Exercise for Preventing Hospitalization and Readmission in Adults With Congestive Heart Failure

Omega-3 supplementation and outcomes of heart failure: A systematic review of clinical trials

BACKGROUNDS

Omega-3 supplements are endorsed for heart failure (HF) patients to reduce hospitalizations and mortality, offering anti-inflammatory and cardioprotective benefits.

METHODS

A comprehensive search was conducted in various databases until November 2022. Eligible studies included clinical trials on patients with HF. Data extraction covered study details, omega-3 specifics, outcomes, and limitations. The JADAD scale was used to assess the risk of bias in randomized controlled trials.

RESULTS

The review process involved 572 records from database searches, resulting in 19 studies after eliminating duplicates and screening. These studies assessed the impact of omega-3 on various clinical outcomes, such as mortality, hospitalization, cardiac function, and quality of life. Studied duration varied from weeks to years. Omega-3 supplementation demonstrated potential benefits such as improved heart function, reduced inflammation, and decreased risk of cardiovascular events.

CONCLUSION

Omega-3 supplementation could benefit heart disease treatment, potentially reducing therapy duration and improving outcomes. Starting omega-3 supplementation for HF patients seems favorable.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

Efficacy and Safety of Different Aerobic Exercise Intensities in Patients With Heart Failure With Reduced Ejection Fraction: Design of a Multicenter Randomized Controlled Trial (HF-EI Trial)

Background: Heart failure (HF) is one of the major causes of mortality worldwide, representing the terminal stage of several cardiovascular diseases. Exercise-based rehabilitation is a beneficial therapy for patients with chronic heart failure (CHF). However, there is a lack of specific guidance on clinical decision-making regarding optimal exercise intensity. It is necessary to optimize the clinical recommendations for HF exercises. We will evaluate the efficacy and safety of different aerobic exercise intensities in patients with heart failure with reduced ejection fraction (HFrEF): the HF-EI trial. This trial aims to assess the appropriate exercise intensity for patients with HFrEF.

Methods: After a baseline assessment to determine the safety of exercise, 180 patients will be randomly assigned to supervised high-intensity exercise training (ET) group, supervised moderate intensity training (MIT) group, and control group at a ratio of 1:1:1. Patients randomly receiving high intensity training (HIT) undergo supervised ET (3 times/week, 30 min) for aerobic endurance at 70% peak oxygen consumption (peak VO₂) intensity for 12 weeks. The MIT patients will perform supervised aerobic ET (3 times/week, 35–42 min) at the anaerobic threshold (AT) intensity for 12 weeks. The control group will continue to maintain their daily activities and will not receive ET. During the baseline and follow-up period, physical examination, laboratory tests, cardiology diagnostic tests, cardiopulmonary exercise tests (CPET), 6-min walk distance (6MWD), scale scores, exercise steps, medications, and clinical events will be monitored. Throughout the research, sport bracelets and patient diaries will be used to monitor and record overall physical activity, training courses, and compliance.

Discussion: The HF-EI trial will evaluate the effects of different aerobic exercise intensities on peak VO₂, quality of life (QoL), and clinical events among patients with HFrEF. The findings of this trial will provide a basis for formulating exercise prescriptions for patients with HFrEF.

Clinical Trial Registration:http://www.chictr.org.cn/, identifier: ChiCTR2000036381.

Exercise capacity is associated with hospital readmission among patients with diabetes

INTRODUCTION

Patients with diabetes are at greater risk of hospital readmission than patients without diabetes. There is a need to identify more modifiable risk factors for readmission as potential targets for intervention. Cardiorespiratory fitness is a predictor of morbidity and mortality. The purpose of this study was to examine whether there is an association between exercise capacity based on the maximal workload achieved during treadmill stress testing and readmission among patients with diabetes.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included adult patients with diabetes discharged from an academic medical center between July 1, 2012 and December 31, 2018 who had a stress test documented before the index discharge. Univariate analysis and multinomial multivariable logistic regressions were used to evaluate associations with readmission within 30 days, 6 months, and 1 year of discharge. Exercise capacity was measured as metabolic equivalents (METs).

RESULTS

A total of 580 patients with 1598 hospitalizations were analyzed. Mean METs of readmitted patients were significantly lower than for non-readmitted patients (5.7 (2.6) vs 6.7 (2.6), p<0.001). After adjustment for confounders, a low METs level (<5) was associated with higher odds of readmission within 30 days (OR 5.46 (2.22-13.45), p<0.001), 6 months (OR 2.78 (1.36-5.65), p=0.005), and 1 year (OR 2.16 (1.12-4.16), p=0.022) compared with medium (5-7) and high (>7) METs level. During the 6.5-year study period, patients with low METs had a mean of 3.2±3.6 hospitalizations, while those with high METs had 2.5±2.4 hospitalizations (p=0.007).

CONCLUSIONS

Lower exercise capacity is associated with a higher risk of readmission within 30 days, 6 months, and 1 year, as well as a greater incidence of hospitalization, in patients with diabetes. Future studies are needed to explore whether exercise reduces readmission risk in this population.