpoints was not different between frail and nonfrail patients (P interaction>0.1 for each). Aerobic ET was associated with a nominally greater improvement in Kansas City Cardiomyopathy Questionnaire scores at 3 months among frail versus nonfrail participants without a significant treatment interaction by frailty status (P interaction>0.2).

CONCLUSION

Among patients with chronic stable HFrEF, baseline frailty modified the treatment effect of aerobic ET with a greater reduction in the risk of all-cause hospitalization but not mortality.

Opportunità cliniche e impatto sul sistema sanitario di un trattamento ottimale del paziente post-sindrome coronarica acuta

Despite the improvement of revascularization procedures, patients with acute coronary syndrome often develop recurrent ischemic events, suggesting a high residual cardiovascular risk in these patients, which requires a strict clinical monitoring as well as an optimal control of modifiable risk factors.

To this aim, an optimal management of index event and appropriate preventive measures are equally important. Hospital care by cardiologists should be followed by outpatient management by general practitioners, as established by specific diagnostic and therapeutic pathways, which should warrant an optimal support to the patient. A strict collaboration between hospital and primary care is crucial to monitor and adapt drug therapy after the acute event and improve adherence of the patients to prescribed treatments and implementation of life-style modifications, with benefits also in term of cost-effectiveness. In this context, individualized rehabilitation programs should also be offered to patients with acute coronary syndromes, in order to improve survival and quality of life.

Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project)

OBJECTIVE

To determine whether a multicomponent intervention based on physical activity with technological support and nutritional counselling prevents mobility disability in older adults with physical frailty and sarcopenia.

DESIGN

Evaluator blinded, randomised controlled trial.

SETTING

16 clinical sites across 11 European countries, January 2016 to 31 October 2019.

PARTICIPANTS

1519 community dwelling men and women aged 70 years or older with physical frailty and sarcopenia, operationalised as the co-occurrence of low functional status, defined as a short physical performance battery (SPPB) score of 3 to 9, low appendicular lean mass, and ability to independently walk 400 m. 760 participants were randomised to a multicomponent intervention and 759 received education on healthy ageing (controls).

INTERVENTIONS

The multicomponent intervention comprised moderate intensity physical activity twice weekly at a centre and up to four times weekly at home. Actimetry data were used to tailor the intervention. Participants also received personalised nutritional counselling. Control participants received education on healthy ageing once a month. Interventions and follow-up lasted for up to 36 months.

MAIN OUTCOME MEASURES

The primary outcome was mobility disability (inability to independently walk 400 m in <15 minutes). Persistent mobility disability (inability to walk 400 m on two consecutive occasions) and changes from baseline to 24 and 36 months in physical performance, muscle strength, and appendicular lean mass were analysed as pre-planned secondary outcomes. Primary comparisons were conducted in participants with baseline SPPB scores of 3-7 (n=1205). Those with SPPB scores of 8 or 9 (n=314) were analysed separately for exploratory purposes.

RESULTS

Mean age of the 1519 participants (1088 women) was 78.9 (standard deviation 5.8) years. The average follow-up was 26.4 (SD 9.5) months. Among participants with SPPB scores of 3-7, mobility disability occurred in 283/605 (46.8%) assigned to the multicomponent intervention and 316/600 (52.7%) controls (hazard ratio 0.78, 95% confidence interval 0.67 to 0.92; P=0.005). Persistent mobility disability occurred in 127/605 (21.0%) participants assigned to the multicomponent intervention and 150/600 (25.0%) controls (0.79, 0.62 to 1.01; P=0.06). The between group difference in SPPB score was 0.8 points (95% confidence interval 0.5 to 1.1 points; P<0.001) and 1.0 point (95% confidence interval 0.5 to 1.6 points; P<0.001) in favour of the multicomponent intervention at 24 and 36 months, respectively. The decline in handgrip strength at 24 months was smaller in women assigned to the multicomponent intervention than to control (0.9 kg, 95% confidence interval 0.1 to 1.6 kg; P=0.028). Women in the multicomponent intervention arm lost 0.24 kg and 0.49 kg less appendicular lean mass than controls at 24 months (95% confidence interval 0.10 to 0.39 kg; P<0.001) and 36 months (0.26 to 0.73 kg; P<0.001), respectively. Serious adverse events occurred in 237/605 (39.2%) participants assigned to the multicomponent intervention and 216/600 (36.0%) controls (risk ratio 1.09, 95% confidence interval 0.94 to 1.26). In participants with SPPB scores of 8 or 9, mobility disability occurred in 46/155 (29.7%) in the multicomponent intervention and 38/159 (23.9%) controls (hazard ratio 1.25, 95% confidence interval 0.79 to 1.95; P=0.34).

