An 82-year-old female with heart failure (HF), hypertension, diabetes mellitus, atrial fibrillation, prior stroke, and osteoarthritis was hospitalized with HF exacerbation in the setting of presumed dietary indiscretion. Over the preceding week she had been traveling to visit family for the holidays. Her diet was atypical, she developed a cough, rhinorrhea, and was feeling slightly more dyspneic with increased edema in her ankles. She did not weigh herself until returning home and was 11 pounds higher than average. She self-managed this by doubling her prescribed dose of furosemide for 3 days, but her weight did not improve significantly. She reported feeling worsening weakness and her blood pressure at home was 104/55, which was low for her. She felt very unsteady when ambulating in her home and fell without reported loss of consciousness. She called her physician, went to the hospital, and was admitted for further care.
At admission her temperature was 99.1° F, blood pressure was 112/61 mmHg, heart rate 89 bpm, and oxygen saturation 95%. Her physical examination revealed mild bibasilar rales, an irregular rhythm, and 2+ bilateral edema to her knees. Her outpatient medications included furosemide 80 mg once daily, lisinopril 40 mg once daily, and diltiazem ER 360 mg once daily.
While hospitalized an echocardiogram was obtained and showed an unchanged left ventricular ejection fraction of 45-50%, grade 3 diastolic dysfunction with elevated filling pressures, mild mitral regurgitation, and tricuspid regurgitation with an estimated pulmonary artery systolic pressure of 42 mmHg. She was diuresed with IV furosemide and after 3 days her weight was significantly improved. She was able to ambulate without dyspnea on the ward, she was feeling more stable but still weak, and her blood pressure was improved at 122/76. Discharge to home was anticipated for the following day.
The correct answer is: A. Consider referral to a cardiac rehabilitation-like program that can begin within days of discharge to improve strength and balance and monitor overall adherence, diet, and recovery.
Prevalence of HF is increasingly common among older adults. In particular, incidence of heart failure with preserved ejection fraction (HFpEF) doubles each decade after 65 years, such that it eventually becomes the dominant type of HF among seniors.1 Moreover, HF in older adults is typically associated with the additional challenges of geriatric syndromes, including frailty, polypharmacy, and multimorbidity, which complicate management. In this case, the patient suffers acutely from a combination of HFpEF exacerbations (i.e., volume overload in conjunction with low blood pressures) which are likely contributing to her instability and susceptibility to falls.
Detrimental consequences from HF among older adults are also commonly exacerbated by HF management. Deconditioning and hemodynamic perturbations from medicines are more likely in older age. Poor sleep and nutrition and cognitive limitations often compound these vulnerabilities. Such vulnerabilities can arise when treatment goes smoothly (e.g., increased susceptibility to deconditioning and post-hospitalization syndrome) and they are especially likely if and when common difficulties arise (e.g., increased sequelae due to concurrent diseases, polypharmacy, delirium, and prolonged lengths of stay), all of which are more common with advancing age.2,3
Cardiac rehabilitation (CR) is a comprehensive lifestyle program that can have particular benefit for older HF patients. However, the Centers for Medicare and Medicaid Services (CMS) currently do not reimburse CR for patients with heart failure with reduced ejection fraction (HFrEF) or HFpEF immediately following hospitalization due to the relative lack of data regarding its efficacy and safety in this population. The CMS decision to limit eligibility to CR for patients with stable HF without change in medications for at least 6 weeks (answer C) was primarily based on the weight of existing data from clinical trials and the relative lack of trial information to justify broader administration.
Although the 2010 HF clinical guidelines had already included CR as a Class I recommendation based on multiple small trials and a preponderance of clinical gestalt,4 CMS limited CR only for HFrEF and after 6 weeks based on the eligibility criteria in the landmark trial, Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION).5,6 Whereas the weight of data showing benefit of exercise therapy and CR for HfpEF is growing (and some have argued that it is now even greater than HFrEF), CMS has yet to broaden CR eligibility criteria to HFpEF or to immediate post-HF-hospitalization. Recently, an NIH Working Group concluded that exercise training should be recommended as therapy for patients with HF and specifically that timing such as early after acute decompensated HF or even during hospitalization should be considered.7 Other thought leaders have made similar recommendations.8,9 Furthermore, exercise training is the only therapy that improves muscle weakness to increase exercise tolerance and quality of life in patients HFpEF,10 which may be critical in modifying HF-associated frailty.11
While there have been recurrent efforts to broaden CMS eligibility criteria for CR to include HFpEF,5,9 their rules have not yet changed. Many believe it is only a matter of time before this occurs. Multiple small studies have demonstrated the safety and utility of exercise training to improve functional capacity in older patients with HFpEF.12 Currently, the ongoing REHAB-HF (A Trial of Rehabilitation Therapy in Older Acute Heart Failure Patients) trial may provide corroborating data that have the potential to broaden CMS funding decisions.
