Article

Greater Effect of HF Rehab Intervention Seen Among Frail vs Prefrail Patients

Author(s):

Patients included in this subanalysis of data from the REHAB-HF trial were 60 years and older and had been hospitalized for acute decompensated heart failure.

Worse baseline frailty status did not prevent older patients who had been hospitalized for acute decompensated heart failure (ADHF) from seeing significant improvement in their physical functioning and quality of life (QOL) following a 3-month tailored and multidomain rehabilitation intervention.

Findings were published in JAMA Cardiology from the investigation that compared outcomes between patients with ADHF classified as prefail or as having worse frailty status. The primary outcome was score on the Short Physical Performance Battery (SPPB) at 3 months (scale, 0-12 points, with a score above 10 indicating robustness), and this included all-cause hospitalization and potential mortality rate at 6 months among 337 patients, 57% of whom were considered frail at baseline. The patients in this subanalysis of data from the REHAB-HF trial were also composed of a majority of female patients (53.7%) and Black patients (49.6%). Their mean (SD) age was 72 (8) years.

“Frailty is common among older patients with ADHF and is associated with worse QOL and a higher risk of clinical events,” the study authors wrote. “Frailty can also limit recovery and response to interventions.”

Their primary intervention focused on strength, balance, mobility, and endurance; began during a patient’s hospitalization, if possible; and continued on an outpatient basis 3 days per week for 12 weeks, with each session being 60 minutes. There was also an independent maintenance phase that took place months 4 through 6, with the principal activities being walking and functional strength exercises. The most common comorbidity in the frail and prefrail groups was hypertension, and the most common disease class was New York Heart Association class III in 56% of the prefail cohort and 59% of the frail cohort.

At the 3-month mark, 84.8% of the frail patients and 88.9% of the prefail group were able to supply data to the investigators. Mean (SD) total intervention sessions were equivalent between the groups: 22.3 (12.4) and 23.6 (13.1) sessions, respectively.

Among the frail participants, fewer of those in the intervention arm compared with the control arm had a decline in their SPPB score that exceeded 1 point or more: 12% vs 35% (P = .002). Such a decline was considered substantial, according to the study authors. A stark contrast in this outcome was seen among the participants with prefrail status at baseline. Outcomes were comparable between the intervention and control arms, with 17% and 19%, respectively, having a 1-point or more decline in their SPPB score.

The investigator also saw a significant interaction between baseline frailty status and the treatment arm for overall SPPB score. Among the frail participants, the intervention had a 2.6-fold greater effect compared with the prefrail participants: 2.1 (95% CI, 1.3-2.9) vs 0.8 (95% CI, –0.1 to 1.6; P for interaction = .03).

As a percentage, the relative improvement in SPPB score was 77% (95% CI, 56%-98%) for the frail participants in the intervention arm vs 18% (95% CI, –1.0% to 38.0%; P < .001) for the control arm. The equivalent percentage changes among prefrail participants were 44% (95% CI, 21%-66%) and 21% (95% CI, –12.0% to 53%; P = .21).

In addition, although the trends they saw “favored a larger intervention effect size with significant improvement among frail vs prefrail participants,” the study authors wrote, interaction was only significant for gait speed between frail and prefrail patients: 0.8 (95% CI, 0.5-1.1) vs 0.1 (95% CI, –0.3 to 0.4; P for interaction = .003).

Modified Fried criteria were used to stratify baseline frailty status, and by the 3-month follow-up, the intervention arm had significantly fewer frailty criteria vs the control arm compared with baseline (P = .04):

  • Intervention arm: 2.4 (1.0) vs 1.4 (1.0)
  • Control arm: 2.5 (1.0) vs 1.7 (1.0)

Overall, a 1-unit decrease in frailty criteria at 3 months was linked to a lower risk of all-cause hospitalization and combined all-cause rehospitalizations and death at 6 months (both P < .001):

  • All-cause hospitalization: risk ratio (RR), 0.65 (95% CI, 0.52-0.80)
  • Combined outcome: RR, 0.62 (95% CI, 0.50-0.76)

“Recent analyses support that in chronic HF, frail patients can achieve at least similar physical function and clinical benefits through cardiac rehabilitation as nonfrail patients,” the authors wrote. “The present study significantly extends this prior literature finding that frailty is associated with substantially more robust improvements in physical function in response to a physical rehabilitation intervention among older patients with ADHF.”

Still, they recommend caution in interpreting their results for a larger patient population because REHAB-HF was not adequately powered to determine the effect of the intervention on clinical events, they noted, and more deaths were seen among the prefrail vs the frail patients (7 vs 2).

At present, the study investigators are conducting another analysis of data of their intervention, but among a patient population with HF with preserved ejection fraction, “a preplanned subgroup that had higher rates of frailty and appeared to receive more benefit from the intervention than those with HF with reduced EF.”

Reference

Pandey A, Kitzman DW, Nelson MB, et al. Frailty and effects of a multidomain physical rehabilitation intervention among older patients hospitalized for acute heart failure: a secondary analysis of a randomized clinical trial. JAMA Cardiol. Published online January 4, 2023. doi:10.1001/jamacardio.2022.4903

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