Review of Trials on Exercise-Based Rehabilitation Interventions Following Acute Decompensated Heart Failure: OBSERVATIONS FROM THE WHO INTERNATIONAL CLINICAL TRIALS REGISTRY PLATFORM

Effect of Exercise Rehabilitation in Patients With Acute Heart Failure: A Systematic Review and Meta-analysis

BACKGROUND

Exercise rehabilitation is conducive to increasing functional ability and improving health outcomes, but its effectiveness in patients with acute heart failure (AHF) is still controversial.

PURPOSE

In this study, our aim was to systematically examine the efficacy of exercise rehabilitation in people with AHF.

METHODS

A search was conducted for randomized controlled trial studies on exercise rehabilitation in patients with AHF up to November 2021. Two investigators conducted literature selection, quality assessments, and data extractions independently. The primary outcome was 6-minute walk distance, and the secondary outcomes were left ventricular ejection fraction, quality of life, Short Physical Performance Battery, readmission, and mortality. RevMan (version 5.3) software was used for the meta-analysis.

RESULTS

Twelve studies with 1215 participants were included. Exercise rehabilitation significantly improved the 6-minute walk distance (mean difference [MD], 33.04; 95% confidence interval [CI], 31.37-34.70; P < .001; I2 = 0%), quality of life (MD, -11.57; 95% CI, -19.25 to -3.89; P = .003; I2 = 98%), Short Physical Performance Battery (MD, 1.40; 95% CI, 1.36-1.44; P < .001; I2 = 0%), and rate of readmission for any cause (risk ratio, 0.48; 95% CI, 0.26-0.88; P = .02; I2 = 7%), compared with routine care. However, no statistically significant effects on left ventricular ejection fraction (MD, 0.94; 95% CI, -1.62 to 3.51; P = .47; I2 = 0%) and mortality (risk ratio, 1.07; 95% CI, 0.64-1.80; P = .79; I2 = 0%) were observed.

CONCLUSIONS

Compared with routine care, exercise rehabilitation improved functional ability and quality of life, reducing readmission in patients with AHF.

Effects of early mobilisation program on functional capacity, daily living activities, and N-terminal prohormone brain natriuretic peptide in patients hospitalised for acute heart failure. A randomised controlled trial

Background

Patients hospitalised for acute decompensated heart failure (ADHF) show reduced functional capacity, limited activities of daily living (ADL), and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP). The management of these patients focuses mainly on medical therapy with little consideration for in-patient cardiac rehabilitation. There has been a growing interest in evaluating the efficacy of early mobilisation, as the core for in-hospital rehabilitation, in ADHF patients in the last decade; however, the randomised trials on this topic are few.

Objective

This randomised-controlled study, therefore, aimed to further test the hypothesis that early supervised mobilisation would have beneficial effects on functional capacity, ADL, and NT-proBNP in stabilised patients following ADHF.

Methods

This is a single-centered, randomised-controlled, parallel-group trial in which 30 patients hospitalised for ADHF were randomly assigned to two groups; the study group (age = 55 . 4 ± 5 . 46 years, n 1 = 15 ) and the control group (age = 55 . 73 ± 5 . 61 years, n 2 =15). Inclusion criteria were ADHF on top of chronic heart failure independent of etiology or ejection fraction, clinical/hemodynamic stability, age from 40 to 60 years old, and both genders. Exclusion criteria were cardiogenic shock, acute coronary ischemia, or significant arrhythmia. Both groups received the usual medical care, but only the study group received an early structured mobilisation protocol within 3 days of hospital admission till discharge. The outcome measures were the 6-min walk distance (6-MWD) and the rating of perceived exertion (RPE) determined from the 6-min walk test at discharge, the Barthel index (BI), NT-proBNP, and the length of hospital stays (LOS).

Results

The study group showed significantly greater improvements compared to the controls in the 6-MWD (252 . 28 ± 92 . 32 versus 106 . 35 ± 56 . 36 m, P < 0 . 001 ), the RPE (12 . 53 ± 0 . 91 versus 15 . 4 ± 1 . 63 , P < 0 . 001 ), and the LOS (10 . 42 ± 4 . 23 versus 16 . 85 ± 6 . 87 days, p = 0 . 009 ) at discharge. Also, the study group showed significant improvements in the BI compared to baseline [100 (100-100) versus 41.87 (35-55), p = 0 . 009 ] and the controls [100 (100-100) versus 92.5(85-95), p = 0 . 006 ]. The mean value of NT-proBNP showed a significant reduction only compared to baseline (786 . 28 ± 269 . 5 versus 1069 . 03 ± 528 . 87 pg/mL, p = 0 . 04 ) following the intervention. The absolute mean change (Δ ) of NT-proBNP showed an observed difference between groups in favor of the study group (i.e., Δ = ↓ 282 . 75 ± 494 . 13 pg/mL in the study group versus ↓ 26 . 42 ± 222 . 21 pg/mL in the control group, p = 0 . 077 ).

Conclusion

Early structured mobilisation under the supervision of a physiotherapist could be strongly suggested in combination with the usual medical care to help improve the functional capacity and daily living activities, reduce NT-proBNP levels, and shorten the hospital stay in stabilised patients following ADHF. Trial registration number: PACTR202202476383975.