For now, clinicians are left with the difficult situation wherein HF guidelines recommend exercise as soon as possible for HFrEF and HFpEF, but with CR available for reimbursement much more restricted. Most clinicians and now even some insurance companies are allowing HFpEF patients to enroll in CR as soon as possible based on current literature, but the field remains dynamic.
Cardiac rehabilitation can play a decisive role in improving physical function, quality of life, symptoms, morbidity, and mortality, and can also address the idiosyncratic complexities of care that often arise in old age. The exercise training provided by CR programs limits the effects of muscle atrophy and weakness that occurs with HF and aging and which increases predisposition to frailty, diminished physical self-confidence, and dependency. Our patient would benefit greatly from increased muscle strength and balance to help reduce her risks of subsequent falls and more serious, potentially life-threatening, injuries. A supervised exercise program can reduce patients' anxiety of their symptoms and reduce the risk of falls and fall-related injuries. A systematic review of 17 trials of exercise interventions in community-dwelling older adults, regardless of heart disease status, found that all falls, including falls which produced major injuries, were reduced.13 Although the etiologies of falls in older adults vary, they are frequently due to imbalance that results from weakness.14 CR programs have been demonstrated to increase strength, and to thereby improve balance and reduce falling risks.15 The multifaceted nature of CR adds to this benefit as effects of arrhythmias, medication interactions, sleep impairments, and/or dietary limits (e.g., dehydration) are also considered, with the impact that falling risks are reduced even further.
In addition to the exercise and strength component, CR programs provide education which focuses on improving patients' insight and understanding of their disease and healthful behaviors. Studies show that CR education can be successfully tailored to achieve meaningful impact despite cognitive limitations associated with age and disease.16,17 Despite the mounting evidence for the benefits of CR on important clinical outcomes it remains underused, particularly among older HF patients.
References
- Upadhya B, Taffet GE, Cheng CP, Kitzman DW. Heart failure with preserved ejection fraction in the elderly: scope of the problem. J Mol Cell Cardiol 2015;83:73-87.
- Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013;368:100-2.
- Graf C. Functional decline in hospitalized older adults. Am J Nurs 2006;106:58-67.
- Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation, Thomas RJ, King M, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures. Circulation 2010;122:1342-50.
- Decision memo for cardiac rehabilitation (CR) programs—chronic heart failure (CAG-00437N). 2014, Centers for Medicare & Medicaid Services.
- Flynn KE, Pina IL, Whellan DJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301:1451-9.
- Fleg JL, Cooper LS, Borlaug BA, et al. Exercise training as therapy for heart failure: current status and future directions. Circ Heart Fail 2015;8:209-20.
- Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail 2013;1:540-7.
- Keteyian SJ. Exercise training in patients with heart failure and preserved ejection fraction: findings awaiting discovery. J Am Coll Cardiol 2013;62:593-4.
- Shah SJ, Kitzman DW, Borlaug BA, et al. Phenotype-specific treatment of heart failure with preserved ejection fraction: a multiorgan roadmap. Circulation 2016;134:73-90.
- Khan H, Kalogeropoulos AP, Georgiopoulou VV, et al. Frailty and risk for heart failure in older adults: the health, aging, and body composition study. Am Heart J 2013;166:887-94.
- Pandey A, Parashar A, Kumbhani DJ, et al. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. Circ Heart Fail 2015;8:33-40.
- El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.
- Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc 1997;45:735-8.
- Kim S, Lockhart T. Effects of 8 weeks of balance or weight training for the independently living elderly on the outcomes of induced slips. Int J Rehabil Res 2010;33:49-55.
- Caminiti G, Ranghi F, De Benedetti S, et al. Cognitive impairment affects physical recovery of patients with heart failure undergoing intensive cardiac rehabilitation. Rehabil Res Pract 2012;2012:218928.
- Gunstad J, Macgregor KL, Paul RH, et al. Cardiac rehabilitation improves cognitive performance in older adults with cardiovascular disease. J Cardiopulm Rehabil 2005;25:173-6.
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