A Longitudinal Study of Quality of Life in Patients with Chronic Heart Failure Following an Exercise Training Program

Barriers and Facilitators to Delivering Inpatient Cardiac Rehabilitation: A Scoping Review

Objective

The purpose of this scoping review was to summarize the literature on barriers and facilitators that influence the provision and uptake of inpatient cardiac rehabilitation (ICR).

Methods

A literature search was conducted using PsycINFO, MEDLINE, EMBASE, CINAHL and AgeLine. Studies were included if they were published in English after the year 2000 and focused on adults who were receiving some form of ICR (eg, exercise counselling and training, education for heart-healthy living). For studies meeting inclusion criteria, descriptive data on authors, year, study design, and intervention type were extracted.

Results

The literature search resulted in a total of 44,331 publications, of which 229 studies met inclusion criteria. ICR programs vary drastically and often focus on promoting physical exercises and patient education. Barriers and facilitators were categorized through patient, provider and system level factors. Individual characteristics and provider knowledge and efficacy were categorized as both barriers and facilitators to ICR delivery and uptake. Team functioning, lack of resources, program coordination, and inconsistencies in evaluation acted as key barriers to ICR delivery and uptake. Key facilitators that influence ICR implementation and engagement include accreditation and professional associations and patient and family-centred practices.

Conclusion

ICR programs can be highly effective at improving health outcomes for those living with CVDs. Our review identified several patient, provider, and system-level considerations that act as barriers and facilitators to ICR delivery and uptake. Future research should explore how to encourage health promotion knowledge amongst ICR staff and patients.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Improving Heart Failure Outcomes in Ambulatory and Community Care: A Scoping Study

Despite a large body of literature testing interventions to improve heart failure care, care is often suboptimal. This scoping study assesses organizational interventions to improve heart failure outcomes in ambulatory settings. Fifty-two studies and systematic reviews assessing multicomponent, self-management support, and eHealth interventions were included. Studies dating from the 1990s demonstrated that multicomponent interventions could reduce hospitalizations, readmissions, mortality, and costs and improve quality of life. Self-management support appeared more effective when included in multicomponent interventions. The independent contribution of eHealth interventions remains unclear. No studies addressed management of comorbidities, geriatric syndromes, frailty, or end of life care. Few studies addressed risk stratification or vulnerable populations. Limited reporting about intervention components, implementation methods, and fidelity presents challenges in adapting this literature to scale interventions. The use of standardized reporting guidelines and study designs that produce more contextual evidence would better enable application of this work in health system redesign.

Pathophysiological Relationships Between Heart Failure and Depression and Anxiety

Depression and anxiety are common comorbid conditions in patients with heart failure. Patients with heart failure and depression have increased mortality. The association of anxiety with increased mortality in patients with heart failure is not established. The purpose of this article is to illustrate the similarities of the underlying pathophysiology of heart failure, depression, and anxiety by using the Biopsychosocial Holistic Model of Cardiovascular Health. Depression and anxiety affect biological processes of cardiovascular function in patients with heart failure by altering neurohormonal function via activation of the hypothalamic-pituitary-adrenal axis, autonomic dysregulation, and activation of cytokine cascades and platelets. Patients with heart failure and depression or anxiety may exhibit a continued cycle of heart failure progression, increased depression, and increased anxiety. Understanding the underlying pathophysiological relationships in patients with heart failure who experience comorbid depression and/or anxiety is critical in order to implement appropriate treatments, educate patients and caregivers, and educate other health professionals.

Depression, psychological distress, and quality of life in patients with cardioverter defibrillator with or without cardiac resynchronization therapy

Congestive heart failure is frequent and leads to reduced exercise capacity, reduced quality of life (QoL), and depression in many patients. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) offer therapeutic options and may have an impact on QoL and depression. This study was performed to evaluate physical and mental health in patients undergoing ICD or combined CRT/ICD-implantation (CRT-D). Echocardiography, spiroergometry, and psychometric questionnaires [Beck Depression Inventory, General World Health Organization Five Well-being Index (WHO-5), Brief Symptom Inventory and 36-item Short Form (SF-36)] were obtained in 39 patients (ICD: 17, CRT-D: 22) at baseline and 6-month follow-up (FU) after device implantation. CRT-D patients had a higher NYHA class and broader left bundle branch block than ICD patients at baseline. At FU, ejection fraction (EF), peak oxygen uptake, and NYHA class improved significantly in CRT-D patients but remained unchanged in ICD patients. Patients with CRT-D implantation showed higher levels of depressive symptoms, psychological distress, and impairment in QoL at baseline and FU compared to ICD patients. These impairments remained mostly unchanged in all patients after 6 months. Overall, these findings imply that there is a need for careful assessment and treatment of psychological distress and depression in ICD and CRT-D patients in the course of device implantation as psychological burden seems to persist irrespective of physical improvement.