CONCLUSIONS

A multicomponent intervention was associated with a reduction in the incidence of mobility disability in older adults with physical frailty and sarcopenia and SPPB scores of 3-7. Physical frailty and sarcopenia may be targeted to preserve mobility in vulnerable older people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02582138.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Mobility Status Plays an Important Role in the Risk of Cardiovascular Rehospitalizations in Patients with Heart Failure Undergoing Cardiac Rehabilitation: A Retrospective Cohort Study

The aim of this study was to investigate the association between mobility status and cardiovascular rehospitalizations in patients with heart failure undergoing cardiac rehabilitation. This retrospective cohort study included patients with heart failure undergoing cardiac rehabilitation. Mobility status was evaluated using functional ambulation categories (FAC), and each cardiovascular hospitalization was recorded by the case manager. A Poisson regression model was used to analyze the association between mobility status and cardiovascular rehospitalizations. This study included 154 patients with heart failure undergoing cardiac rehabilitation. For cardiovascular rehospitalizations within 6 months, the Poisson regression model reported that the impaired mobility group had a higher risk than the fair mobility group (incidence rate ratio (IRR) = 2.38, 95% CI 1.27-4.46, p = 0.007). For cardiovascular rehospitalizations within 12 months, the Poisson regression model also reported that the impaired mobility group had a higher risk than the fair mobility group (IRR = 1.91, 95% CI 1.16-3.13, p = 0.010). Other covariates, such as LVEF, peak oxygen consumption, and PAOD, could have impacted the risk of cardiovascular rehospitalizations. Among patients with heart failure undergoing cardiac rehabilitation, the impaired mobility group had a twofold risk of cardiovascular rehospitalizations, compared with the fair mobility group within both 6 and 12 months.

Outcomes With Multidisciplinary Cardiac Rehabilitation in Post-acute Systolic Heart Failure Patients-A Retrospective Propensity Score-Matched Study

Background

Cardiac rehabilitation (CR) is recommended for patients with acute heart failure (HF). However, the results of outcome studies and meta-analyses on CR in post-acute care are varied. We aimed to assess the medium- to long-term impact of CR and ascertain the predictors of successful CR.

Methods

In this propensity score-matched retrospective cohort study, records of consecutive patients who survived acute HF (left ventricular ejection fraction <40) and participated in a multidisciplinary HF rehabilitation program post-discharge between May 2014 and July 2019 were reviewed. Patients in the CR group had at least one exercise session within 3 months of discharge; the others were in the non-CR group. After propensity score matching, the primary (all-cause mortality) and secondary (HF readmission and life quality assessment) outcomes were analyzed.

Results

Among 792 patients, 142 attended at least one session of phase II CR. After propensity score matching for covariates related to HF prognosis, 518 patients were included in the study (CR group, 137 patients). The all-cause mortality rate was 24.9% and the HF rehospitalization rate was 34.6% in the median 3.04-year follow-up. Cox proportional hazard analysis revealed that the CR group had a significant reduction in all-cause mortality compared to the non-CR group (hazard ratio [HR]: 0.490, 95% confidence interval [CI]: 0.308-0.778). A lower risk of the primary outcome with CR was observed in patients on renin-angiotensin-aldosterone system (RAAS) inhibitors, but was not seen in patients who were not prescribed this class of medications (interaction p = 0.014).

Conclusions

Cardiac rehabilitation participation was associated with reduced all-cause mortality after acute systolic heart failure hospital discharge. Our finding that the benefit of CR was decreased in patients not prescribed RAAS inhibitors warrants further evaluation.

Discharge disposition and 1-year readmission in acute-phase hospitalized patients with heart failure: a retrospective observational multi-center study

Patients hospitalized for acute heart failure (HF) tend to experience declines in physical function and activities of daily living (ADL) due to bed rest and restricted mobilization. This could result in some patients being transferred to rehabilitation hospitals. This study aims to examine the relationship between discharge disposition and 1-year readmission and mortality rates in HF patients. Nine hundred fifty six consecutive HF patients who were hospitalized for acute decompensated HF and underwent rehabilitation were divided into two groups: home (returned home) or transfer (transferred to rehabilitative or long-term care hospital units due to decline in physical function and/or ADL) groups. The primary and secondary outcomes were 1-year readmission and mortality rates after discharge, respectively. Of the 956 patients, 8.6% (n = 82) were transferred to rehabilitative or long-term care hospital units. Over a 1-year follow-up period, all-cause and HF readmission rates were 50.1% (n = 479) and 27.2% (n = 260), respectively. The transfer group had significantly lower readmission rates compared to home group after adjusting for the pre-existing risk factors (hazard ratio for all-cause and HF readmission: 0.600 and 0.552, 95% CI 0.401-0.897 and 0.314-0.969; P = 0.013 and P = 0.038, respectively). There was no significant relationship between discharge disposition and all-cause mortality rate. Low ADL defined as Barthel index < 60 points was identified as a predictor of all-cause and HF readmission among the home group (odds ratio for all-cause and HF readmission rates: 2.156 and 1.847, 95% CI 1.026-4.531 and 1.036-2.931; P = 0.043 and P = 0.037, respectively). This multi-center study demonstrated that HF patients transferred to rehabilitative or long-term care hospital units after an acute hospitalization had a significantly decreased 1-year all-cause and HF readmission rates compared to patients who returned to their home. These findings may help in selecting a discharge disposition for older HF patients with ADL decline.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Clinical characteristics and frailty status in heart failure with preserved vs. reduced ejection fraction

