By Michael H. Crawford, MD, Editor

SYNOPSIS: A tailored, progressive physical rehabilitation program started in the hospital and continued for three months in older, relatively frail acute heart failure admissions resulted in significantly improved physical function vs. usual care but did not reduce six-month readmission rates.

SOURCE: Kitzman DW, Whellan DJ, Duncan P, et al. Physical rehabilitation for older patients hospitalized for heart failure. N Engl J Med 2021;385:203-216.

Physical limitations are common in patients admitted for acute heart failure and are exacerbated by hospital bed rest, leading to a vicious cycle that often ends in readmission. Whether an early transitional, tailored, progressive rehabilitation program would improve physical function and reduce readmissions was the subject of this multicenter, randomized, single-blind, controlled study. Patients at least age 60 years who could walk 4 meters (13 feet) with or without a support device, who were living independently before admission, and for whom discharge home was planned were enrolled. They were randomized to the tailored rehabilitation intervention or usual care, which could include standard cardiac rehabilitation or physical therapy programs. The tailored program started in the hospital and continued on for three 60-minute one-on-one outpatient visits per week for four weeks and home exercises on the off days, which included walking for 30 minutes and strength exercises. The outpatient visits focused on strength, balance, mobility, and endurance.

After three months, the intervention group received an exercise prescription they were to continue indefinitely, and they were phoned every month for six months to assess their progress. The control group received a phone call at two weeks and follow-up visits at one and three months. The primary outcome was the Short Physical Performance Battery (SPPB) at three months, which included standing balance, gait speed, and a strength test. Each were scored 0-4 points, where 4 is best, for a total possible score of 12. The secondary endpoint was rehospitalization rate at six months. Between 2014 and 2019, 349 patients were randomized (average age = 73 years, 52% women, 46% Black, 53% with heart failure with preserved ejection fraction). In addition, 97% were either frail or pre-frail. The SPPB score at three months was 8.3 in the intervention group and 6.9 in the control group (P < 0.001), and all three measures increased significantly. Specifically, walking endurance increased from 11 minutes to 22 minutes. The rehospitalization rate at six months was 1.2% vs. 1.3%, which was not significant, nor was mortality (21% vs. 16%). Adherence to the intervention at six months was 78%. The authors concluded a tailored, progressive physical rehabilitation intervention started in the hospital in older patients admitted for acute heart failure and continued for three months exhibited greater improvement in physical function vs. usual care.

COMMENTARY

Physical limitations are common in heart failure patients because of multiple comorbidities and reduced left ventricular function. Hospitalization often improves their heart failure but does not necessarily improve their physical functioning. This study by Kitzman et al is unique in that they applied their intervention to relatively frail elderly patients with multiple comorbidities, starting in the hospital and continuing as outpatients. Also, the study was multicentered, blinded, controlled, and involved a diverse population. In addition, the beneficial results of the intervention occurred despite 43% of the control group undergoing some form of physical therapy or cardiac rehabilitation after discharge as part of usual care. Remarkably, 83% of the intervention group was engaging in regular exercise at home six months after discharge. On the negative side, there was no change in clinical events, such as rehospitalization. Although not significant, mortality was higher in the intervention group. Also, 30 patients in the intervention group dropped out. Finally, the long-term benefits of the intervention are unknown.

Although clearly of some benefit to the patients, initiation of such a program in the hospital and continuing on an outpatient basis would be costly. This was a one-on-one intervention, which was tailored to each patient’s rehabilitation needs. The outpatient sessions lasted 60 minutes each and were conducted three times a week for a duration of three months, with periodic phone calls for up to six months. Considering the resources expended, the results are good but not spectacular. However, exploratory endpoints, such as six-minute walk test, frailty index, cognitive assessment, and depression, improved, and there were no subgroups where the intervention was not effective. Until your hospital system has the resources to start such a program, ensuring that all heart failure discharges are at least referred for cardiac rehabilitation would be a good start.