Bibliographic reference
Dalane W. Kitzman, M.D., David J. Whellan, M.D., M.H.S., Pamela Duncan, P.T., Ph.D., Amy M. Pastva, P.T., Ph.D., Robert J. Mentz, M.D., Gordon R. Reeves, M.D., M.P.T., M. Benjamin Nelson, M.S., Haiying Chen, Ph.D., Bharathi Upadhya, M.D., Shelby D. Reed, Ph.D., Mark A. Espeland, Ph.D., LeighAnn Hewston, D.P.T., M.Ed., et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure, N Engl J Med July 2021; 385:203-216.
DOI: 10.1056/NEJMoa2026141
Abstract
Those elderly patients hospitalized for acute heart failure are characterized by high physical frailty, poor quality of life, slow recovery as well as frequent hospitalizations. Actions that address physical frailty in this population are currently not well defined.
This study evaluated a progressive rehabilitation intervention of 36 sessions, initiated during or immediately after hospital discharge. The “Short Physical Performance Battery” score was analyzed at three months and the rate of re-hospitalization was analyzed at six months.
This study demonstrated that early progressive and personalized rehabilitation interventions in patients admitted for acute heart failure bring significant improvement of physical functions compared to “standard” assistance. They do not, however, seem to affect the risk of hospitalization.
Background
Acute heart failure is the main cause of hospital admissions in the United States (as well as in Italy) and is associated with frequent re-hospitalizations, low quality of life, high mortality and high economic and social costs. After a heart failure exacerbation, physical functionality worsens as a result of hospitalization and several days of bed rest. As a consequence, patients lose their autonomy and the risk of re-hospitalization and post-discharge mortality is high. Nevertheless, current guidelines for managing patients with acute heart failure do not take into consideration interventions aimed at reducing the physical dysfunction of admitted patients. Previous studies that evaluated the impact of physical exercise have excluded recently hospitalized patients.
The objective of this study is to determine whether early rehabilitation interventions may improve the physical functionality of elderly patients and decrease the rate of hospitalization.
Study characteristics
A total of 349 patients aged 60 years or older were enrolled in this multicenter, randomized, controlled trial. All patients were hospitalized for acute heart failure (regardless of the ejection fraction), could walk for at least 4 meters, were independent prior to admission and were to be discharged to home. Patients were randomly assigned to the rehabilitation intervention group or to the standard assistance group.
The rehabilitation intervention (REHAB-HF) is based on the following 4 important domains of physical functions: strength, balance, mobility and endurance. Outpatient sessions of 60 minutes were performed for 3 days per week for 12 weeks. Low intensity walking, which was gradually increased to 30 minutes/day, and strength exercises were performed at home on days when patients not being evaluated as outpatients.
The Short Physical Performance Battery score (SPPB) at three months was selected as the main outcome of this study. This tool is a standardized and reproducible measurement of global physical functionality and evaluates 3 components; static balance, walking velocity, and strength (measured by the time needed to get up out of the chair 5 times). A score which varies from 0 to 4 is assigned for each component, with the total score ranging from 0 to 12. A lower score indicates a more severe dysfunction. The rate of re-hospitalization at 6 months was also evaluated as a secondary outcome.
Results
The authors reported high adherence at the end of the follow-up period by the rehabilitation intervention group. Excluding the 12 subjects who died during the observation period, adherence to the intervention was 67% and rose to 78% after adjustment for sessions missed (due to other medical appointments or illness).
After three months, the subjects enlisted in the rehabilitation intervention group had a significant improvement of the SPPB score. At 6 months, no differences were seen between the two groups regarding hospitalization rate and mortality risk. Patients in the intervention group reported higher rates of chest pain, hypotension, dizziness, hyper- and hypoglycemia whereas a higher rate of fallings and heart failure recurrence was reported in the control group.
What’s new?
This study shows that early rehabilitation intervention helps prevent physical dysfunction, which leads to a loss of autonomy in elderly patients admitted for heart failure. This is the first trial to include a population characterized by a high level of frailty in which the rehabilitation program is started so early.
Finally, the results of this trial also suggest a possible reduction of depression, which is known to have an important impact on the life quality of the elderly patients suffering from chronic heart failure.
Limitations
Firstly, the study failed to show any benefit of the rehabilitation intervention on the clinical events. That said, loss of physical function and autonomy are highly relevant components of heart failure. Another limitation is that this study evaluated the effect of these interventions in a limited group of subjects, as the inclusion criteria considerably reduced the number of patients that could have been enrolled.
Perspectives
Patients hospitalized for acute heart failure are characterized by high frailty, physical dysfunction and depression. All of these factors may play a role in patient re-hospitalization, loss of functional autonomy and mortality. This study showed that an early rehabilitation intervention may contribute to improved balance, strength and mobility. As a result, applying these interventions to a wider population could have important public health implications.
Edited by Iris Zeqaj
