It's Not Always Coverage-Social Factors, Barriers Can Keep Heart Failure Patients From Exercising

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The findings suggest that addressing heart patients' social needs is the first step toward getting them to exercise more.

It was once believed that lack of Medicare coverage was what stood between heart failure patients and going to cardiac rehabilitation. But after February 2014, when a policy change ended that problem, patients stayed away anyway.

So what’s the problem? For many, lack of social support—or the perception of it—and actual barriers to exercise may make the difference in how much exercise a patients with heart disease gets. And when it comes to patients with heart disease, a little exercise goes a long way.

A study published this week in the journal Circulation: Heart Failure sought to gain insight into the effect of social support and barriers on exercise. Results from a randomized controlled trial at the Duke Clinical Research Institute were published in “Psychosocial Factors, Exercise Adherence, and Outcomes in Heart Failure Patients,” led by Lauren B. Cooper, MD.


Primary results of the HF-ACTION trial were previously published; it examined the efficacy and safety of exercise for patients with stable, chronic HF with reduced ejection fraction. Patients were randomized to usual care or usual care plus exercise training, which was 3 sessions per week for 36 sessions over 3 months of increased duration and intensity. Gradually, patients transitions to a home program for another 2 years.

The current results examined how perceived social support and actual barriers to exercise, measured at baseline, correlated to with exercise time—and with outcomes.

Of the 2331 patients enrolled, nearly all (2278) took part in the surveys to assess both social support and barriers. For patients randomized to complete exercise training, baseline perceived social support scores correlated weakly with exercise time at 3 and 12 months, as did the baseline scores for actual barriers. Patients with the worst adherence were most likely to be young, female, and African American, with high body mass index. Patients with poor adherence also had lower exercise capacity as measured by peak oxygen volume and a 6-minute walk test. They also had a lower quality of life, and higher levels of depression.

In examining the barrier scores, researchers found an association between a higher baseline barrier score and an increase in all-cause death or hospitalization, though this did not persist after adjustments. “Thus,” the researchers wrote, “barriers to exercise training may capture the psychosocial factors associated with worse outcomes,” while scores may offer an “independent” assessment of what is to come.

Because the prior results showed the exercise intensity and time were associated with lower risk of CV death or HF hospitalization, the researchers say improving support structures for patients may be the path to better health, if more exercise is the goal.


Cooper LB, Mentz RJ, Sun JL, et al. Psychosocial factors, exercise adherence, and outcomes in heart failure patients [published online November 17, 2015]. Circ Heart Fail 2015; doi:10.1161/CIRCHEARTFAILURE.115.002327.