Early Cardiac Rehabilitation to Reduce Heart Failure Readmissions

PURPOSE

This research was conducted to determine whether early participation in cardiac rehabilitation (CR) reduces readmissions following heart failure (HF) hospitalization.

METHODS

A retrospective quasiexperimental comparison group design was used. Electronic medical records were abstracted for HF patients discharged between March 2013 and December 2017. The treatment group was defined as patients with HF who attended ≥1 CR session within 6 wk following discharge. The comparison group was defined as patients with HF without additional HF hospitalizations during the previous year, discharged to home/self-care, and did not attend CR within 6 wk. Readmission rates at 30 d and 6 wk were compared between groups using χ 2 analysis and logistic regression.

RESULTS

Out of 8613 patients with HF, 205 (2.4%) attended ≥1 CR within 6 wk post-discharge. The treatment group had lower, but not statistically significant, readmission rates than the comparison group for 30-d readmissions for HF ( P = .13), and 6-wk readmission rates for HF ( P = .05). The treatment group had lower all-cause readmissions at 30 d (P < .01) and 6 wk ( P < .01) than the comparison group. Multivariable logistic regression revealed that early CR attendance was associated with reduced 30-d all-cause readmissions (adjusted OR = 0.4: 95% CI, 0.2-0.7) and 6-wk all-cause readmissions (adjusted OR = 0.5: 95% CI, 0.3-0.8).

CONCLUSIONS

This study contributes to the existing evidence for allowing early unrestricted CR participation with the aim of improving the health of patients with HF and reducing rehospitalization rates.

The effects of early rehabilitation on functional exercise tolerance in decompensated heart failure patients: Results of a multicenter randomized controlled trial (ERIC-HF study)

Objective

To analyze (1) the effect of an aerobic training program on functional exercise tolerance in decompensated heart failure (DHF) patients; (2) to assess the effects of an aerobic training program on functional independence; and (3) dyspnea during activities of daily living.

Design

A randomized controlled clinical trial with follow-up at discharge.

Settings

Eight hospitals. Recruitment took place between 9/ 2017 and 3/2019.

Group Assignments

Patients with DHF who were admitted to the hospital, were randomly assigned to usual rehabilitation care guideline recommended (control group) or aerobic training program (exercise group).

Main outcome

Functional exercise tolerance was measured with a 6-min walking test at discharge.

Results

In total 257 patients with DHF were included, with a mean age of 67 ± 11 years, 84% (n = 205) had a reduced ejection fraction and the hospital stay was 16 ± 10 days. At discharge, patients in the intervention group walked further compared to the control group (278 ± 117m vs 219 ± 115m, p < 0.01) and this difference stayed significant after correcting for confounders (p < 0.01). A significant difference was found favoring the exercise group in functional independence (96 ± 7 vs 93 ± 12, p = 0.02) and dyspnea associated to ADL (13 ± 5 vs 17 ± 7, p < 0.01) and these differences persisted after correcting for baseline values and confounders (functional independence p < 0.01; dyspnea associated with ADL p = 0.02).

Conclusion

The ERIC-HF program is safe, feasible, and effective in increasing functional exercise tolerance and functional independence in hospitalized patients admitted due to DHF.

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.

Characteristics, outcomes and long-term survival of heart failure patients undergoing inpatient cardiac rehabilitation

OBJECTIVE

To investigate the association of CR participation with all-cause mortality after a hospitalization for HF and to describe the characteristics and functional and clinical outcomes of heart failure (HF) patients undergoing inpatient cardiac rehabilitation (CR).

DESIGN

Multicenter cohort study. The association between CR participation and all-cause mortality from discharge from the acute care setting was assessed using Cox regression analysis adjusting for established prognostic factors.

SETTING

Six inpatients rehabilitation facilities (IRF).

PARTICIPANTS

3,219 HF patients admitted to inpatient CR between January 2013 and December 2016. Of these patients, 1,455 had been transferred directly from acute care hospitals after a hospitalization for HF (CR-Group 1) and 1,764 had been admitted from the community due to worsening functional disability or worsening clinical conditions (CR-Group 2). Six hundred thirty-three patients not referred to CR after a hospitalization for HF served as control group (non-CR Group).

INTERVENTION

Cardiac rehabilitation.

MAIN OUTCOME MEASURE

long-term mortality. Secondary outcomes were: 1. Change in functional capacity, as assessed by change in 6-minute walking distance (6MWD) from admission to discharge; 2. Clinical outcomes of the index inpatient rehabilitation admission, including in-hospital mortality and unplanned (re)admission to the acute care.

RESULTS

Compared with the non-CR Group, the adjusted hazard ratios of mortality at 1, 3, and 5 years for CR-Group 1 patients were 0.82 (0.68-0.97), 0.81 (0.71-0.93), and 0.80 (0.70-0.91). 6MWD increased from 230 to 292 m (p<.001) and 43.4% of the patients gained >50 m improvement. Overall, 2.5% of the patients died in hospital and 4.7% of the patients experienced unplanned (re)admissions to acute care, with significant differences between Group 1 and Group 2.

CONCLUSIONS

Our data show that inpatient CR is effective in improving functional capacity and suggest that inpatient CR provided in the earliest period following a hospitalization for HF is associated with long-term improved survival.