Aims

The aim of this study was to elucidate the clinical characteristics, including frailty status, of patients with heart failure with preserved ejection fraction (HFpEF) in comparison with those in patients with heart failure with reduced ejection fraction (HFrEF) in a super‐aged region of Japan.

Methods and results

Of the 1061 Japanese patients enrolled in the Kochi YOSACOI study, a multicentre registry, we divided 645 patients (median age of 81 years [interquartile range, 72–87 years]; women, 49.1%) into two groups, HFpEF patients (61.2%) and HFrEF patients (38.8%). Physical frailty was diagnosed on the basis of the Japanese version of Cardiovascular Health (J‐CHS) Study criteria. Patients for whom left ventricular ejection fraction data were not available (n = 19), patients with heart failure with mildly reduced ejection fraction (n = 172), and patients who were not assessed by the J‐CHS criteria (n = 225) were excluded. The median ages of the HFpEF and HFrEF patients were 84 and 76 years, respectively. The proportion of patients with HFpEF gradually increased with advance of age. The proportion of patients with three or more comorbidities was larger in HFpEF patients than in HFrEF patients (77.9% vs. 65.6%, P = 0.003). Handgrip strength was significantly lower in HFpEF patients than in HFrEF patients for both men (P < 0.001) and women (P = 0.041). Comfortable 5 m walking speed was significantly slower in HFpEF patients than in HFrEF patients (P < 0.001). The proportions of patients with physical frailty were 55.2% in HFpEF patients and 46.8% in HFrEF patients, and the proportion was significantly higher in HFpEF patients (P = 0.043). In multivariate analysis, physical frailty was associated with advanced age [odds ratio (OR), 1.030; 95% confidence interval (CI), 1.010–1.050; P = 0.023] and low albumin level (OR, 0.334; 95% CI, 0.192–0.582; P < 0.001) in HFpEF patients, and physical frailty was associated with women (OR, 2.150; 95% CI, 1.030–4.500; P = 0.042) and anaemia (OR, 2.840; 95% CI, 1.300–6.230; P = 0.003) in HFrEF patients.

Conclusions

In a super‐aged population of HF patients in Japan, HFpEF patients are more likely to be frail/have a high frailty status compared with HFrEF patients. The results suggested that physical frailty is associated with extracardiac factors in both HFpEF patients and HFrEF patients.

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.

Acute-Phase Initiation of Cardiac Rehabilitation for Short-Term Improvement in Activities of Daily Living in Patients Hospitalized for Acute Heart Failure

BACKGROUND

Whether acute-phase cardiac rehabilitation (CR) is beneficial for short-term improvement in activities of daily living (ADL) in patients hospitalized for acute heart failure (AHF) remains unclear.

AIM

To investigate the association of acute-phase initiation of CR with short-term improvement in ADL in patients hospitalized for AHF.

METHODS

We retrospectively analyze data from the Diagnosis Procedure Combination Database, a nationwide inpatient database. Patients hospitalized for HF between January 2010 and March 2018 are included. Propensity score matching and generalized linear models are built to examine the association between improvement in ADL and acute-phase CR initiation, defined as the initiation of CR within two days of admission.

RESULTS

Among 306,826 eligible patients, CR is initiated in 45,428 patients (14.8%) within two days of hospital admission. Propensity score matching creates 45,427 pairs. CR initiation within two days of hospital admission is associated with ADL improvement (risk ratio: 1.018; 95% confidence interval: 1.004-1.032), particularly in elderly patients, females, and individuals with low ADL at admission, body mass index of 18.5-24.9 kg/m2, and New York Heart Association class IV.

CONCLUSIONS

Our analyses highlight the possibility that acute-phase CR initiation may result in short-term improvement in ADL in patients hospitalized for AHF.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

The Efficacy and Safety of Phase I Cardiac Rehabilitation in Patients Hospitalized in Cardiac Intensive Care Unit With Acute Decompensated Heart Failure: A Study Protocol for a Randomized, Controlled, Clinical Trial

Background

Cardiac rehabilitation (CR) improves outcomes in patients with heart failure. However, data on CR efficacy in patients with acute decompensated heart failure is limited. This study is designed to assess the efficacy and safety of CR in patients hospitalized in cardiac intensive care unit (CICU) with acute decompensated heart failure (ADHF).

