Although the U.S. Centers for Medicare Services (CMS) has extended cardiac rehabilitation (rehab) coverage to patients with heart failure with reduced ejection fraction (HFrEF), enrolling these patients in cardiac rehab may prove difficult, according to a recent Council Perspective published June 15 in the Journal of the American College of Cardiology. As part of a new series of perspectives from different ACC Councils in the Journal, members from the ACC’s Prevention of Cardiovascular Disease Section assessed the challenges and opportunities that cardiac rehab presents for HFrEF patients.

Cardiac rehab has been established as a safe and effective program for patients with acute coronary symptoms, revascularization, and/or chronic coronary heart disease, yet these patients continue to underutilize cardiac rehab programs. “The inherent weakness of [cardiac rehab] research has contributed to [this] poor … utilization,” the Council remarks. In terms of cardiac rehab for HFrEF patients, “skepticism regarding the utility of exercise therapy... [is] magnified by safety concerns,” as well as the challenge of adherence to a cardiac rehab program. The Council notes that patients with HFrEF tend to experience arrhythmia, hemodynamic instability and fluid overload more so than patients with coronary heart disease.

The authors note that while the results of the HF-ACTION trial show that HFrEF patients may reduce their risk of all-cause mortality/hospitalization through exercise training, these results are not taken seriously by all. Researchers reported a 15 percent decrease in cardiovascular mortality/heart failure hospitalization in the trial, but “only approximately 30 percent of [participants] in the [trial’s exercise group] exercised at or above target number of minutes per week.” They add that the lack of adherence to exercise training in the trial leaves some unconvinced that the program can be effective and safe for HFrEF patients.

“The HF-ACTION trial provides a greater rationale to justify CMS financing for [cardiac rehab] for HFrEF... yet still leaves residual concerns and questions,” according to the Council. There is an “increased emphasis on cardiac rehab” because of this financing, but it is necessary to further research the utility of cardiac rehab for HFrEF patients and how to best accomplish adherence to programs. 

Keywords: Arrhythmias, Cardiac, Coronary Disease, Exercise Therapy, Heart Failure, Hemodynamics, Hospitalization, Medicare, Research, Research Personnel

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