HEART FAILURE

AN OMINOUS DISEASE

Conflicts of Interest

• I Have No Conflicts

of Interest to Disclose

Objective

• At the conclusion of this presentation, the participants will be able to identify benefits and details of Cardiac Rehabilitation Program for heart failure patients

BREAKING NEWS

The Centers for Medicare and Medicaid Services (CMS) has confirmed effective date for patients with heart failure(HF) to receive cardiac rehabilitation services is: February 18, 2014

Who is Eligible

STABLE CHRONIC HEART FAILURE PATIENTS

• Pts. who have not had recent (<6 weeks) or

planned (< 6 months) major cardiovascular

hospitalizations or procedures.

• Left ventricular ejection fraction <35%

• New York Heart Association (NYHA) class II

to IV symptoms (despite being on HF therapy

for at least 6 wks)

(HF is preferred over CHF because some pts. present without signs or symptoms of volume overload)

Why CMS Supported CR for HF

• 2009- CMS found little evidence in existing literature that supported CR for HF pts.

• 2009- (O’Connor) HF-ACTION Study (HF:A Controlled Trial Investigating Outcomes of Exercise Training)

a. Largest single trial (n=2331)- most well

designed and provided best evidence of

benefit

HF-ACTION STUDY- April 2003 to

February 2007

• Randomly assigned

a. Exercise training (60-70% HRR)

b. Usual Care (no formal exercise

prescription-exercise was simply

encouraged)

HF-ACTION STUDY (published in 2009)

• Age range 51-68 (Median age of 59)

• 72% men

• LVEF < 35% (Mean 25%)

• Follow-up ( goal of a minimum of 1 yr. and

maximum of 4 yrs. - median 30.1 months)

HF-ACTION STUDY

• Exercise Training Group

a. Structured, group based, and supervised

exercise

b. 3 sessions/week for a total of 36 sessions

in 3 months

c. Followed by home based 5x/week for 40

min. exercise on a treadmill or stationary

bicycle

HF-ACTION STUDY

All Patients Received Educational Materials

a. Medications

b. Fluid Management

c. Symptom Exacerbation

d. Sodium Intake

e. Activity Level of 30 min (as tolerated)

HF-ACTION STUDY RESULTS

• 11% reduction in the adjusted risk for the combined endpoint of all-cause mortality or hospitalization

• Quality of life and mental depression also improved

COURSE of ACTION

• One of the most propitious course of action

in helping HF patients deal with their

complications is…….

Cardiac

Rehabilitation 36 sessions- for most insurances

3 x/week- highly encouraged

30-60 min of aerobic exercise and weight training if tolerable

Monitor HR, O2, BP and RPE

Progress according to patients’ tolerance

COMPONENTS OF CARDIAC REHAB

Education • Nutrition and Heart Disease • Dining In/Dining Out • Making Sense of Food Labels • Achieving a Healthy Weight • Heart Talk: How it Works and More • Stress and Heart Disease • Relaxation • Managing Risk Factors • Cardiac Meds- Part 1 and 2 • Heart Stories • The Science of Exercise • Tools for Empowering Your Healing Process

Aerobic Benefits of CR for HF Patients

• Lower response to submaximal exercise • Improves diastolic function • Improved endothelial function • Increased skeletal muscle oxidative capacity • Enhanced vagal tone and lower sympathetic tone • Has anti-inflammatory and anti-oxidative effects • Lower all-cause mortality or hospitalization • Improved quality of life • Reduced peripheral vasoconstriction • Decreases circulating catecholamine levels • Affects left ventricular remodeling

COMPONENTS OF CARDIAC REHAB Aerobic Exercise

Low-intensity, longer duration workout are preferred over

high-intensity activities

Start with shorter sessions and gradually build up

Take frequent breaks

Include warm-up and cool-down

Watch for fatigue and SOB

Benefits of Strength Training in CR for HF Patients

• Dynamic resistive training has anti-inflammatory effects

• Improves insulin resistance

• Counteract loss of skeletal mass and strength

• Increases muscle strength and endurance

• Improves QOL

Best Practice in Weight Training

• Training in a dynamic way • Avoid valsalva maneuvers • Keep training at low to moderate intensity- high repetition and low resistance • Sustained maximal isometric exercise is contraindicated because of excessive rise in BP and lowering of SV

Program Statistics for CHF Patients

From January, 2017 thru July, 2017 Total patients enrolled= 268 Total CHF patients= 78 (38%) Average EF= 36% Average EF for non CHF= 54%

Average MET level starting for CHF patients= 4.85 Finishing program= 6.59

Average MET level starting for non CHF patients= 4.9 Finishing program= 7.18

GOALS FOR CR

Control symptoms

Improve QOL

Prevent hospitalization

Prevent mortality

Provide patient education

OUR CHALLENGE

As exercise specialists, we need to break down possible existing barriers and fears related to exercising patients with HF and use our knowledge in delivering effective health interventions so that both efficiency and safety are guaranteed.

POSTER PATIENT

1972- CABG (36 yrs old)

Current Age=81

1979- CABG (43 yrs. old)

1990- MI (54 yrs old)

1994- CABG (58 yrs old)

2007- Pacemaker (71 yrs. old)

2013- ICD (77 yrs. old)

2016- Angioplasty (80 yrs. old)

Current- CHF and EF= 30-35%

1990-Cardiac Rehab- at New Heart

2016 Cardiac Rehab- Presbyterian Healthplex

2017- Current Member in Cardiac Maintenace Program – Presbyterian Healthplex