Methods

This is a single-center, randomized controlled, single-blind clinical trial. A total of 120 participants hospitalized in CICU with ADHF will be randomly allocated in the ratio of 1:1 to two groups: CR group and control group. Participants will receive tailored and progressive CR intervention or attention control. The CR intervention include personalized breathing training, small muscle group resistance training, and aerobic endurance training based on the physical fitness assessment results. The subjects will receive the CR training for 5 days and will be followed up for 6 months. The primary endpoints are the score of the short physical performance battery (SPPB) and 6-month all-cause rehospitalization. The secondary endpoints include cardio-pulmonary function, activities of daily living (ADL), in-hospital mortality rate and 6-month all-cause mortality rate.

Discussion

This randomized, controlled, clinical trial will assess whether CR improves physical function and reduces rehospitalization in patients hospitalized in CICU with ADHF. The results will provide further research-based evidence for the clinical application of CR in patients with ADHF.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100050151. Registered on 19 August 2021.

The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure

BACKGROUND

Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%-80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group.

CONCLUSIONS

A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670.

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.

Exercise training in cardiac rehabilitation: Setting the right intensity for optimal benefit

Cardiac rehabilitation (CR) programs are recommended standard-of-care by all major cardiovascular medicine professional organizations. Exercise training is the cornerstone for CR, with aerobic training being the primary form of training. The benefits of exercise training are multiple; however, improved cardiorespiratory fitness is of utmost importance. Moderate-intensity continuous training, supplemented with resistance training, has traditionally been the most common form of exercise training in CR. This review discusses the role of aerobic exercise training in CR and the importance of effective and personalized exercise prescription for optimized results. We also focus on the benefits and utility of high-intensity interval training across different clinical populations commonly seen in the CR setting.

The year in cardiovascular medicine 2021: heart failure and cardiomyopathies

In the year 2021, the universal definition and classification of heart failure (HF) was published that defines HF as a clinical syndrome with symptoms and/or signs caused by a cardiac abnormality and corroborated by elevated natriuretic peptide levels or objective evidence of cardiogenic congestion. This definition and the classification of HF with reduced ejection fraction (HFrEF), mildly reduced, and HF with preserved ejection fraction (HFpEF) is consistent with the 2021 ESC Guidelines on HF. Among several other new recommendations, these guidelines give a Class I indication for the use of the sodium-glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and empagliflozin in HFrEF patients. As the first evidence-based treatment for HFpEF, in the EMPEROR-Preserved trial, empagliflozin reduced the composite endpoint of cardiovascular death and HF hospitalizations. Several reports in 2021 have provided novel and detailed analyses of device and medical therapy in HF, especially regarding sacubitril/valsartan, SGLT2 inhibitors, mineralocorticoid receptor antagonists, ferric carboxymaltose, soluble guanylate cyclase activators, and cardiac myosin activators. In patients hospitalized with COVID-19, acute HF and myocardial injury is quite frequent, whereas myocarditis and long-term damage to the heart are rather uncommon.

Sex differences in the prevalence and prognostic impact of physical frailty and sarcopenia among older patients with heart failure

BACKGROUND AND AIMS

Frailty and sarcopenia are common and confer poor prognosis in elderly patients with heart failure; however, gender differences in its prevalence or prognostic impact remain unclear.

METHODS AND RESULTS

We included 1332 patients aged ≥65 years, who were hospitalized for heart failure. Frailty and sarcopenia were defined using the Fried phenotype model and Asian Working Group for Sarcopenia criteria, respectively. Gender differences in frailty and sarcopenia, and interactions between sex and prognostic impact of frailty/sarcopenia on 1-year mortality were evaluated. Overall, 53.9% men and 61.0% women and 23.7% men and 14.0% women had frailty and sarcopenia, respectively. Although sarcopenia was more prevalent in men, no gender differences existed in frailty after adjusting for age. On Kaplan-Meier analysis, frailty and sarcopenia were significantly associated with 1-year mortality in both sexes. On Cox proportional hazard analysis, frailty was associated with 1-year mortality only in men, after adjusting for confounding factors (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.19-3.16; P = 0.008 for men; HR, 1.63; 95% CI, 0.84-3.13; P = 0.147 for women); sarcopenia was an independent prognostic factor in both sexes (HR, 1.93; 95% CI, 1.13-3.31; P = 0.017 for men; HR, 3.18; 95% CI, 1.59-5.64; P = 0.001 for women). There were no interactions between sex and prognostic impact of frailty/sarcopenia (P = 0.806 for frailty; P = 0.254 for sarcopenia).

