Cardiac Rehabilitation for Heart Failure

Editor's Note: Commentary based on Forman DE, Sanderson BK, Josephson RA, Raikhelkar J, Bittner V; American College of Cardiology's Prevention of Cardiovascular Disease Section. Heart failure as a newly approved diagnosis for cardiac rehabilitation: challenges and opportunities. J Am Coll Cardiol 2015;65:2652-9.

A recent article in the June 23, 2015 issue of the Journal of the American College of Cardiology is a state-of-the-art review of cardiac rehabilitation (CR) for patients with congestive heart failure. The authors summarize recent research, including the Heart Failure–A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial, which ultimately resulted in Medicare approval of cardiac rehabilitation for patients with chronic heart failure secondary to left ventricular systolic dysfunction. The authors also address emerging and challenging patient groups and areas of care, such as patients with left ventricular assist devices (LVADs), patients with heart failure with preserved ejection fraction (HFPEF), very elderly patients, research opportunities, and patient adherence to chronic exercise regimen. The article concludes by framing cardiac rehabilitation in the context of the changing U.S. health care system and discussing integration of CR into novel models of cardiac care.

The article summarizes proof of principal, that aerobic exercise training for patients with heart failure with reserved ejection fraction (HFREF) is feasible, safe, and efficacious and results in improvements in mortality and hospitalization (after adjustment for important baseline characteristics). In order to make CR an accessible and effective intervention, the authors address many systemic, procedural, and patient barriers. Broader geographic dissemination, reduction in high total copayments, attention to traditionally underserved groups such as women and minorities, and home-based or tele-rehabilitation are all offered as potential areas of improvement. Enrollment of patients in CR early after a cardiac hospitalization, limited pre-exercise assessment (vs. extensive assessment that was used in clinical trials), utilization of mobile technology, and particular emphasis on patient adherence were factors on which individual CR programs could focus to improve delivery of this underutilized intervention.

LVAD use is increasing, and ambulatory patients with LVADs still experience substantial functional impairment that may benefit from CR. The limited data available to address this important population, the difficulty in designing evidence-based exercise prescriptions, and the open vista for impactful clinical investigation in this area were highlighted.

HFPEF now comprises at least half of all patients diagnosed with heart failure, and their functional impairment is profound, and similar to those with HFREF. CR has the potential to not only improve the morbidity of those with HFPEF, but also help elucidate the pathophysiology of this enigmatic condition. Importantly, HFPEF is often associated with comorbidities, such as obesity, diabetes, hypertension, and peripheral arterial diseaes. Each of these comorbidities has been proven to improve with exercise, and there is optimism that formal CR, with structured exercise, will be substantially beneficial to this expanding population of patients.

The authors review the long history of CR for those with coronary artery disease and highlight the extensive evidence base on the one hand and the pervasive and persistent underutilization on the other hand. This background serves as a clarion call to those who care for patients with HFREF to not allow history to repeat itself. Health care providers at multiple levels must strive to ensure that CR for heart failure is widely available, patients are appropriately referred and enrolled, and adherence is optimized.

This succinct article summarizing the state of the field and the opportunity provided by improved insurance coverage should be of interest to all members of the heart team, particularly those interested in prevention and heart failure.

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