A new physical rehabilitation program for patients with advanced people heart attack (HF) which aimed to improve your exercise capacity before focusing on endurance was successful in a randomized trial of ways that seem to have eluded some previous exercise training studies in the environment. the HF.
Often frail patients following the training regimen, initiated prior to hospital discharge for acute decompensation, worked on skills such as mobility, balance, and strength that were considered necessary if the exercises intended for increase exercise capacity were successful.
A huge percentage stayed with the 12-week program. They benefited from gains in balance, walking ability, and strength, which were followed by significant gains in 6-minute walking distance (6MWD) and measures of physical functioning, fragility, and quality of life. Patients continued the elements of the program at home for up to 6 months.
At that time, death and rehospitalizations did not differ between those assigned to the regimen and similar patients who had not participated in the program, although the trial was not based on clinical events.
Rehabilitation strategy appeared to work in a wide range of subgroups of patients by age, sex, severity of symptoms, ejection fraction, and whether or not they were. obesity or had comorbidities such as ischemic cardiopathy, diabetes o chronic kidney disease.
There was also evidence that benefits were more pronounced in patients with HF and conserved ejection fraction (HFpEF) compared with those with HF and reduced ejection fraction (HFrEF), observed Dalane W. Kitzman, MD, Wake Forest School of Medicine, Winston-. Salem, North Carolina.
Kitzman presented the results of the REHAB-HF Essay (Rehabilitation Therapy in Older Acute Heart Failure Patients) during the fully virtual scientific session of the American College of Cardiology (ACC) 2021 and is the lead author of the same day publication at the New England Journal of Medicine.
An earlier pilot program unexpectedly demonstrated that these newly hospitalized patients with HF “have significant alterations in mobility and balance,” he explained. “If so, it would be dangerous to subject them to traditional endurance workouts, such as a treadmill on foot or even by bicycle.”
The unusual program, Kitzman said, analyzes these problems before engaging patients in resistance exercises, dealing with mobility, balance, and basic strength, enough to stand up repeatedly from a sitting position, to example. “If you’re not able to stand up to yourself with confidence, you won’t be able to walk on a treadmill.”
This model of exercise rehabilitation, Kitzman said, “is used in geriatric research and allows them to increase endurance safely. By geriatric studies it is known that if you go directly to resistance in these more fragile patients and large, they improve little and often have injuries and falls “.
The functional outcomes examined at REHAB-HF “are the most important for patients,” noted Eileen M. Handberg, PhD, Shands Hospital, University of Florida, Gainesville, in a presentation on the trial for the media. .
“It’s about being able to get out of a chair without help, not fall, walk farther and feel better as opposed to the more traditional outcome measure that has been used in cardiac rehabilitation trials, which has been the test of ‘Treadmill exercise most patients don’t have the ability to do very well anyway, “said Handberg, who is not part of REHAB-HF.
“This opens up rehabilitation, potentially, to the sickest, who also need a better quality of life,” he said.
“I was very impressed that you had 83% adherence to exercise at home for 6 months, which greatly overshadows what we had HF ACTION“Said Vera Bittner, MD, University of Alabama, Birmingham, as a guest speaker after Kitzner’s formal presentation of the trial.” And it certainly overshadows what we see in the typical cardiac rehabilitation program. “
Both Bittner and Kitzner participated in HF-ACTION, a randomized exercise training trial for patients with chronic and stable HFrEF who were almost less ill than those with REHAB-HF.
Of the 349 REHAB-HF patients, those assigned to the program scored significantly higher on the three-component short-term physical performance battery (SPPB) at 12 weeks (8.3 vs. 6.9; Pg <.001), compared to those assigned to a common care approach that, for some, include more conventional cardiac rehabilitation.
The SPPB, validated in trials as an indicator of clinical outcomes, according to Kitzner and colleagues, includes standing balance tests, gait speed for 4 minutes on foot, and strength. The latter is the test that measures the time required to climb from a chair 5 times.
In subgroup analyzes, the intervention was successful against the standard care approach in men and women, at all ages and regardless of ejection fraction; state of symptoms; and whether the patient had diabetes, ischemic heart disease, or atrial fibrillation or he was obese.
Many patients who were invited to participate in the trial were unable to because they lived too far away from the program, Handberg noted.
“It would be nice to see if COVID-19 lessons could be applied to this population,” making distance participation possible, “perhaps using family members as rehabilitation help,” he said.
With the support of research grants from the National Institutes of Health, the Kermit Glenn Phillips II Chair in Cardiovascular Medicine and the Oristano Family Fund of the Wake Forest School of Medicine.
American College of Cardiology (ACC) 2021 Scientific Sessions. Summary 406-09. Filed May 16, 2021.
N Engl J Med. Published online May 16, 2021. Summary