CONCLUSIONS

Frailty and sarcopenia negatively affect older patients with heart failure from both sexes.

CLINICAL TRIALS

This study was registered at the University Hospital Information Network (UMIN-CTR, unique identifier: UMIN000023929) before the first patient was enrolled.

The need for long-term personalized management of frail CVD patients by rehabilitation and telemonitoring: a framework

Due to advances in cardiovascular medicine and preventive cardiology, patients benefit from a better prognosis, even in case of significant disease burden such as acute and chronic coronary syndromes, advanced valvular heart disease and chronic heart failure. These advances have allowed CVD patients to increase their life expectancy, but on the other hand also experience aging-related syndromes such as frailty. Despite being underrecognized, frailty is a critical, common, and co-existent condition among older CVD patients, leading to exercise intolerance and compromised adherence to cardiovascular rehabilitation. Moreover, frail patients need a different approach for CR and are at very high risk for adverse events, but yet are underrepresented in conventional CR. Fortunately, recent advances have been made in technology, allowing remote monitoring, coaching and supervision of CVD patients in secondary prevention programs with promising benefits. Similarly, we hypothesized that such programs should also be implemented to treat frailty in CVD patients. However, considering frail patients' particular needs and challenges, telerehabilitation interventions should thus be appropriately adapted. Our purpose is to provide, for the first time and based on expert opinions, a framework of how such a cardiac telerehabilitation program could be developed and implemented to manage a prevention and rehabilitation program for CVD patients with frailty.

The Impact of Cardiac Rehabilitation on Activities of Daily Life in Elderly Patients With Heart Failure

Background: In elderly chronic heart failure (HF) patients, activities of daily living (ADLs) require the use of a high proportion of patients’ peak aerobic capacity, heart rate, and ventilation.

Objectives: To assess the effects of short-term comprehensive cardiac rehabilitation (CR) on the metabolic requirement of ADLs in elderly patients with chronic HF.

Methods: The study population comprised 99 elderly chronic HF patients (mean age 72 ± 5 years, 80% male, 61% ejection fraction <40%, mean NT-proBNP 2,559 ± 4,511 pg/ml) participating in a short-term (mean days 19 ± 7) residential CR program. Before and after CR, participants, while wearing a portable ergospirometer, performed a standardized ADL battery: ADL1 (getting dressed), ADL2 (folding 8 towels), ADL3 (putting away 6 bottles), ADL4 (making a bed), ADL5 (sweeping the floor for 4 min), ADL6 (climbing 1 flight of stairs carrying a 1.5 Kg load), and ADL7 (a standard 6-min walking test).

Results: After CR, task-related oxygen uptake did not change in any of the domestic ADLs. Notably, there was a significant decrease in the cumulative time required to perform ADLs (ADL 1–4 and ADL6; from 412 ± 147 to 388 ± 141 s, p = 0.001) and a reduction in maximal heart rate in ADL1 and 3 (p = 0.005 and p = 0.027, respectively). Changes occurred in the 6MWT with an increase in oxygen uptake (p = 0.005) and in the distance covered (p < 0.001) and a significant decrease in the Borg scale of dyspnea (p = 0.004).

Conclusion: Elderly patients with chronic heart failure who are engaged in a short-term residential CR program improve the performance of routine ADLs.

Medical management of acute heart failure

Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.

Cardiac rehabilitation - The answer for the second chance

In the United States and worldwide, the leading cause of death in females is cardiovascular disease (CVD). However, compared to males, females have overall higher mortality rates, especially within the first few years of having an acute myocardial infarction (AMI). Despite the increased awareness of CVD in females and established benefits of cardiac rehabilitation (CR) programs, there is still delayed initiation of care, under-recognition of atypical presentations of angina in females, under referral of females to CR, and under-representation of females in CVD trials. In this paper, we will investigate the barriers to female participation in CR, explore the fundamental differences in physiology between males and females, and current limitations in CVD trials where females are under-represented. Finally, we aim to provide potential methods to increase enrollment of females in CR and CR related trials.

Cardiac rehabilitation in older adults: Apropos yet significantly underutilized

Cardiac Rehabilitation (CR) is a comprehensive disease management program that utilizes exercise training, behavioral modification, education, and psychosocial counseling to optimize outcomes and functionality in patients with cardiovascular disease (CVD)1). While CR was initially designed as an exercise training and fitness program for younger patients, usually men, after debilitating hospitalizations for myocardial infarction or cardiac surgery, evidence has expanded to also include other types of CVD in women as well as men, including heart failure, valvular disease, and peripheral arterial disease2-4). As the population of older adults continues to expand, age-related CVD is endemic and is commonly associated with exercise decline, diminished quality of life, and dependence. CR has the potential to counterbalance these patterns, and therefore stands out as a particularly important consideration for older adults with CVD. Nevertheless, CR remains highly underutilized5,6). Novel approaches to CR including home-based and hybrid CR programs show promise for enhanced outreach to patients who may not otherwise participate. This review summarizes the current data available regarding CR in older adults with CVD with a focus on geriatric-specific complexities, current barriers to utilization, and approaches to enhance participation and effectiveness.