Testosterone therapy during exercise rehabilitation in male patients with chronic heart failure who have low testosterone status: a double-blind randomized controlled feasibility study

BACKGROUND

This study assessed the feasibility of a 12-week program of exercise, with and without intramuscular testosterone supplementation, in male patients with chronic heart failure (CHF) and low testosterone status and collected preliminary data for key health outcomes.

METHODS

Male patients with CHF (n = 41, age 67.2 years, range 51-84 years) with mean ± SD testosterone levels of 10.7 ± 2.6 nmol/L (309 ± 76 ng/dL) were randomly allocated to exercise with testosterone or placebo groups. Feasibility was assessed in terms of recruitment, intervention compliance, and attrition. Outcomes included an incremental shuttle walk test, peak oxygen uptake, muscular strength, echocardiographic measures, N-terminal pro-brain natriuretic peptide, inflammatory markers, depression (Beck Depression Inventory), and health-related quality of life (Minnesota Living with Heart Failure Questionnaire and Medical Outcomes Study Short-Form).

RESULTS

Attrition was 30% but with 100% compliance to exercise and injections in patients who completed the study. Similar improvements in shuttle walk test (18% vs 19%), body mass (-1.3 kg vs -1.0 kg), and hand grip strength (2.1 kg vs 2.5 kg) from baseline were observed in both groups. The exercise with testosterone group showed improvements from baseline in peak oxygen uptake (P < .01), Beck Depression Inventory (P < .05), leg strength (P < .05), and several Medical Outcomes Study Short-Form quality of life domains (P < .05), which were generally not apparent in the exercise with placebo group. Echocardiographic measures, N-terminal pro-brain natriuretic peptide, and inflammatory markers were mostly unchanged.

CONCLUSIONS

This study shows for the first time that testosterone supplementation during a program of exercise rehabilitation is feasible and can positively impact on a range of key health outcomes in elderly male patients with CHF who have a low testosterone status.

Anxiety and depression in cardiac patients: age differences and comparisons with the general population

BACKGROUND

Anxiety and depression are often found in cardiac patients, but also in the general population. Therefore, evaluation of these symptoms in patients requires a comparison with norm values. The purpose of this study was to explore differences between cardiac patients and the general population in age dependency of anxiety and depression, and to discuss possible reasons for these differences.

METHODS

A sample of German cardiac patients (n = 2,696) and a sample of the German general population (n = 2,037) were tested using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

While we confirmed a linear age trend of anxiety and depression in the general population, we observed an inverted U-shaped age dependency in the patient sample. Young patients are especially affected by anxiety and depression. Five items of the HADS that mainly contributed to the age differences were identified. Formal characteristics of these 5 items could not explain the age differences. Concerning the meaning of the items, however, most of the items refer to worrying about the future.

CONCLUSIONS

The relatively low rates of anxiety and depression in older patients (compared with the general population) indicate that adaptation processes took place, which should be taken into account in studies concerning the psychological status of patients. Young patients need special attention when dealing with mental distress.

Limitations to high intensity exercise prescription in chronic heart failure patients

BACKGROUND

Interval training is recommended for chronic heart failure patients (CHF), but specific guidelines on setting appropriate workloads have not been fully established. The aim of this study was to compare a traditional method of interval training prescription with a protocol specifically designed for CHF.

METHODS

Ten CHF and 7 healthy controls performed 2 maximal incremental cycle tests to determine interval training workload; a standard test (10Wmin(-)(1)) and a steep test (25W.10(-)(s)). Peak work rate and oxygen uptake (VO(2 peak)) were determined. Training workloads were defined as 100% standard test and 50% steep test peak work rate.

RESULTS

Training workload determined from the standard test was higher than from the steep test in healthy controls (151 ± 17W vs 118 ± 13W; P<0.01), whereas in CHF there was no significant difference between methods (88 ± 10W vs 96 ± 9W; P>0.05). Steep test VO(2peak) reached 91 ± 5% of standard test VO(2 peak) in controls, and 99 ± 4% in CHF, with no significant differences between tests in either group.

CONCLUSION

Prescribing interval training from a standard test results in higher workloads than from a steep test in healthy individuals, but in CHF both methods prescribe similar workloads. However it should not be assumed that the two tests can be used interchangeably for CHF. This small-sized study raises issues about interval training prescription that may be hypothesis-generating for future larger-scale studies.