Elderly Patients With Heart Failure May Benefit From Progressive Rehabilitation

A progressive rehabilitation program that evaluated improvements made in strength, balance, mobility, and endurance measures produced superior results among patients randomized to its 36 sessions during or soon after hospitalization for acute decompensated heart failure vs those randomized to usual care, according to the study published in New England Journal of Medicine.

Following electronic review of 27,300 hospital admission records, this multicenter controlled trial investigated the physical functioning improvements among a cohort of 349 patients, randomizing them 1:1, with 175 in the study group (those who participated in the transitional, tailored, progressive program that continued after hospital discharge) and 174 in the usual care group. All patients were enrolled between September 2014 and September 2019, prior to hospital discharge and after screening at admission.

The primary outcome was Short Physical Performance Battery (SPPB) score (range of 0-12), for which 87% of the entire study cohort provided data, and the secondary outcome was 6-month rehospitalization rate for any cause, for which 99% of the entire study cohort provided data. For the SPPB, a lower score means greater physical dysfunction.

“Interventions to address physical frailty in this population are not well established,” the authors wrote. “A key goal was to increase each patient’s endurance.”

Ninety-seven percent of the study and control groups met the criteria for frail or prefrail status per Fried criteria at baseline, and the study group had a mean (SD) of 5.4 (2.0) comorbidities. The most common comorbidities in both groups were hypertension (91%, study group; 93%, control group), hyperlipidemia (63% and 69%, respectively), diabetes (58% and 47%), atrial fibrillation (51% and 50%), and history of coronary revascularization, including percutaneous coronary intervention and coronary artery bypass graft (31% and 27%).

The overall retention rate in the intervention group was 82%, and 67% (78% following adjustment for other medical appointments and illness) attended all 36 rehabilitation sessions, completing a mean (standard error [SE]) of 24.3 (1.0) outpatient sessions.

At the 3-month mark (the outpatient phase), differences were already apparent between the groups. The least squares mean (SE) SPPB score was 8.3 (0.2) in the intervention group compared with 6.9 (0.2) in the usual care group (mean between-group difference, 1.5; 95% CI, 0.9-2.0; P <.001). Both of these numbers were up from 6.0 (2.8) and 6.1 (2.6), respectively, at baseline.

The investigators’ analyses also revealed a doubled mean (SD) endurance from the first (10.7 [5.9] min) to the last session (22.0 [11.1] min) among the intervention group.

In addition, by the 6-month mark (months 4-6 were the maintenance phase of the rehabilitation intervention), fewer hospitalizations for any cause had occurred in the intervention group than in the control group: 1.18 vs 1.28 (rate ratio [RR], 0.93; 95% CI, 0.66-1.19). However, more deaths for any cause were seen in the intervention group vs the control group, and most of these were cardiovascular related: 21 and 15, respectively, vs 16 and 8.

Overall, the mortality rate from any cause was 0.13 in the intervention group and 0.10 in the control group (RR, 1.17; 95% CI, 0.61-2.27).

The mean (SD) age in the intervention group was 73.1 (8.5) years, and in the control group, 72.7 (7.7) years; the mean body mass indices were 32.9 (8.2) and 33.0 (8.9) kg/m², respectively; 57% and 52%, respectively, had New York Heart Association class III disease; and 53% of each group had heart failure with preserved ejection fraction.

The investigators’ analyses also revealed greater mean (SD) improvements among the intervention vs the control group, respectively, from baseline to 3 months in the following measures:

• Balance score: 2.6 (1.3) to 3.2 (0.1) vs 2.7 (1.3) to 2.9 (0.1)
• 4-minute walk score: 2.3 (1.0) to 3.0 (0.1) vs 2.3 (1.0) to 2.5 (0.1)
• Chair rise score: 1.1 (1.2) to 2.1 (0.1) vs 1.2 (1.2) to 1.5 (0.1)
• 6-minute walk distance (meters): 194 (104) to 293 (8) vs 193 (107) to 260 (8)
• Gait speed (m/sec): 0.60 (0.23) to 0.80 (0.02) vs 0.61 (0.22) to 0.68 (0.02)
• Frailty status: 2.3 (1.1) to 1.4 (0.1) vs 2.4 (1.1) to (1.6 (0.1)
• Kansas City Cardiomyopathy Questionnaire score: 40 (21) to 69 (2) vs 42 (21) to 62 (2)
• EQ-5D-5L score: 58 (22) to 71 (2) vs 58 (21) to 65 (2)
• Geriatric Depression Scale-15 score: 4.7 (3.3) to 3.3 (0.2) vs 4.7 (3.4) to 4.1 (0.2)

“Our trial was designed to address several critical evidence gaps regarding physical rehabilitation in patients with heart failure,” the authors wrote. “Physical dysfunction, frailty, and depression are often unrecognized clinically in older patients hospitalized for heart failure.”

Importantly, they added, a marked behavioral change was seen by 6 months, with 83% of patients in the intervention group reporting regular home exercise.

Reference

Kitzman DW, Whellan DJ, Duncan P, et al. Physical rehabilitation for older patients hospitalized for heart failure. N Engl J Med. Published online May 16, 2021. doi:10.1056/NEJMoa2026141