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.

Physical Rehabilitation in Older Patients Hospitalized with Acute Heart Failure and Diabetes: Insights from REHAB-HF

BACKGROUND

Prior studies showed an attenuated response to exercise training among patients with heart failure and type 2 diabetes mellitus. We explored the interaction between diabetes status and a novel, transitional, tailored, progressive rehabilitation intervention that improved physical function compared with usual care in the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial.

METHODS

The effect of the intervention on 3-month Short Physical Performance Battery (SPPB) (primary endpoint), 6-minute walk distance (6MWD), modified Fried frailty criteria, and quality-of-life scores (Kansas City Cardiomyopathy Questionnaire [KCCQ] and EuroQoL Visual Analogue Scale [VAS]) was compared between participants with and without diabetes. Differences in 6-month clinical outcomes were also explored.

RESULTS

Of the 349 participants enrolled in REHAB-HF, 186 (53%) had diabetes. The prevalence of diabetes was higher in the intervention group (59% vs 48%). Participants with diabetes had worse baseline physical function by the SPPB and 6MWD, but similar frailty and quality-of-life scores. There was a consistent improvement with the intervention for 3-month SPPB, 6MWD, and VAS regardless of diabetes status (all interaction P value > .6), but participants with diabetes had significantly less improvement for frailty (P = .021) and a trend toward lower improvement in KCCQ (P = .11). There was no significant interaction by diabetes status for 6-month clinical event outcomes (all interaction P value > .3).

CONCLUSIONS

Participants with diabetes had worse baseline physical function but showed similar clinically meaningful improvements from the intervention. There was less benefit for frailty with the intervention in participants with diabetes.

A Stepwise Guide to the Diagnosis and Treatment of Heart Failure with Preserved Ejection Fraction

Heart failure with a preserved ejection fraction (HFpEF) is a growing epidemic owing to an increasingly obese and aging patient population. Making the diagnosis of HFpEF is often challenging as patients frequently have multiple co-morbidities and alternative reasons for exercise intolerance that is hallmark to the disease. Additionally, a universal diagnostic algorithm and definition of HFpEF is lacking. The treatment of HFpEF is equally challenging as there has been significant difficulty in identifying therapies to improve survival in HFpEF, and management to date requires intensive optimization of HFpEF risk factors. In this review, we highlight a stepwise approach to the diagnosis and management of HFpEF inclusive of 1) how to establish a clinical diagnosis of HFpEF, 2) when to refer for invasive testing, 3) treatment of HFpEF including pharmacologic, non-pharmacologic, and risk factor modification interventions, and 4) when to refer to a dedicated HFpEF center or advanced heart failure specialist. With this systematic stepwise approach to HFpEF management, we aim to improve accurate diagnosis of the disease as well as raise awareness of all available therapeutic options for this challenging patient population. Heart failure with preserved ejection fraction (HFpEF) is becoming increasingly common due to our aging patient population with a higher prevalence of hypertension, diabetes, and obesity. Accurate diagnosis is important, particularly to ensure that an alternative heart failure diagnosis is not missed. We highlight a stepwise approach to the diagnosis of HFpEF, including when to pursue exercise or invasive hemodynamic testing. We also discuss pertinent treatment options by both medication class and co-morbidity status.

Exercise: a molecular tool to boost muscle growth and mitochondrial performance in heart failure?

Impaired exercise capacity is the key symptom of heart failure (HF) and is associated with reduced quality of life and higher mortality rates. Unfortunately, current therapies, although generally lifesaving, have only small or marginal effects on exercise capacity. Specific strategies to alleviate exercise intolerance may improve quality of life, while possibly improving prognosis as well. There is overwhelming evidence that physical exercise improves performance in cardiac and skeletal muscles in health and disease. Unravelling the mechanistic underpinnings of exercise‐induced improvements in muscle function could provide targets that will allow us to boost exercise performance in HF. With the current review we discuss: (i) recently discovered signalling pathways that govern physiological muscle growth as well as mitochondrial quality control mechanisms that underlie metabolic adaptations to exercise; (ii) the mechanistic underpinnings of exercise intolerance in HF and the benefits of exercise in HF patients on molecular, functional and prognostic levels; and (iii) potential molecular therapeutics to improve exercise performance in HF. We propose that novel molecular therapies to boost adaptive muscle growth and mitochondrial quality control in HF should always be combined with some form of exercise training.

Hybrid cardiac rehabilitation - The state of the science and the way forward

Cardiac rehabilitation (CR) improves exercise capacity and health-related quality of life (HRQoL) in a broad range of patients, including those with coronary artery disease, heart failure (HF), after heart valve surgery, and after heart transplantation. Unfortunately, in traditional center-based CR programs participation and adherence are low. A hybrid model of CR, combining center-based and home-based CR services, has been proposed and is currently being studied as a potential way to help bridge the participation gap, while maintaining the beneficial patient outcomes from CR. However, the ideal composition of a hybrid CR program has not been universally agreed upon. In the present review, we define hybrid CR as any combination of supervised center-based and monitored home-based exercise, where at least two of the core components of CR are addressed. Using this definition, we searched for studies comparing hybrid CR with: (1) traditional center-based CR among CAD patients, (2) usual care among CAD patients, and (3) usual care among HF patients. We found nine studies which fit both our definition and comparison groups. The structure of the hybrid CR programs differed for each study, but typically began with a center-based component lasting 2-11 weeks and transitioned to a home-based component lasting 10-22 weeks, with 3-5 exercise sessions per week composed of either walking (usually with a treadmill) or cycling for 25-35 min at 60-75% maximal heart rate. Patients recorded data from home exercise sessions, via either a digital heart rate monitor or accelerometer, into logbooks which were reviewed by a therapist at specified intervals (often via telephone). Counseling on risk factor management was predominantly provided during the center-based component. In these studies, hybrid CR led to similar short-term outcomes compared to traditional CR in patients with coronary artery disease (CAD), as well as increased adherence and reduced delivery costs. Compared with usual care, in patients with CAD, hybrid CR reduced cardiovascular events, and improved lipid profiles, exercise capacity, and HRQoL. In patients with HF, compared with usual care, hybrid CR improved physical function, exercise capacity, and HRQoL. Ongoing studies may clarify the combination of center-based and home-based CR which produces superior outcomes, and may also better define the role that technology should play in CR interventions.

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.

Malnutrition and Frailty Are Critical Determinants of 6-Month Outcome in Hospitalized Elderly Patients With Heart Failure Harboring Surgically Untreated Functional Mitral Regurgitation

Background: Hospitalized patients with acute decompensated heart failure (ADHF) frequently exhibit aggravating mitral regurgitation (MR). Those patients do not always undergo surgical mitral valve repair, but particularly in the elderly, they are often treated by conservative medical therapy. This study was aimed to investigate factors affecting 6-month outcomes in hospitalized patients with heart failure (HF) harboring surgically untreated MR.

Methods: We screened the presence of MR in hospitalized patients with HF between September 2017 and May 2020 in the Yamaguchi Prefectural Grand Medical (YPGM) center. At the time of discharge of these patients, individuals with surgically unoperated MR, including primary and secondary origin, were consequently recruited to this single-center prospective cohort study. The patients with severe MR who undergo surgical mitral valve treatment were not included in this study. The primary endpoint was all-cause readmission or all-cause death and the secondary endpoint was HF-related endpoint at 6 months after discharge. The Cox proportional hazard regression analyses were employed to assess the predictors for the composite endpoint.

Results: Overall, 489 patients with ADHF were admitted to the YPGM center. Of those, 146 patients (30% of total patients with HF) (median age 83.5 years, 69 men) were identified as harboring grade II MR or greater. Consequently, all the recruited patients were diagnosed as functional MR. During a median follow-up of 186.0 days, a total of 55 patients (38%) reached the primary or secondary endpoints (HF death and readmission in 31 patients, other in 24 patients). As a result of multivariate analysis, geriatric nutritional risk index [hazard ratio (HR) = 0.932; 95% CI = 0.887–0.979, p = 0.005], age (HR = 1.058; 95% CI = 1.006–1.112, p = 0.027), and left ventricular ejection fraction (HR = 0.971; 95% CI = 0.945–0.997, p = 0.030) were independent predictors of all-cause death or all-cause admission. Body mass index (HR = 0.793; 95% CI = 0.614–0.890, p = 0.001) and ischemic heart disease etiology (HR = 2.732; 95% CI = 1.056–7.067, p = 0.038) were also independent predictors of the HF-related endpoints.

Conclusion: Malnutrition and underweight were substantial predictors of adverse outcomes in elderly patients with HF harboring surgically untreated moderate-to-severe functional MR.

Protocol for a multicentre, prospective observational cohort study in Japan: association among hospital-acquired disability, regular exercise and long-term care dependency in older patients after cardiac surgery

INTRODUCTION

Cardiac surgery for older patients, postoperative functional decline and the need for long-term care have received increasing attention as essential outcomes in recent years. Therefore, prevention of functional decline and long-term care dependency after cardiac surgery are important; however, our current understanding of postoperative functional trajectory and effects of postoperative regular exercise on long-term functional decline and long-term care dependency is limited. Therefore, we will conduct a multicentre, prospective cohort study to (1) examine the effect of hospital-acquired disability on long-term functional decline and long-term care dependency and (2) investigate the favourable effect of postoperative regular exercise on long-term functional decline and long-term care dependency in older patients after cardiac surgery.

METHODS AND ANALYSIS

We designed a prospective, multicentre cohort study to enrol older patients aged≥65 years undergoing elective coronary artery bypass graft or valve surgery. We will conduct medical record reviews to collect data on patient demographics, comorbidities, operative details, progression of in-hospital postoperative cardiac rehabilitation and functional trajectory from a few days before cardiac surgery to the day before hospital discharge. They will be followed up for 2 years to obtain information on their health status including functional status, regular exercise and clinical events by mail. Primary endpoints of this study are long-term functional decline and long-term care dependency after cardiac surgery. Secondary endpoints are readmission due to cardiac events or all-cause mortality.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Department of Physical Therapy, Faculty of Health Science, Juntendo University, and of each collaborating hospital. We obtained written informed consent from all study participants after the description of the study procedures. Publication of the study results is anticipated in 2025.

Common elements of service delivery models that optimise quality of life and health service use among older people with advanced progressive conditions: a tertiary systematic review

INTRODUCTION

Health and social care services worldwide need to support ageing populations to live well with advanced progressive conditions while adapting to functional decline and finitude. We aimed to identify and map common elements of effective geriatric and palliative care services and consider their scalability and generalisability to high, middle and low-income countries.

METHODS

Tertiary systematic review (Cochrane Database of Systematic Reviews, CINAHL, Embase, January 2000-October 2019) of studies in geriatric or palliative care that demonstrated improved quality of life and/or health service use outcomes among older people with advanced progressive conditions. Using frameworks for health system analysis, service elements were identified. We used a staged, iterative process to develop a 'common components' logic model and consulted experts in geriatric or palliative care from high, middle and low-income countries on its scalability.

RESULTS

78 studies (59 geriatric and 19 palliative) spanning all WHO regions were included. Data were available from 17 739 participants. Nearly half the studies recruited patients with heart failure (n=36) and one-third recruited patients with mixed diagnoses (n=26). Common service elements (≥80% of studies) included collaborative working, ongoing assessment, active patient participation, patient/family education and patient self-management. Effective services incorporated patient engagement, patient goal-driven care and the centrality of patient needs. Stakeholders (n=20) emphasised that wider implementation of such services would require access to skilled, multidisciplinary teams with sufficient resource to meet patients' needs. Identified barriers to scalability included the political and societal will to invest in and prioritise palliative and geriatric care for older people, alongside geographical and socioeconomic factors.

CONCLUSION

Our logic model combines elements of effective services to achieve optimal quality of life and health service use among older people with advanced progressive conditions. The model transcends current best practice in geriatric and palliative care and applies across the care continuum, from prevention of functional decline to end-of-life care.

PROSPERO REGISTRATION NUMBER

CRD42020150252.

Real-world experience of feasibility and efficacy of electrical muscle stimulation in elderly patients with acute heart failure: A randomized controlled study

BACKGROUND

Reduced aerobic capacity and deconditioning contributes to morbidity and mortality in elderly acute heart failure (AHF) patients. Electrical muscle stimulation (EMS) has shown to be a suitable alternative to exercise in AHF. However, feasibility and efficacy are unknown in a real-world setting.

METHODS

This is a prospective, open label blinded, randomized, controlled study, investigating feasibility and efficacy of high-intensity versus low-intensity EMS versus controls in elderly AHF patients. Patients and investigators were blinded to the intervention. EMS was offered to > 60 years old AHF patients, initiated during hospitalization and continued at home. Outcome measures included changes in 6-min walking test distance (6-MWTD), functional capacity and quality-of-life at 3 and 6 weeks.

RESULTS

Among 97 consecutive AHF patients (78.1 ± 9.4 years, 42.3% females), 60 (61.9%) were eligible for EMS. Of these, 27 provided written informed consent and were randomly assigned to high-intensity (n = 10), low-intensity EMS (n = 9) and controls (n = 8). 13/27 completed the intervention. Main reason for dropouts was intolerance of the overall intervention burden. MACE occurred in 5 and were not associated with the study. EMS groups showed significant improvement of 6-MWTD (controls vs low-intensity p = 0.018) and of independence in daily living (for both p < 0.05).

CONCLUSIONS

Changes in 6-MWTD suggest efficacy of EMS. Whereas all tolerated EMS well, the burden of study intervention was too high and resulted in a consent rate of <50% and high dropouts, which limit the interpretability of our data. Less demanding EMS protocols are required to evaluate the full potential of EMS in elderly AHF patients.